AgeCare Woodhaven (380 Church Street, Markham, Ontario) is operated by AgeCare, a for-profit operator of long-term care homes in Canada. There are approximately 190 beds.
AgeCare Woodhaven is formerly owned and operated by Chartwell, a for-profit operator of senior accommodations in Canada. The facility was previously known as Chartwell Woodhaven Long Term Care Residence.
Our research team carefully reviewed and summarized inspection reports for AgeCare Woodhaven. You can read the original copies of the reports in the Government of Ontario website.
Inspection Reports for AgeCare Woodhaven
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 Woodhaven, conducted by Angie King and Asal Fouladgar, focused on a range of issues, including responsive behaviours, falls prevention and management, and a series of complaints related to various aspects of care.
- Plan of Care: The inspection identified failure to review and revise a resident’s plan of care upon reassessment when their care needs changed. The issue centered on a resident’s personal care aids, where the resident’s behavior of removing and hiding their personal aid was not documented in their plan of care. Observations and staff interviews revealed instances where the resident removed and misplaced their personal aid, including one incident where it was found in a beverage and another where it was found in the resident’s undergarment.
Following discussions with the inspection team, a Registered Practical Nurse (RPN) updated the resident’s plan of care to include the behavior of removing and hiding their personal aid along with corresponding interventions.
The Resident Care Coordinator (RCC) acknowledged that this behavior, identified in the resident’s Minimum Data Set (MDS) assessment, had been overlooked in the previous plan of care revision.
The update was made on September 29, 2023, effectively addressing the non-compliance issue. The inspector concluded that the non-compliance was remedied by the licensee before the end of the inspection
Inspection Reports for Chartwell Woodhaven 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.
🔍 February 2023: Inspection
The inspection for Chartwell Woodhaven Long Term Care Residence, conducted by Rita Lajoie and Angie King, covered issues such as misuse of resident’s money, responsive behaviours, improper resident care, and falls.
- Resident Care: The licensee failed to report immediately to the Director about the improper care of resident #003, which was brought to attention through a complaint from the resident’s Power of Attorney (POA). The complaint alleged injury to the resident by staff, but a Critical Incident System (CIS) report was submitted two days later. The delay in reporting was acknowledged as a mistake by the Interim Director of Care (DOC)/Nursing Corporate Consultant.
- Report Inclusions: Two instances of non-compliance were identified related to the content of reports made to the Director. Both instances involved failing to include the names of staff members who were present at and responded to an incident. This lack of detailed reporting was confirmed in an interview with the interim DOC/Nursing Corporate Consultant.
🔍 June 2022: Inspection (Part 2)
The inspection for Chartwell Woodhaven Long Term Care Residence, conducted by Lucia Kwok, Asal Fouladgar, Najat Mahmoud and Rexel Cacayurin, addressed multiple complaints about resident care.
- Communication and Response System: The inspection identified a failure in ensuring the resident-staff communication system was accessible, evidenced by a malfunctioning call bell.
- Nutrition Care and Hydration Programs: There was a lapse in recording a resident’s weight during a specified month, which is crucial for monitoring health and well-being.
- Orientation: Agency staff were not provided with required training, specifically on the home’s zero tolerance policy for abuse and neglect, within the mandated timeframe.
- Plan of Care: The care plan did not reflect a resident’s needs and preferences as per their SDM’s request for bed positioning. Secondly, documentation was missing in the provision of care set out in the plan of care, especially during an outbreak period.
- Administration of Drugs: A medication was administered to a resident without a proper prescription, indicating a breach in medication administration protocols.
- Policy to Promote Zero Tolerance: The home failed to comply with its written policy to promote zero tolerance of abuse and neglect, specifically in handling a report of inappropriate treatment of a resident.
- Transferring and Positioning Techniques: Unsafe positioning techniques were used with a resident’s assistive device, contrary to recommendations for their comfort and safety.
🔍 June 2022: Inspection (Part 1)
The inspection for Chartwell Woodhaven Long Term Care Residence, conducted by Moses Neelam, Lucia Kwok, Asal Fouladgar, Rexel Cacayurin and Najat Mahmoud, covered a range of complaints, follow-up actions, and critical incidents. The inspection addressed issues concerning significant changes in resident conditions, abuse, infection control and prevention, and compliance with previously issued orders.
- Infection Prevention and Control (IPAC): The facility failed to implement the IPAC standard issued by the Director. The inspection revealed expired alcohol-based hand rub (ABHR) across different units and instances of improper mask use by staff, posing a risk of infection spread.
The inspection confirmed compliance with previously issued orders related to infection control and prevention, as well as abuse, demonstrating the facility’s efforts to address specific regulatory requirements.
🔍 February 2022: Complaints Inspection (Part 2)
The inspection for Chartwell Woodhaven Long Term Care Residence, conducted by Moses Neelam, was focused on a complaint regarding various care issues.
- Plan of Care: The licensee did not ensure that the resident’s substitute decision-maker was given the opportunity to participate fully in the implementation of the resident’s plan of care. This was highlighted by a complaint regarding the administration of a treatment that was refused by the Power of Attorney (POA) but was administered due to a miscommunication, resulting in a treatment being given without consent.
A Voluntary Plan of Correction was requested to ensure that the resident, their substitute decision-maker, and any other designated persons are given the opportunity to participate fully in the development and implementation of the resident’s plan of care.
🔍 February 2022: Complaints Inspection (Part 1)
The inspection for Chartwell Woodhaven Long Term Care Residence, conducted by Moses Neelam, involved an extensive review of various care aspects, including abuse, falls, medical condition, safe positioning, appropriate diagnostics, functioning equipment, infection control, food, and medication administration.
- Protecting Residents from Abuse: The inspection identified instances where the licensee did not protect residents from physical and emotional abuse. This included altercations between residents leading to injury and inappropriate comments and actions by staff towards residents, negatively impacting their well-being.
- Plan of Care: There were shortcomings in ensuring that residents’ written plans of care included all necessary interventions and care details as mandated. Missing interventions in the care plan posed a risk to residents not receiving needed care.
- Transferring and Positioning: The licensee failed to ensure safe transferring and positioning devices or techniques were used when assisting residents. This non-compliance highlighted risks of injury to residents due to unsafe care practices.
- Dining and Snack Service: Issues were found with the temperature of food and fluids served, not meeting the requirements of being safe and palatable. This resulted in residents missing meals due to the unpalatable temperature of the food.
A Compliance Order was issued to address failures in protecting residents from abuse, requiring re-training for staff on proper communication and care approaches and ensuring interventions are documented and followed as per the residents’ care plans.
Voluntary Plans of Correction (VPCs) were requested for the deficiencies in the written plan of care for residents, safe transferring and positioning of residents, and ensuring food and fluids are served at appropriate temperatures.
🔍 February 2022: Critical Incident Inspection
The inspection for Chartwell Woodhaven Long Term Care Residence, conducted by Lucia Kwok, included a follow-up on a previously issued Compliance Order related to the availability of fall prevention equipment and investigated logs related to alleged staff-to-resident abuse and a significant change in a resident’s condition.
- Infection Prevention and Control (IPAC) Program: The inspection identified failures in the implementation of the IPAC program, notably in the appropriate use of Personal Protective Equipment (PPE), staff hand hygiene practices, availability of PPE, and the disposal of soiled linen. These failures were observed during a COVID-19 outbreak at the facility, highlighting a significant risk of infectious agent transmission.
- Reporting Abuse Incidents: The licensee did not immediately report two alleged staff-to-resident abuse incidents to the Director as required, demonstrating a delay in addressing potential abuse situations.
- Skin and Wound Care: There were failures in ensuring that residents at risk of altered skin integrity received timely skin assessments upon their return from the hospital. This oversight put residents at risk of not receiving prompt treatment and monitoring for their skin conditions.
- Dining and Snack Service: Proper techniques to assist residents with eating were not consistently used, putting residents at risk for choking due to improper feeding assistance techniques.
A Compliance Order was issued to address the IPAC program’s failures, requiring immediate corrective actions such as on-the-spot education for staff and visitors not adhering to IPAC measures, ensuring PPE caddies are fully stocked, and conducting audits on PPE usage and soiled linen disposal processes.
Voluntary Plans of Correction (VPC) were requested for the non-compliance issues related to reporting abuse incidents and skin and wound care assessments, emphasizing the need for immediate reporting of abuse suspicions and ensuring thorough skin assessments for residents at risk.