AgeCare Royal Oak (1750 Division Road North, Kingsville) is operated by AgeCare, a for-profit operator of long-term care homes in Canada. There are approximately 160 beds.
AgeCare Royal Oak is formerly owned and operated by Chartwell, a for-profit operator of senior accommodations in Canada. The facility was previously known as Chartwell Royal Oak Long Term Care Residence.
Our research team at Caring Magazine carefully reviewed and summarized inspection reports for AgeCare Royal Oak. You can read the original copies of the reports in the Government of Ontario website.
Inspection Reports for AgeCare Royal Oak
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.
🔍 October 2023: Inspection
The inspection at AgeCare Royal Oak, conducted by Jennifer Bertolin, Cassandra Taylor, Stacey Sullo and Adriana Congi, addressed multiple intakes related to responsive behaviors and fall prevention and management.
- Personal Assistant Services Device: The inspection found a failure to provide a Personal Assistant Services Device (PASD) as specified in a resident’s care plan, an essential fall prevention intervention. This was remedied by the licensee prior to the conclusion of the inspection.
- Falls Prevention and Management: The facility failed to comply with its Resident Falls Prevention policy by not completing a Scott Falls Risk Assessment after a resident experienced a significant fall. This oversight was identified as a risk to the resident’s safety due to the delay in assessment and implementation of necessary interventions.
- Behaviours and Altercations: The inspection found non-compliance with the Head Injury Routine (HIR) policy. After an altercation between two residents resulted in a head injury, a HIR was not completed for the injured resident, contrary to policy requirements.
- Additional Training for Direct Care Staff: There was a failure to ensure that all staff providing direct care to residents received annual falls prevention and management training. The incomplete training across staff members posed a risk to resident safety due to potential gaps in current falls prevention knowledge.
Each non-compliance issue was addressed through written notifications.
Inspection Reports for Chartwell Royal Oak 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.
🔍 April 2023: Inspection
The inspection at Chartwell Royal Oak Long Term Care Residence, completed by Christie Birch, Terri Daly and Jennifer Bertolin, addressed complaints, follow-ups, and critical incidents relating to falls prevention and management, and infection prevention and control. The inspection also reviewed compliance with previously issued orders.
- Infection Prevention and Control: A significant issue of non-compliance was identified concerning the IPAC standards. The facility failed to ensure staff adherence to the Minister’s Directive and COVID-19 guidance document for long-term care homes in Ontario, specifically regarding the requirement for all staff, students, and volunteers to wear a medical mask throughout their shifts indoors, irrespective of immunization status. Observations included six staff members in a nursing station not wearing masks properly, contrary to the expectation set by the Director of Care. This lapse was recognized as increasing the risk of infection transmission within the home.
The facility was found to be in compliance with previously issued orders, which were inspected by Terri Daly. These orders pertained to the legislation’s sections on operational and management standards.
🔍 March 2023: Inspection
The inspection at Chartwell Royal Oak Long Term Care Residence, conducted by Terri Daly, Cassandra Aleksic and Julie D’Alessandro, reviewed various complaints and critical incidents. This inspection focused on falls with injury, an unexpected death of a resident, concerns related to sufficient staffing, care, and services, and infection prevention and control among other issues.
- Plan of Care: An issue regarding the failure to revise a resident’s plan of care when their needs changed was identified and remedied by the licensee during the inspection. The plan of care was updated to reflect the resident’s current interventions.
- Resident’s Bill of Rights: The licensee did not fully respect a resident’s treatment choices as documented in their plan of care, specifically failing to provide a requested treatment. This was noted as a failure to uphold the resident’s rights.
- Sufficient Linen Supply: There was a failure to maintain a sufficient supply of clean peri-cloths for resident care. Despite the policy stating the need for adequate linen supplies, interviews revealed a shortage impacting care.
- Policy Compliance for Outdoor Courtyard Use: There was a failure to comply with the home’s policy on outdoor courtyard use, necessitating development of protocols for checking and monitoring courtyard doors and education for staff responsible for these checks.
Chartwell Royal Oak Long Term Care Residence was ordered to assess and ensure adequate outdoor lighting in courtyards for resident safety, maintaining records of assessments and any lighting replacements.
The facility was also ordered to ensure courtyard doors were equipped with locks to restrict unsupervised resident access, including auditing all exit doors leading to secure areas.
🔍 June 2022: Inspection
The inspection conducted at Chartwell Royal Oak Long-Term Care Residence, conducted by Cassandra Taylor, Ina Reynolds, Susan Crann, and Marian Keith, covered a range of critical incidents, complaints, and follow-ups related to falls prevention and management, nutrition and hydration, and housekeeping.
- Safe Storage of Drugs: The inspection identified a failure to securely store medications. Specifically, a medication room was found unlocked with a broken lock mechanism, leaving medications accessible. This breach was acknowledged by the Assistant Director of Care (ADOC) and the Director of Care (DOC), who confirmed that the door lock had been broken since April 23, 2022, and that some medications had been moved, but not all substances were secured properly. The home’s policies require medications to be stored in locked rooms or medication carts, which was not adhered to in this instance. This oversight posed a potential risk to residents who could access medications not prescribed to them. The broken door was fixed promptly once the issue was brought to management’s attention during the inspection.
The inspection also verified compliance with a previously issued order.
🔍 April 2022: Complaints Inspection
During the course of this inspection, Non-Compliances were not issued.
🔍 April 2022: Critical Incident Inspection
During a Critical Incident System inspection at Chartwell Royal Oak Long Term Care Residence, inspectors Debbie Warpula and Peter Hannaberg evaluated several critical incidents related to a resident fall resulting in a fracture, staffing issues, and staff-to-resident neglect.
- Neglect by PSWs: The inspection found that the facility failed to protect residents from neglect by two Personal Support Workers (PSWs). Allegations of neglect were reported but lacked detailed information on the extent of neglect or the outcomes of any investigations.
- Investigation and Response: The home’s policies on abuse and neglect were reviewed, highlighting a zero-tolerance approach. However, specific instances of neglect reported by a PSW, such as inadequate continence care and altered skin integrity, were not adequately investigated or resolved. Interviews with staff revealed that the alleged neglect was observed, but there was no thorough follow-up or communication with the reporting PSW.
The inspection led to the issuance of a compliance order, requiring Chartwell Royal Oak Long Term Care Residence to ensure all residents are protected from abuse and neglect, conduct thorough investigations, take appropriate actions in response to incidents, and properly document all incidents and investigations.