Seven Oaks (9 Neilson Road, Scarborough), also known as the Seven Oaks Home for the Aged or Seven Oaks Long-Term Care Home, is operated by the City of Toronto. It has a capacity of approximately 250 beds.
In 2005, Seven Oaks experienced an outbreak of Legionnaires’ disease, a type of pneumonia. A total of 135 people were infected: 70 residents, 39 staff, 21 visitors, and 5 people who lived or worked near the home. 23 residents died. For the first 10 days, the cause of the outbreak was unknown.
In 2014, Madame Justice Barbara Conway approved the deal between the plaintiffs in the class action suit against the province of Ontario and the city of Toronto. Under the settlement terms, eligible class members received up to $30,000 in base payments, depending on the extent of their illness. Surviving family members received up to $20,000. Those stricken with the less severe Pontiac fever were awarded $500.
November 2023 🔎
The inspection, led by Britney Bartley, took place over several days in October 2023.
- Non-Compliance with Plan of Care: The home failed to reassess and revise a resident’s care plan when their care needs changed, particularly in managing their responsive behaviors. The resident, who demonstrated such behaviors over several months, was involved in altercations with another resident. The staff, including Personal Support Workers and Registered Nurses, did not have clear directives on handling these behaviors until after the resident was found with potential injuries. This failure posed a risk of inadequate management of the resident’s behaviors.
- Inadequate Communication with Substitute Decision-Maker: The home also failed to properly inform a resident’s substitute decision-maker (SDM) about an altercation involving another resident. Although a Registered Nurse attempted to contact the SDM, the effort was not documented, and the SDM was left uninformed until they inquired about the incident six days later. This lack of communication may have delayed the SDM’s participation in developing the resident’s care plan.
September 2023 🔎
The inspection, led by Fiona Wong and Cindy Cao, took place from August 28 to September 1, 2023.
- Compliance Order: A previously issued Compliance Order related to the Fixing Long-Term Care Act, 2021, section 24 (1), was found to be in compliance.
- Non-Compliance in Skin and Wound Care: The home failed to properly assess two residents using a clinically appropriate assessment instrument for skin and wound assessment when they exhibited altered skin integrity. In one case, a Registered Practical Nurse (RPN) began but did not complete the assessment. In another instance, the assessment was not completed at all after the resident sustained altered skin integrity. This failure was confirmed by interviews with three RPNs and the Director of Care (DOC). This lack of proper assessment delayed the identification and treatment of the residents’ skin conditions.
May 2023 🚨
The inspection, led by Fiona Wong and Ann McGregor, involved several complaints and critical incidents. The inspection report was amended due to software issues.
- Plan of Care – Nutritional Care: The staff failed to collaborate effectively in the development and implementation of a resident’s nutritional care plan. Despite a dietitian’s recommendations to manage a resident’s nutritional risk, the interventions were frequently refused, and no action was taken to address these refusals.
- Responsive Behaviours: The home did not comply with its policy on managing responsive behaviours. Staff failed to complete necessary monitoring tools and referrals for a resident exhibiting new or worsening behaviour.
- Emergency Plans: Staff did not adhere to the “Code Blue Procedure During COVID-19 Pandemic” policy during a medical emergency. The first nurse on the scene inappropriately left the resident to call 911, contrary to the policy.
- Plan of Care – Clear Directions: The plan of care for a resident with a history of responsive behaviours contained contradictory interventions, causing confusion among staff.
- Compliance Order: A compliance order was issued due to a failure to protect a resident from physical abuse and neglect. Specific actions were mandated, including staff education and auditing, with a compliance deadline of August 11, 2023. An Administrative Monetary Penalty of $5500 was also imposed.
February 2023 🔎
The inspection was conducted by Sami Jarour, Rita Lajoie, Joanne Zahur, and Deborah Nazareth.
- Non-Compliance Remedied: Issues of non-compliance, particularly regarding visitor logs not including contact information, were remedied during the inspection. The IPAC lead updated the visitor logs to include this information.
- Infection Prevention and Control: There was a failure to comply with Universal Masking requirements in a common area, posing a potential risk of infection transmission.
- Reporting and Complaints: The home did not respond adequately to a written complaint, failing to explain why the complaint was considered unfounded.
- Reporting Critical Incidents: The home did not inform the Director within one business day of a resident’s fall that led to hospitalization and significant change in status.
- Behaviours and Altercations: The home failed to develop and implement strategies to manage a resident’s responsive behaviours, which led to harm to another resident.
- Medication Management System: There were lapses in documenting medication administration, potentially risking resident safety.
- Plan of Care: The home was ordered to review and audit care related to falls prevention and toileting for a resident who was not constantly monitored, leading to an injury.
July 2022 🚨
The inspection, led by Jennifer Batten, took place over multiple days in June 2022 and involved follow-up on a previous Compliance Order and a critical incident involving a resident’s attempted suicide.
Key issues identified include non-compliance with regulations concerning the safe and secure environment, specifically an unlocked door leading outside, which was rectified during the inspection. Concerns were also raised about the inadequacy of dining room furnishings for resident comfort and safety during meals, and lapses in serving meals at safe and palatable temperatures, risking residents’ enjoyment and safety.
Additionally, the report highlighted failures in medication management, particularly in administering insulin in accordance with prescriber instructions, and in securely storing medication and treatment creams. These issues pose significant risks to resident health and safety.
The inspection also revealed failures in providing assistance during meals, with several residents served meals without available staff assistance. In terms of personal care, the report noted improper positioning of residents during meals, increasing risks of choking and aspiration.
March 2022 🚨
The inspection report, completed by Ama Agyemang, focused on a Complaint inspection. Additionally, the inspection was in response to a declared COVID-19 outbreak at the facility.
A significant finding from the inspection was a non-compliance issue, which requires staff participation in the implementation of the infection prevention and control program. Specifically, the inspection noted instances of non-compliance, such as RPN #108 not adhering to the four moments of hand hygiene after removing garbage and before interacting with residents. Additionally, staff were observed not following the elevator capacity requirement, potentially increasing the risk of infection transmission.
As a result of these findings, a Written Notification (WN) of non-compliance was issued. The licensee was requested to prepare a voluntary plan of correction to ensure staff compliance with the infection prevention and control program.
July 2021 🔎
The inspection report, conducted by Susan Semeredy, focused on a Critical Incident System inspection.
- Window Safety: The facility failed to comply with the regulation ensuring that windows accessible to residents could not be opened more than 15 centimeters. This non-compliance was highlighted by an incident where a resident exited through a bedroom window into a secured courtyard and then left the courtyard due to an open gate, a result of ongoing yard work.
- Hazardous Substances: The report identified a failure to keep hazardous substances inaccessible to residents. This was exemplified by an unattended housekeeping cart on the fourth floor, which contained cleaning chemicals accessible to residents.
- Infection Prevention and Control: The facility did not ensure staff participation in the infection prevention and control program. Specific instances included a housekeeper entering a designated isolation room without appropriate personal protective equipment (PPE), and a PSW entering the same room to retrieve a meal tray without the necessary PPE.
For each area of non-compliance, the licensee was requested to prepare a voluntary plan of correction.
June 2021 🚨
The inspection report, completed by Jack Shi, was a Critical Incident System inspection carried out on June 7-10, 2021. The inspection focused on various critical incidents, including an allegation of improper treatment of a resident and several incidents related to falls.
- Infection Prevention and Control: The facility failed to comply with Directive #3 from the Chief Medical Officer of Health, which outlines specific precautions and procedures for COVID-19. This included staff and visitors not wearing eye protection within 2 meters of residents, improper use of masks, and failure to adhere to gown requirements in contact/droplet precaution areas. These lapses in protocol posed a risk of transmitting infectious diseases.
- Plan of Care: The facility did not follow a resident’s care plan related to fall prevention interventions. The Personal Support Worker (PSW) acknowledged not applying the intervention, despite being aware it was part of the resident’s care plan. Another case involved a PSW not following a resident’s care plan during provision of care, resulting in the resident’s fall and injury.
- Safe Transferring Techniques: The facility failed to ensure safe transferring techniques were used by a PSW and Registered Nurse (RN) following a resident’s fall, potentially aggravating the resident’s injury.
- Air Temperature Monitoring: The facility did not measure and document air temperatures in one common area on every floor of the home, as required.
- Critical Incident Reporting: The facility failed to include the names of all staff members involved in a resident’s fall in the Critical Incident System (CIS) report.
The inspection resulted in the issuance of five Written Notifications (WNs), two Voluntary Plans of Correction (VPCs), and one Compliance Order (CO).
February 2021 ✅
There were no findings of non-compliance. The report was completed by Romela Villaspir.
January 2021 🔎
The inspection was carried out by Romela Villaspir, and it involved a thorough evaluation of the Infection Prevention and Control (IPAC) practices at the facility.
- Non-Compliance with IPAC Program: The facility failed to ensure staff participation in the implementation of the IPAC program. This was evident in several observations, such as staff and residents not wearing masks or not practicing hand hygiene properly, and a lack of appropriate signage and PPE use.
- Observations of IPAC Practices: The inspector noted several instances of non-compliance, including residents without masks in common areas, improper donning and doffing of PPE by staff, and inadequate distancing between residents.
- Critical Incident Report: A report submitted by the home related to the suspected outbreak indicated that measures were implemented on a specific floor, but the inspection revealed lapses in these measures.
As a result of these findings, the facility received one Written Notification (WN) and one Compliance Order (CO). The order emphasized the need for strict adherence to IPAC practices, including proper hand hygiene, use of PPE, and maintaining physical distancing, especially in outbreak situations.
This inspection highlighted the critical importance of rigorous infection control measures in long-term care facilities, particularly during outbreaks, to protect the health and safety of residents and staff. The facility was required to address these issues promptly to comply with regulatory standards.
November 2020 🚨
The inspection conducted by Moses Neelam was a Critical Incident System inspection, covering multiple dates from October 20 to November 4, 2020.
The inspection found that previously issued compliance orders were being followed, but there were new instances of non-compliance that needed to be addressed.
- Failure to Protect from Abuse: The home failed to protect resident #012 from abuse by resident #008. Incidents of inappropriate interactions between residents were noted, where consent could not be clearly determined due to cognitive impairments. The licensee’s failure to protect these residents from potential abuse was a significant concern.
- Unsafe Transferring Techniques: There was a failure to ensure safe transfer techniques for resident #006 using a mechanical lift. This incident involved improper application of the sling, leading to the resident slipping, falling, and sustaining an injury that required hospital intervention.
The facility received two Written Notifications (WNs), one Voluntary Plan of Correction (VPC), and one Compliance Order (CO) as a result of this inspection. These addressed various areas of concern including duty to protect residents from abuse and ensuring the use of safe transferring and positioning techniques.
January 2020 ✅
There were no findings of non-compliance. The report was completed by Susan Semeredy and Jack Shi.
December 2019 🚨
The inspection conducted by Amandeep Bhela, Angiem King, and Susan Semeredy was a complaint-based inspection held from November 27 to December 10, 2019.
- Allegations of Abuse: The inspection investigated three logs related to abuse. It was found that the facility failed to comply with its written policy promoting zero tolerance of abuse and neglect of residents. A particular incident involved a resident (resident #001) alleging physical abuse from a Personal Care Attendant (PCA #115). The incident was not immediately reported by staff members as required, despite the resident’s complaints to various staff members.
- Failure to Investigate and Act: The licensee did not promptly investigate the alleged abuse incident and take appropriate action. This non-compliance was highlighted in the interaction between resident #001 and PCA #115, where the resident reported rough handling during care. The home’s response to these allegations was not in accordance with its policy and regulatory requirements.
- Individualized Personal Care: There was a failure in providing individualized personal care, including hygiene care and grooming, on a daily basis. Resident #001 reported discomfort and pain during peri-care provided by PCA #115, but their care plan did not include any specific interventions for their sensitivity.
The facility received three Written Notifications (WNs) and was requested to prepare three Voluntary Plans of Correction (VPCs).