AgeCare Pine Grove (8403 Islington Avenue North, Woodbridge, Ontario) is operated by AgeCare, a for-profit operator of long-term care homes in Canada. There are approximately 90 beds.
AgeCare Pine Grove is formerly owned and operated by Chartwell, a for-profit operator of senior accommodations in Canada. The facility was previously known as Chartwell Pine Grove Long Term Care Residence.
Our research team at Caring Magazine carefully reviewed and summarized inspection reports for AgeCare Pine Grove. You can read the original copies of the reports in the Government of Ontario website.
Inspection Reports for AgeCare Pine Grove
Chartwell completed its sale of long-term care homes to AgeCare on September 6, 2023. Inspection results after this date should not be attributed to Chartwell operations.
🔍 September 2023: Inspection
During the course of this inspection, the inspector(s) made relevant observations, reviewed records and conducted interviews, as applicable. There were no findings of non-compliance.
Inspection Reports for Chartwell Pine Grove Long Term Care Residence
Chartwell completed its sale of long-term care homes to AgeCare on September 6, 2023. Inspection results before this date should not be attributed to AgeCare operations.
🔍 August 2023: Inspection
The inspection report for Chartwell Pine Grove Long Term Care Residence was originally issued, and amended to include updates to the scope of hypoglycemia audits and training requirements for staff.
- Plan of Care: The inspection found that the care specified in a resident’s plan was not provided as required. Specifically, a resident needed two staff members for assistance due to responsive behaviors, but only one Personal Support Worker (PSW) was observed providing help, contradicting the care plan.
- Transferring Techniques: Unsafe transferring techniques were used by staff when assisting two residents. In one case, staff improperly placed their hand on a resident’s neck during a transfer. In another instance, a PSW used an incorrect transferring device, leading to a resident’s injury.
- Medication Management System: The facility did not follow its own “Diabetic Management” policy. A resident who received insulin did not have the required Capillary Blood Glucose (CBG) checks as mandated by the policy, putting the resident at risk of hypoglycemia.
- Monitoring After Glucagon Administration: Post-glucagon administration for severe hypoglycemia was not monitored according to the facility’s policies. Required hourly monitoring of CBG after administering glucagon was not adhered to, risking resident health.
The facility was ordered to train all registered nursing staff on hypoglycemia and glucagon policies, maintain records of training, audit all episodes of hypoglycemia, and ensure corrective actions are taken as per the Minister’s Directive updated on April 11, 2022. This directive outlines the required response to glucagon use, including notification and review procedures, which the facility failed to follow, leading to repeated severe hypoglycemia incidents without proper documentation or follow-up.
🔍 February 2023: Proactive Compliance Inspection
The inspection report for Chartwell Pine Grove Long Term Care Residence focused on several key areas including medication management, nutrition, safety, quality improvement, pain management, falls prevention, and resident care.
- Security Measures: A specific door on the third floor leading to a non-residential area was found unlocked due to a broken maglock on the initial day of inspection. The Environmental Service Manager acknowledged the issue, which was addressed promptly.
- Promotion of Zero Tolerance Policy: The policy to promote zero tolerance of abuse and neglect of residents was not posted as required. This oversight was rectified by the Administrator by ensuring the policy was displayed in the reception area.
- Care Plan Adherence: There was a failure to provide care as specified in a resident’s care plan, particularly regarding meal preferences. This was acknowledged by the Registered Dietitian, highlighting the need for staff to adhere to individual care plans to ensure resident satisfaction and well-being.
🔍 December 2022: Inspection
The inspection report for Chartwell Pine Grove Long Term Care Residence focused on multiple critical incidents involving injuries of unknown cause, falls with significant injuries, and issues related to the prevention of abuse and neglect.
- Infection Prevention and Control Lead: The home was found non-compliant because it did not have a dedicated Infection Prevention and Control (IPAC) lead. The acting IPAC lead had primary responsibilities other than IPAC, which compromised the implementation of the IPAC program and potentially placed residents at risk of infectious diseases.
- Reporting Certain Matters to Director: The home failed to report alleged abuse of two residents to the Director immediately, as required. The delay in submitting a Critical Incident System report for the alleged abuse incidents contradicted the home’s own policies and regulatory requirements, indicating a significant lapse in protocol adherence.
🔍 April 2022: Complaints Inspection
The inspection at Chartwell Pine Grove Long Term Care Residence focused on a complaint related to housekeeping and responsive behaviours among residents. The inspection team, led by April Chan, also completed a mandatory Infection Prevention and Control (IPAC) checklist.
The inspection identified non-compliance in the management of responsive behaviours. Specifically, it was found that the home failed to identify and document behavioural triggers for a resident with cognitive and physical impairments who had a history of responsive behaviours. Clinical notes had indicated potential triggers related to social interactions with another resident, which were not captured in the care plan.
🔍 April 2022: Critical Incident Inspection
The inspection report for Chartwell Pine Grove Long Term Care Residence focused on falls prevention, following specific incidents logged in the system.
- Plan of Care: The facility failed to implement the specified fall prevention and management plan for a resident at risk of falls due to cognitive and physical impairments. Despite having a care plan that included three specific interventions, observations revealed that these interventions were not provided as outlined, putting the resident at risk for falls and potential injury.
To address this non-compliance, the facility was required to develop a Voluntary Plan of Correction to ensure that fall prevention and management interventions are effectively implemented for residents as specified in their care plans.