Sunset Manor

Sunset Manor (49 Raglan Street, Collingwood) is a nursing home that is owned and operated by Simcoe County. There are approximately 280 beds.

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Inspection Reports for Sunset Manor

Our research team carefully reviewed and summarized inspection reports for Sunset Manor. You can read the original copies of the reports in the Government of Ontario website.

September 2023: Inspection

During the course of this inspection, the inspectors made relevant observations, reviewed records and conducted interviews, as applicable. There were no findings of non-compliance.

July 2023: Inspection

The inspection at Sunset Manor, by inspectors Katherine Adamski, Craig Michie, Amanpreet Kaur Malhi, and Alicia Campbell, identified multiple areas of non-compliance.

The inspection focused on various critical incident intakes related to abuse, neglect, unexpected deaths, improper care, transfers, and falls prevention, as well as a complaint related to skin and wound management.

• Plan of Care: The licensee did not have accurate and clear directions in a resident’s plan of care, particularly regarding equipment needed for transfers. This issue was remedied by updating the plan of care. Additionally, outcomes of care set out in the plan were not documented, particularly regarding a resident’s refusal of care, leading to the resident not receiving necessary continence and evening care.
• Transferring and Positioning Techniques: Safe transferring techniques were not followed as per the resident’s assessment and the home’s Minimal Lift Program Policy, resulting in a resident’s fall and injury.
• Administration of Drugs: PRN (as needed) pain medications were not administered according to the prescriber’s instructions, leading to prolonged suffering for a resident experiencing increased pain.

June 2023: Director’s Order

The Director’s Order can be read on the Government of Ontario website.

April 2023: Inspection

The inspection, led by Romela Villaspir along with additional inspectors Sharon Perry and Gabriella Del Principe, conducted at Sunset Manor revealed several areas of non-compliance.

• Duty to Protect: The facility failed to protect a resident from abuse by a co-resident. Despite having interventions identified in the care plan to prevent inappropriate touching, a resident was observed inappropriately touching a co-resident. This negligence could have negatively impacted the co-resident’s quality of life.
• Notification Re Incidents: The licensee did not immediately inform the Substitute Decision-Maker (SDM) of the results of an investigation into an abuse incident, potentially delaying communication and decision-making between the home and the SDM.
• Plan of Care: The staff and others involved in different aspects of a resident’s care failed to collaborate effectively in their assessments, leading to a lack of coordinated and integrated care. The facility did not provide care as specified in the plans of care for three residents. This included improper medication administration, inadequate intervention completion, and failure to ensure functional alert devices.
• Continence Care and Bowel Management: The plan of care for a resident’s continence was not implemented as required, potentially causing discomfort and risk of altered skin integrity for the resident.
• Responsive Behaviours: Strategies to respond to a resident’s responsive behaviours were not implemented as per their care plan, possibly increasing the risk of injury.
• Training and Orientation: An Agency Personal Support Worker (PSW) was not provided with necessary training on falls prevention and management, increasing the risk of inadequate care provision to residents

January 2023: Lifting of Cease of Admissions

Sunset Manor reopened for new admissions after the province lifted its cease admissions order that has been in place since June 10, 2021.

January 2023: Inspection

The inspection report for Sunset Manor reveals several areas of non-compliance:

• Plan of Care The facility failed to ensure that three residents were put to bed at their preferred times as specified in their care plans, potentially impacting their quality of life and not respecting their choices.
• Oral Care: Two residents requiring assistance with mouth care, including denture cleaning, were not offered proper oral care, which could lead to poor oral hygiene and infections.
• Menu Planning: Residents were not offered a beverage and a snack in the evening as required, increasing their nutritional and dehydration risks.
• Conditions of Licence: The licensee failed to comply with previous compliance orders related to skin and wound care and the administration of medications. In particular, weekly wound assessments and medication administration were not conducted as prescribed. This negligence put residents at risk of negative health effects.

The facility was issued AMPs for failing to comply with compliance orders related to medication administration and skin and wound care.

A new order was issued to ensure proper medication administration, with a requirement for daily audits and keeping accurate records.

A complaint regarding incorrect intervention in a resident’s plan of care was addressed and corrected by updating the resident’s clinical records.

October 2022: Inspection

The inspection report for Sunset Manor outlines various issues of non-compliance and the corresponding actions taken by the facility.

1. Residents’ Bill of Rights: There were incidents where a resident’s right to privacy and confidentiality of personal health information was not fully respected. In one case, a resident was transported uncovered and naked, and in another instance, a staff member discussed another resident’s care information in a non-private setting.
2. Plan of Care: The facility failed in some instances to provide care as specified in the residents’ plans. This includes inconsistencies in applying physician-ordered treatments and missed physiotherapy exercises.
3. Skin and Wound Care: The licensee did not consistently complete necessary skin assessments or apply the correct treatments for wounds, which could have impeded healing and increased the risk of harm to residents.
4. Altercations and Other Interactions: Steps to minimize the risk of altercations and potentially harmful interactions between residents were not effectively implemented.
5. Infection Prevention and Control (IPAC): The facility did not fully comply with the standards issued by the Director with respect to IPAC. There were lapses in routine practices, including proper use of Personal Protective Equipment (PPE) and hand hygiene.
6. Medication Management System: Written policies and protocols for the medication management system were not fully implemented, leading to incorrect administration of drugs.
7. Directives by Minister: The facility failed to fully carry out the Minister’s Directive regarding COVID-19 response measures, specifically in case and outbreak management and testing protocols.

The facility was issued compliance orders related to skin and wound care and medication management systems. Additionally, administrative monetary penalties were imposed for failing to comply with certain regulations.

Several issues of non-compliance were found and subsequently remedied by the licensee. These include updates to residents’ electronic Treatment Administration Records (eTAR) for accurate care directions, proper implementation of wound care protocols, correct application of treatments, and proper handling of medications.

September 2022: Inspection

This inspection for Sunset Manor, which included critical incident, complaint, and follow-up components.

• Plan of Care: Several residents did not have their plans of care reviewed and revised as required. This included issues such as the use of a weighted blanket as a fall risk strategy, failure to complete annual blood work, improper wheelchair function usage, and not ensuring residents were awake and alert before providing food or fluids.
• Bathing: There were failures to ensure that residents were bathed at least twice weekly by their preferred method, potentially impacting their dignity and hygiene.
• Housekeeping: Procedures for cleaning and disinfecting tubs, shower chairs, and lift chairs were not followed in accordance with evidence-based practices, increasing the risk of infection spread.
• Infection Prevention and Control: Symptoms indicating the presence of infection were not monitored and recorded for certain residents, potentially impacting their health and well-being.
• Nutritional Care and Hydration Program: The facility failed to monitor and evaluate food intake adequately, make timely referrals to the dietitian, and assess a resident for signs of dehydration.
• Minimizing of Restraining: The report noted a failure in the inclusion of a Personal Assistance Service Device (PASD) in a resident’s plan of care.
• Skin and Wound Care: The facility did not complete weekly skin and wound assessments for several residents, potentially impacting their healing and care.

A Compliance Order was issued, requiring the licensee to conduct audits ensuring that skin and wound re-assessments are completed weekly.

An Administrative Monetary Penalty (AMP) of $5,500 was also issued for failing to comply with specified regulations.

July 2022: Inspection

The inspection report for Sunset Manor details the findings from an inspection carried out between May 9-19, 2022. The inspection focused on various issues, including falls resulting in injury, resident-to-resident abuse, medication administration, and compliance with previously issued orders.

• Plan of Care: After a resident’s fall, there was a lack of clear directions for staff on providing post-fall care. This included inconsistencies in mobility assistance and a failure to update the care plan with physiotherapy recommendations.
• Duty to Protect: A resident experienced physical abuse by another resident. The incident was not adequately addressed, placing the resident at risk of harm.
• Reporting Certain Matters to Director: The facility failed to report an incident of physical abuse to the Director immediately, delaying the Director’s response.
• Skin and Wound Care: There were failures in assessing a resident who sustained bruising from a fall. The facility did not reassess the resident weekly, nor did they ensure an assessment by a registered dietitian.
• Dining and Snack Service: The facility failed to provide the necessary assistance to a resident for safe eating and drinking post-injury.
• Medication Management System: There were multiple medication management issues, including failure to administer medication as prescribed and not following hypoglycemia management protocols.

A Compliance Order (NC#08) was issued, mandating corrective actions in medication management, including audits, staff re-education, and developing new protocols.

An Administrative Monetary Penalty (AMP) of $5,500 was issued for failing to comply with the regulations.

March 2022: Complaints Inspection

The inspection report for Sunset Manor focused on a Complaint inspection. This comprehensive inspection took place over several weeks in early 2022 and addressed various concerns, including responsive behaviors, accommodation charges, medication issues, bathing, and weight loss.

• Responsive Behaviours: The facility was found non-compliant in identifying and responding to residents’ responsive behaviors. This included failing to implement strategies and actions to address these behaviors for residents #016, #017, and #027. The home did not consistently document interventions, assessments, reassessments, and resident responses.
• Bathing: The facility did not ensure a resident was bathed according to their preference. The resident’s plan of care indicated a preference for bathing, but this was not followed, resulting in missed baths and lack of alternatives when the resident refused a bath.

March 2022: Critical Incident Inspection

The document is an inspection report, detailing a comprehensive evaluation of the Sunset Manor. The inspection was a Critical Incident System inspection, carried out over several weeks in early 2022.

• Failure to Investigate Incidents of Abuse Promptly: The home did not immediately investigate a reported incident of physical abuse of a resident by another resident. This delay potentially put the resident at further risk of harm.
• Failure to Report Suspected Abuse Immediately: There was a failure to promptly report suspected abuse to the Director. This could have delayed appropriate response to the incident.
• Non-Compliance in Foley Catheter Documentation: The facility failed to document critical information regarding Foley catheter changes for two residents, potentially risking complications like infections or urine retention.
• Failure in Implementing Hypoglycemia Protocols: The staff did not follow protocols for managing hypoglycemic events in diabetic residents, putting them at risk of severe hypoglycemia.
• Medication Management Non-Compliance: Medications were not administered as per the prescriber’s instructions for three residents. In one case, this led to negative health effects.
• Inadequate Infection Prevention and Control Practices: Staff failed to implement the home’s infection prevention and control program, particularly in ensuring resident hand hygiene before and after meals and snacks.
• Neglect in Skin and Wound Care: The home did not provide weekly reassessments for residents with wounds and altered skin conditions, and failed to implement immediate interventions for wound care, which could have led to worsening conditions.
• Failure in Medication Incident Reporting and Analysis: The facility did not properly report and analyze medication incidents, nor did it take necessary corrective actions.