AgeCare West Williams (200 David Bergey Drive, Kitchener, Ontario) is operated by AgeCare, a for-profit operator of long-term care homes in Canada. There are approximately 160 beds.
AgeCare West Williams is formerly owned and operated by Chartwell, a for-profit operator of senior accommodations in Canada. The facility was previously known as Chartwell Westmount Long Term Care Residence.
Our research team carefully reviewed and summarized inspection reports for AgeCare West Williams. You can read the original copies of the reports in the Government of Ontario website.
Inspection Reports for AgeCare West Williams
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.
🔍 December 2023: Inspection
During an extensive on-site inspection at AgeCare West Williams, multiple intakes involving complaints and critical incidents were evaluated. The inspection, led by Janet Evans with assistance from Gurvarinder Brar, assessed various aspects of resident care, including skin and wound management, continence care, nutrition, infection control, and falls prevention.
The inspection identified a failure to protect residents from neglect, leading to a compliance order. This directive obligates AgeCare West Williams to safeguard residents from abuse and neglect by staff.
A pattern of neglect was identified, including: inadequate response to a resident’s changing condition and care needs; delayed skin assessments and absence of continence and pain assessments when needed; and inconsistencies in following the prescribed dietary supplements and inadequate follow-up on lab work results, impacting the resident’s well-being.
Inspection Reports for Chartwell Westmount 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: Critical Incident Inspection
The inspection for Chartwell Westmount Long Term Care Residence was completed by Yami Salam. This inspection scrutinized various complaints and critical incidents related to resident care, abuse, and the facility’s Falls Prevention and Management Program.
- Plan of Care: The licensee did not inform a resident and their Substitute Decision Maker (SDM) about changes in the resident’s care plan, hindering their participation in care decisions.
- Skin and Wound Care: Failures in weekly skin and wound assessments for two residents with altered skin integrity were noted.
- Pain Management: Initial interventions for a resident’s pain were ineffective, and no comprehensive pain assessment was conducted.
An administrative monetary penalty of $11,000 was issued to Chartwell for failing to protect a resident from physical abuse, marking the second penalty for similar non-compliance within three years. This penalty emphasizes the facility’s repeated failure to adhere to regulatory requirements.
Compliance orders were issued to ensure adherence to residents’ plans of care and to protect residents from abuse. These orders include retraining staff, auditing care plans, and revising policies to include recommendations for behavioral interventions.
🔍 May 2023: Inspection (Part 3)
The inspection for Chartwell Westmount Long Term Care Residence addressed complaints and critical incidents related to alleged neglect of a resident and concerns regarding the plan of care for another resident.
- Administration of Drugs: A hydration intervention for Resident #001 was administered at a higher flow rate than prescribed, putting the resident at risk of fluid overload. Medications for Residents #005, #006, and #007 were not administered within the correct time frame, potentially impacting their health. Specifically, medications were administered either over an hour early or over an hour late.
A medication audit by Registered Nurse revealed medication errors affecting 16 residents, with specific instances of early or delayed administration detailed for Residents #005, #006, and #007.
🔍 May 2023: Inspection (Part 2)
The inspection for Chartwell Westmount Long Term Care Residence addressed issues related to alleged improper care and neglect of residents.
- Falls Prevention and Management: The report indicates non-compliance in monitoring two residents (#002 and #003) as part of the falls prevention and management program. It was found that after unwitnessed falls, a Head Injury Routine (HIR) was not initiated as required, and reassessments using the Scott Fall Risk Assessment were not completed, potentially missing the opportunity to identify and mitigate future fall risks.
- Continence Care and Bowel Management: The licensee failed to assess resident #002’s continence care comprehensively, including causal factors, patterns, and type of incontinence. Additionally, the individualized care plan for continence for resident #002 was not implemented, leading to instances where the resident was not provided assistance with toileting, resulting in incontinence and potential risk of skin issues, injury, or infection.
- Dining and Snack Service: Resident #002 was not provided the necessary personal assistance and encouragement to eat safely and comfortably. Despite declining to go to the dining room for dinner and not being offered a meal tray in their room, the resident was left without adequate supervision or assistance during eating, risking lower nutritional intake or choking incidents.
Chartwell was directed to ensure compliance with established policies and regulations related to falls prevention and management, continence care, and dining and snack services.
🔍 May 2023: Inspection (Part 1)
The inspection report for Chartwell Westmount Long Term Care Residence focuses on critical incidents involving medication management and fall prevention. The inspection team was led by Kristen Owen.
- Duty to Protect: The report outlines a failure to protect resident #003 from neglect by staff. After a fall, an essential intervention to prevent further incidents was not implemented promptly, leading to another fall with injuries for the resident. This lapse in continuous monitoring and intervention implementation directly jeopardized the resident’s health.
- Medication Management System: There was a breach in compliance with the home’s medication management policies. Specifically, after administering medication to resident #003, the electronic Medication Administration Record (eMAR) was not signed as required. This oversight posed a risk for medication-related incidents due to the lack of proper documentation.
- Safe Storage of Drugs: The inspection found a failure to securely store controlled substances. An RPN was observed not adhering to protocols for storing a controlled substance, which should have been kept in a double-locked area but was instead placed in a less secure part of the medication cart during the administration round. This improper storage increased the risk of unauthorized access to the substance and potential medication errors.
The licensee was directed to rectify these failures by ensuring strict adherence to fall prevention strategies, medication management protocols, and secure drug storage practices.
🔍 March 2023: Inspection
The inspection report for Chartwell Westmount Long Term Care Residence was conducted due to complaints and critical incidents related to resident neglect. The inspection focused on continence care, skin and wound prevention and management, infection prevention and control, prevention of abuse and neglect, staffing, training, care standards, and falls prevention and management.
- Failure to Protect: The licensee was found non-compliant for failing to protect a resident from neglect, demonstrating a pattern of inaction that jeopardized the resident’s health, safety, and well-being. Over a three-month period in 2022, a resident experienced a functional decline in health status without an appropriate response or intervention from the care staff.
- Continence Care and Falls Prevention: The report highlighted issues with continence care management and falls prevention. Despite a documented deterioration in the resident’s bowel and bladder continence status, recommended toileting protocols were not implemented, and the resident continued to experience unwitnessed falls without adequate follow-up assessments or interventions.
- Surveillance Monitoring: Video surveillance revealed instances where the resident was left unattended and unassisted, leading to falls and injuries. Notably, there was a failure to complete a skin and wound assessment for a visible head injury and inadequate monitoring post-fall.
- Documentation and Policy Compliance: The inspection identified failures in complying with home policies on skin and wound assessments, head injury routines, and specified care interventions. Incomplete documentation and lack of adherence to care plans and safety checks were also noted.
