AgeCare Willowgrove

AgeCare Willowgrove (1217 Old Mohawk Road, Ancaster, Ontario) is operated by AgeCare, a for-profit operator of long-term care homes in Canada. There are approximately 160 beds.

AgeCare Willowgrove is formerly owned and operated by Chartwell, a for-profit operator of senior accommodations in Canada. The facility was previously known as Chartwell Willowgrove Long Term Care Residence.

Our research team at Caring Magazine carefully reviewed and summarized inspection reports for AgeCare Willowgrove. You can read the original copies of the reports in the Government of Ontario website.

Inspection Reports for AgeCare Willowgrove

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.

At this time, there are no inspection reports for AgeCare Willowgrove.

Inspection Reports for Chartwell Willowgrove 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

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.

🔍  May 2023: Inspection

The inspection for Chartwell Willowgrove Long Term Care Residence, conducted by Barbara Grohmann, Patrishya Allis and Carla Meyer, was in response to both a complaint and critical incidents involving continence care and falls prevention and management.

• Continence Care: An issue with the continence care product list was resolved by consolidating information into a single, updated list to avoid confusion among staff, particularly those unfamiliar with the unit.
• Directive by Minister: The inspection identified a failure to adhere to Minister’s Directives regarding Infection Prevention and Control (IPAC) audits. The lapse was acknowledged by the IPAC lead, highlighting a gap in the audit schedule during a period not affected by an outbreak, potentially impacting the home’s ability to meet minimum IPAC requirements.
• Care Plans and Plans of Care: A resident’s care plan lacked a falls prevention focus and interventions after a fall occurred, not updated until after a second fall that resulted in hospitalization. This oversight was recognized by the Assistant Director of Care, a Registered Nurse, and the Resident Assessment Instrument (RAI) Coordinator, indicating a missed opportunity to implement necessary interventions to reduce fall risk.
• General Requirements for Programs: The facility failed to document actions related to the nursing and personal support services program for a resident as required, including bladder continence, bowel movements, and toilet use, potentially leading to inconsistent care.

🔍  January 2023: Critical Incident Inspection

The inspection report for Chartwell Willowgrove Long Term Care Residence, conducted by Stephanie Smith, Emma Volpatti and Jobby James, focused on falls prevention and management, and infection prevention and control (IPAC).

• Infection Prevention and Control: Incorrect signage regarding additional precautions for a resident was updated to reflect the correct precautions required. This correction was made without posing any risk to the resident, as the initial signage indicated more precautions than necessary.
• IPAC Standards: The facility failed to implement the IPAC Standard correctly, particularly in adhering to additional precautions including the use of appropriate PPE. A PSW entered a resident’s room without the required N95 mask, indicating a breach of the IPAC protocol. This oversight posed a risk of infection spread within the facility.
• Expired Hand Hygiene Products: During the ongoing COVID-19 outbreak at the facility, inspectors found that alcohol-based hand rub (ABHR) used in various care areas was expired, compromising effective hand hygiene practices. The use of expired ABHR, particularly in outbreak situations, increased the risk of infectious agent transmission among residents and staff.

🔍  April 2022: Complaints Inspection

The inspection for Chartwell Willowgrove Long Term Care Residence addressed multiple complaints and a follow-up on a previously issued Compliance Order. The inspection focused on resident neglect, pain and medication management, weight loss, and complaint procedures. The inspection team included Romela Villaspir, Jessica Bertrand, and Nuzhat Uddin.

• Collaboration for Care: The inspection identified failures in staff collaboration across different aspects of care for two residents, particularly in continence care, leading to potential safety risks.
• Participation in Plan of Care: The Substitute Decision-Makers (SDMs) of two residents were not fully involved in the development and implementation of the residents’ care plans, which contradicted the residents’ bill of rights.
• Pain Management and Medication: There was a failure in adhering to pain management strategies for a resident, including not following non-pharmacological interventions recommended after medication was ineffective.
• Complaint Handling: The facility did not adequately handle verbal and written complaints concerning resident care, failing to investigate or provide responses within the required timeframe.
• Infection Prevention and Control (IPAC): Staff did not fully participate in the IPAC program, notably in the correct use of Personal Protective Equipment (PPE) and hand hygiene practices, posing a risk of spreading infections.
• Respect for Residents’ Dignity: A resident’s right to be treated with respect and dignity, particularly regarding personal preferences in dressing, was not upheld.
• Continence Care and Management: There was a lack of comprehensive assessment and individualized care planning for a resident’s continence care needs.

The facility was requested to prepare written plans of correction to address the identified non-compliances.

🔍  July 2021: Complaints Inspection

The inspection report for Chartwell Willowgrove Long Term Care Residence was conducted by inspectors Phyllis Hiltz-Bontje and Leah Curle. This inspection was initiated due to complaints and covered multiple areas including falls, infection prevention and control, skin and wound care, abuse, and responsive behaviour.

• Plan of Care: The inspection identified failures in reviewing and revising residents’ plans of care when their needs changed, particularly after incidents like falls which resulted in injuries. This lack of action increased the risk of further injuries.
• Falls Prevention Program: The facility did not comply with its “Resident Falls Prevention Program,” which required identifying logos on residents’ mobility aids and at their room entrances to signal a high risk of falling. The absence of such identification could lead to situations where residents might fall and injure themselves.
• Personal Assistance Services Devices (PASD) Requirements: The facility failed to ensure the use of PASDs only after meeting specific criteria, such as trying alternatives, which limited residents’ freedom of movement and negatively impacted their ability to socialize.
• Directive by Minister: The facility did not comply with the Minister’s Directive on COVID-19 Surveillance Testing and Access to Homes, specifically failing to follow proper procedures for antigen testing, which posed a risk to residents.
• Infection Prevention and Control Program: Staff did not fully participate in the infection prevention and control (IPAC) program, especially in ensuring resident hand hygiene during snacks, increasing the risk of infection transmission.
• Skin and Wound Care: The facility did not reassess residents with altered skin integrity as required, potentially compromising wound care and healing.

The facility was ordered to comply regarding the review and revision of residents’ care plans. Training for registered staff and the development of an auditing tool to ensure compliance were mandated.

Voluntary plans of correction were requested for other non-compliances, including adherence to the falls prevention program, ensuring PASD criteria satisfaction, following operational directives by the Minister, and participating in the IPAC program.

🔍  July 2021: Critical Incident Inspection

The inspection report for Chartwell Willowgrove Long Term Care Residence, conducted by inspectors Phyllis Hiltz-Bontje and Leah Curle, focused on resident abuse, falls, and a missing resident incident.

• Safety and Security Failures: There were multiple instances where the home failed to ensure a safe and secure environment. This included not maintaining isolation for newly admitted residents, failing to uphold active COVID-19 screening protocols, and not addressing a resident’s identified responsive behavior, putting their safety at risk.
• Care Plans: The report pointed out failures in revising care plans when necessary, particularly concerning falls and responsive behaviors that resulted in injury or posed significant risks to the residents.
• Protecting Residents from Abuse: There were instances of emotional abuse by staff that were not immediately investigated or reported, contravening the home’s duty to protect residents from abuse and neglect.
• Investigation and Reporting: The licensee did not immediately investigate alleged abuse incidents or report them to the Director as required, indicating a significant lapse in compliance with regulatory requirements.
• Temperature Monitoring Protocols: The home failed to measure and document the temperature in resident rooms as mandated, raising concerns about the potential risk of heat-related illnesses.

The findings highlighted failures in multiple aspects of care and safety, leading to the issuance of eight Written Notifications and six Voluntary Plans of Correction.