AgeCare Wenleigh (2065 Leanne Boulevard, Mississauga) is operated by AgeCare, a for-profit operator of long-term care homes in Canada. There are approximately 160 beds.
AgeCare Wenleigh is formerly owned and operated by Chartwell, a for-profit operator of senior accommodations in Canada. The facility was previously known as Chartwell Wenleigh Long Term Care Residence.
Our research team carefully reviewed and summarized inspection reports for AgeCare Wenleigh. You can read the original copies of the reports in the Government of Ontario website.
Inspection Reports for AgeCare Wenleigh
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 for AgeCare Wenleigh, completed by Daria Trzos and Parminder Ghuman, focused on resident care, medication management and falls prevention.
- Falls Prevention: The inspection identified a failure to reassess and revise care plans post-fall incidents, particularly when initial interventions proved ineffective. This lapse in adapting care strategies potentially increased the risk of further injuries.
- SDM Involvement: The home did not fully involve a resident’s substitute decision-maker in the care planning process, especially concerning altered skin integrity, which denied the family the opportunity to participate in the resident’s care.
- Care Plan: Specific instances were noted where the care provided diverged from the established care plans, particularly regarding toileting assistance and pain assessment, leading to increased risks and injuries for the residents involved.
- Complaints Handling: Written care concerns brought forward by a resident’s family were not appropriately investigated or resolved, nor were they forwarded to the Director as required, indicating a failure in the home’s complaints handling process.
- Controlled Substance Management: The inspection revealed issues in the management and storage of controlled substances, including failures in shift change narcotics counting and immediate reporting of missing narcotics, which posed risks for medication errors and unsafe storage practices.
- Staff Training: A significant percentage of direct care staff had not received mandatory annual training on falls prevention, highlighting a gap in staff education and preparedness to effectively mitigate fall risks among residents.
Inspection Reports for Chartwell Wenleigh 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.
🔍 June 2023: Inspection
The inspection for Chartwell Wenleigh Long Term Care Residence, led by Inspector Parminder Ghuman, focused on complaints and critical incidents involving potential neglect, improper care, and issues with skin and wound care, dehydration, bathing, oral care, personal care, residents’ drug regimes, oxygen care, and falls prevention.
- Forwarding Complaints: The facility did not immediately forward a written complaint received in January 2022 about the care of a resident to the Director, a lapse that could potentially expose residents to harm due to neglect.
- Reporting of Investigations: In reporting an incident of potential neglect and improper skin/wound care, the facility failed to provide a comprehensive account, including descriptions of the incident, individuals involved, actions taken, and follow-up actions, as required by regulation.
🔍 February 2023: Inspection
The inspection for Chartwell Wenleigh Long Term Care Residence, led by Kehinde Sangill, focused on a critical incident involving unwitnessed falls resulting in injury.
- Infection Prevention and Control (IPAC): The IPAC lead failed to ensure compliance with the IPAC Standard for Long-Term Care Homes, specifically regarding the provision and use of 70-90% Alcohol-Based Hand Rub (ABHR). Expired ABHR bottles were discovered, posing a low risk to residents as non-expired ABHR was available.
- Hand Hygiene (HH) Program Issues: Observations revealed the use of non-alcohol-based products for resident hand hygiene (HH) before meals, contrary to IPAC standards requiring 70-90% ABHR. This increased the risk of infectious disease transmission.
- Minister’s Directive: The home did not comply with the directive requiring IPAC audits every two weeks when not in an outbreak, conducting audits 19 days apart instead.
- Resident Records: The home failed to keep a resident’s written record up to date, documenting temperatures under a previous room occupant’s name for three weeks without an alternative record for the new resident.
- Routine Practices and Additional Precautions: The proper use of Personal Protective Equipment (PPE) was not ensured, with observed misuse of PPE by staff, including wearing used PPE in inappropriate settings and failing to follow the correct donning and doffing sequences.
🔍 September 2022: Inspection
The inspection for Chartwell Wenleigh Long Term Care Residence, conducted by Adelfa Robles, focused on a critical incident system inspection related to fall with injury, infection prevention and control (IPAC), and restraint/personal assistance services devices (PASD) management.
- Plan of Care: A resident’s plan of care was updated to include a positioning device used for falls prevention, addressing an oversight where the device was not previously indicated in the plan. Another resident’s plan of care was revised to reflect the discontinuation of a therapeutic device no longer in use, ensuring the resident’s current care needs were accurately documented.
- Plan of Care: A resident was observed not wearing a safety device specified in their plan of care for fall prevention. The staff’s failure to follow the plan of care increased the risk of injury from falls.
- Physical Restraining: Observations indicated a resident was restrained with a physical device without a physician’s order or consent, raising concerns about potential agitation and confusion due to the restraint. Another instance of non-compliance involved a resident’s PASD not being removed when not in use, contrary to policy, potentially increasing restlessness.
- IPAC Program Compliance: There were failures in ensuring environmental controls for residents requiring additional IPAC precautions, specifically the lack of gloves at the point of care. Staff did not adhere to hand hygiene protocols before and after contact with a resident and their environment, raising the risk of infection transmission.
- Minister’s Directive: The licensee did not fully comply with COVID-19 screening measures as required, potentially exposing residents and staff to increased risk of COVID-19.
🔍 October 2021: Critical Incident Inspection
The inspection for Chartwell Wenleigh Long Term Care Residence, conducted by Slavica Vucko, investigated reports related to hospitalization due to changes in a resident’s health status and falls prevention.
A notable issue was identified with the home’s compliance with regulations that require staff to use safe transferring and positioning devices or techniques when assisting residents. The inspection revealed a failure in adhering to this requirement, particularly with resident #001, who sustained an injury from an unknown cause requiring hospital treatment.
Resident #001 was not transferred safely according to their plan of care, which specified the need for two staff members during all transfers and the use of a sit-stand lift when necessary. However, on two separate occasions, transfers were conducted by a single staff member, leading to the resident’s injury.
The licensee was issued a Written Notification (WN) and requested to prepare a Voluntary Plan of Correction (VPC) to ensure compliance with the requirement for safe transferring and positioning of residents.
🔍 January 2021: Complaints Inspection
During the course of this inspection, Non-Compliances were not issued.
🔍 January 2021: Critical Incident Inspection
The inspection for Chartwell Wenleigh Long Term Care Residence, conducted by Janet Groux, evaluated compliance with the Fall Prevention and Management Program following incidents reported through Log #016361-20.
The report highlighted a failure to comply regulations, specifically relating to policies, procedures, and records. The home did not adhere to its Falls Prevention and Management policies and procedures for residents #002, #003, and #005.
It was noted that when a Head Injury Routine (HIR) was initiated following falls, the required assessments were not completed as scheduled for 48 hours post-fall. This lapse was identified for three residents, indicating a systemic issue in managing unwitnessed falls and monitoring residents for potential injuries.
Additionally, the Substitute Decision Maker (SDM) for resident #002 was not notified of the fall, contradicting the home’s policy and procedures designed to ensure that families are informed about significant incidents affecting residents.
A Written Notification (WN) was issued, and the licensee was requested to prepare a Voluntary Plan of Correction (VPC).