Wesburn Manor (400 The West Mall, Etobicoke) is owned and operated by the City of Toronto. There are approximately 190 beds.
Inspection Reports for Wesburn Manor
Our research team carefully reviewed and summarized inspection reports for Wesburn Manor. You can read the original copies of the reports in the Government of Ontario website.
November 2023
The inspection, identified as #2023-1607-0006, was conducted under the Fixing Long-Term Care Act, 2021 by the Ministry of Long-Term Care, Long-Term Care Operations Division Toronto District, at Wesburn Manor in Etobicoke. This was a complaint inspection led by Maya Kuzmin.
- The licensee was found non-compliant with O. Reg. 246/22, s. 78 (3) (b), regarding food production safety standards. On November 15, 2023, a resident’s food tray was improperly stored in the resident’s room, violating policies that require Registered Nurses (RN) or Registered Practical Nurses (RPN) to audit tray services and notify the Food and Nutrition department of any concerns. Despite directions from the resident’s family, the Nutrition Manager (NM) acknowledged that this practice did not meet food safety standards, posing a risk of foodborne illness.
October 2023
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.
July 2023
The inspection report for Wesburn Manor in Etobicoke, under the Fixing Long-Term Care Act, 2021 by the Ministry of Long-Term Care, provides critical insights into the operational standards and care provided at this long-term care facility. Conducted between June 21 and June 27, 2023, the inspection was led by Parimah Oormazdi and included both on-site and off-site assessments.
The inspection addressed a complaint and a critical incident system. Specific intakes inspected included issues related to physical abuse/improper transfer and concerns with continence care, skin and wound care, and complaint handling.
- Masking Requirements: There was a failure in complying with the Minister’s Directive on COVID-19 response measures, particularly regarding masking requirements. This was observed during dining service, where two staff members failed to wear masks correctly. The issue was promptly addressed, and corrective actions were taken by the facility.
- Plan of Care: The facility did not revise a resident’s care plan timely after a significant change in their status, particularly concerning an infection. This oversight increased the risk of delayed treatment and recurrence of infection.
- Reporting Abuse: There was a delay in reporting an allegation of abuse to the Director, potentially hindering a timely response to the incident.
The facility implemented remedies promptly for the non-compliance regarding COVID-19 masking protocols.
Written notifications were issued for the failure to update a resident’s care plan and for the delayed reporting of suspected abuse. These are critical areas where the facility needs to take immediate action to ensure compliance and the safety and dignity of residents.
April 2023
The inspection was conducted from March 27 to 31 and April 3 to 4, 2023, and encompassed both a complaint inspection and a Critical Incident (CI) inspection. It specifically addressed a complaint related to Infection Prevention and Control (IPAC) and a critical incident concerning an injury of unknown cause.
The lead inspector was Maya Kuzmin, with Patricia McFadgen also participating.
Non-compliance was discovered during this inspection but was satisfactorily remedied by the licensee before the conclusion of the inspection. The specific non-compliance was related to IPAC standards. It was found that the licensee had not properly implemented the standard or protocol issued by the Director concerning IPAC. This lapse was identified when a Personal Support Worker (PSW) and a Registered Practical Nurse (RPN) acknowledged that a droplet contact precautions (DCP) sign, which indicated the need for specific personal protective equipment, was posted outside a resident’s room but should have been removed as the residents were no longer in isolation. The PSW subsequently removed the DCP poster.
The licensee addressed the non-compliance effectively by removing the unnecessary DCP poster, thus ensuring that the care environment was accurately represented in terms of IPAC requirements. The inspector was satisfied with the resolution and deemed no further action necessary. It was determined that there was no risk of harm to residents from the presence of the additional precaution signage when it was no longer needed.
December 2022
The report was led by Nicole Ranger, accompanied by inspectors Helina Leung and Maya Kuzmin.
The inspection, occurring on various dates between November 8 and 17, 2022, focused on multiple intakes related to falls resulting in injury, an unknown injury, staff to resident neglect, fall prevention, and medication administration.
- Non-Compliance with IPAC Standards: A staff member was observed with improperly worn surgical mask, which was rectified upon notification. The IPAC standard requires correct mask usage to prevent infection risks.
- Posting of Reports: An issue regarding the posting of inspection reports containing personal information was identified and corrected by removing the report from public view.
- Plan of Care Non-Compliance: The care plan for a resident, who experienced a fall, was not appropriately updated. This oversight posed a risk for injury associated with falls.
- IPAC Protocol Violations: Hand hygiene assistance was not provided to residents before meals, and there was improper handling of PPE, along with a failure to implement de-escalation processes post-isolation. These lapses increased infection transmission risks.
- Reporting and Complaints Non-Compliance: There was a failure to inform the Director about an incident causing significant change in a resident’s health condition after a fall, which should have been reported within one business day.
The licensee took remedial actions before the conclusion of the inspection. These actions were deemed satisfactory by the inspectors.
June 2022
The inspection was led by Inspector Nital Sheth with additional inspectors Joy Ieraci, Manish Patel, and Kim Lee.
The inspection was carried out from June 8-10 and 13-17, 2022, focusing on a Proactive Compliance Inspection.
- Non-Compliance with Outdoor Courtyard Security: The door to a secured outdoor courtyard was found unlocked and unsupervised, posing a potential security risk. However, no residents were present in the vicinity at the time. A Registered Practical Nurse (RPN) immediately locked the door, and staff confirmed the need for the area to be locked when unsupervised. This non-compliance was rectified on June 8, 2022.
- Infection Prevention and Control Program: The inspection found that two Personal Support Workers (PSW) were not correctly wearing surgical masks, breaching the home’s IPAC policy. This was observed at the nursing station where the PSWs had their masks pulled down to their chins, increasing the risk of infection transmission. After being notified, the staff acknowledged their error. The policy review and staff interviews further supported this finding.
The inspection identified areas of non-compliance which were promptly addressed by the licensee.
July 2021
The inspection, led by Inspector Nital Sheth and amended by the same, was carried out over several days in July 2021, specifically from July 14 to 21.
The inspection was a Complaint inspection, focusing on a specific complaint related to an identified care area for a resident at Wesburn Manor.
The inspection resulted in one written notification of non-compliance. It was found that the licensee failed to document the provision of care set out in the plan of care for a resident. Specifically, the record for the identified care had missing documentation for seven days. Staff interviews revealed that they were required to document the resident’s provision of identified care in the Point of Care (POC) record.
February 2021
During the course of this inspection, Non-Compliances were not issued.