Tendercare Living Centre: Reviews & Inspection Reports

Tendercare Living Centre (1020 McNicoll Avenue, Scarborough) is operated by Extendicare, a for-profit operator of long-term care homes in Canada. There are approximately 250 beds.

According to corporate records, Tendercare Nursing Homes Limited was founded by Louis Lukenda, Christopher Doherty, and William Sullivan in Sault Ste. Marie in 1973.

Louis Lukenda served as chairman and CEO of Extendicare from 1990 to 2007. His son, Tim Lukenda, succeeded leadership, serving as the president and CEO of Extendicare from 2008 to 2018, while also becoming a director of Tendercare Living Centre in 2003.

Inspection Reports for Tendercare Living Centre

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

🔍 December 2023: Inspection

The inspection for Tendercare Living Centre identified non-compliance issues, particularly concerning medication management and the handling of hypoglycemic events. The inspection team included Suzanna McCarthy, Nicole Lemieux and Ana Best.

Mandatory Review and Analysis of Hypoglycemic Events: The facility was ordered to establish an interdisciplinary team to review every severe or unresponsive hypoglycemic event and any instances where glucagon was administered. This team must include the Medical Director, the Administrator, the Director of Nursing and Personal Care, and the pharmacy service provider. Regular meetings and written records of these meetings and any identified trends or changes implemented are required.
Medication Management System: The facility must ensure training for all registered staff on hypoglycemic event management. This includes understanding the facility’s policy on Diabetes Management-Hypoglycemia, responding to hypoglycemic events, and knowing when to refer to a physician or nurse practitioner. Documentation of the training, attendee lists, completion dates, training materials, and test results are required.

The complaint leading to these orders was related to the unexpected death of Resident #005, who experienced a severe hypoglycemic event. An examination of the resident’s clinical records revealed that proper protocol for managing hypoglycemic events, including notifying a physician or nurse practitioner following repeated hypoglycemic episodes, was not followed. Additionally, the facility did not regularly review and analyze hypoglycemic events or implement corrective actions and improvements, contributing to the risk of negative outcomes from such events.

To address these non-compliances, Tendercare Nursing Homes was given a compliance order to establish and maintain rigorous procedures for managing hypoglycemic events, including staff training and interdisciplinary reviews of incidents.

🔍 October 2023: Inspection

The inspection for Tendercare Living Centre was focused on concerns related to staff-to-resident neglect, falls prevention, pest control, and medication management. The inspection team included Suzanna McCarthy, Nicole Lemieux, and Ana Best.

IPAC Manager Information: The facility initially failed to list the contact information of the Infection Prevention and Control (IPAC) Manager on their website, which was remedied by updating the website on September 15, 2023.
Residents’ Bill of Rights: There was a failure to respect and promote a resident’s right to participate fully in making decisions about their care, specifically regarding medication management. The facility did not honor the resident’s request to have medication scheduled at a set time each night.
Accommodation Services: The facility was found not to be maintained in a safe condition and in a good state of repair, as evidenced by conditions such as torn drapes, water damage, and evidence of rodents.
General Requirements for Pest Control: The facility did not have a written description of its pest control program that included protocols for reducing risk and monitoring outcomes. There was also evidence of pests, and immediate action was not taken to address this issue.
Infection Prevention and Control: The facility failed to follow the IPAC standard issued by the Director regarding hand hygiene and the proper use of Personal Protective Equipment (PPE). Specifically, the Alcohol-Based Hand Rub (ABHR) used had only 60% alcohol content instead of the required 70-90%.

🔍 May 2023: Inspection

The inspection for Tendercare Living Centre focused on various aspects including pain management, infection prevention and control, abuse and neglect, and falls prevention and management. The inspection team, led by Reethamol Sebastian, included Ana Best and Lucia Kwok.

Pain Management: The facility failed to comply with communication and pain assessment methods for a resident post-fall. Despite a policy requiring comprehensive pain assessment, this was not followed when a resident complained of pain after a fall.
Masking Requirement: The licensee did not comply with the operational Minister’s Directive related to staff masking requirements. Staff were observed not wearing masks appropriately, increasing the risk of COVID-19 transmission.
Neglect by Personal Support Worker: A resident was mishandled by a PSW, constituting neglect. The PSW was disciplined and underwent training before returning to work.
Falls Prevention and Management: Post-fall assessments using appropriate tools were not completed for a resident who had fallen and complained of pain.
Skin and Wound Care: The facility failed to conduct necessary skin and wound assessments and weekly reassessments for a resident with altered skin integrity.
Infection Prevention and Control Program: There were deficiencies in the IPAC standard adherence, specifically related to PPE availability and expired hand sanitizer.
Reporting Investigations Outcomes: The facility failed to report the outcome of an investigation involving staff to resident physical abuse to the Director.
Record Keeping: The disciplinary action record of a staff member involved in an incident was not properly maintained at the facility.

🔍 January 2023: Inspection

The inspection for Tendercare Living Centre addressed complaints and critical incidents involving staff-to-resident and resident-to-resident abuse, misuse of a resident’s money, falls, and resident care issues. The inspection also followed up previous compliance orders. The inspection team, led by Patricia Mata, included Rexel Cacayurin.

Reporting Abuse: The facility failed to immediately report an allegation of abuse by Registered Practical Nurse (RPN) #119 to the Director, putting the resident at risk for further abuse.
Residents’ Bill of Rights: The right to refuse treatment was not respected. The Substitute Decision-Maker (SDM) requested to discontinue a treatment, but the Registered Nurse (RN) did not follow through.
Infection Prevention and Control: The facility did not comply with the Infection Prevention and Control (IPAC) standard. This included staff failing to perform hand hygiene and visitors not adhering to PPE requirements.
Transferring and Positioning Techniques: A resident was injured due to improper transferring technique by a PSW. The resident’s care plan required two staff for transfers, but only one PSW was involved.

🔍 August 2022: Inspection

The inspection for Tendercare Living Centre addressed various complaints, follow-ups, and critical incidents. The inspection team included Britney Bartley and Susan Semeredy.

Residents’ Bill of Rights: The right of a resident to receive visitors of their choice was not respected. The Executive Director denied entry to a registered social worker, arranged by the resident’s Power of Attorney, impacting the resident’s right to visitation.
Reporting and Complaints: The facility failed to respond to complainants within 10 business days, delaying the resolution of concerns related to the Residents’ Bill of Rights.
Air Temperature: The home did not consistently complete daily air temperature checks in the afternoon, evening, or night, risking residents’ health due to potential heat-related illnesses.
Food Production: The preparation and serving of food did not consistently preserve taste, appearance, and food quality, impacting the nutritional status of a resident on a therapeutic diet.
Dining and Snack Service: Staff lacked processes to be aware of residents’ diets, special needs, and preferences during meal service, posing risks of incorrect diet texture and beverage consistency.
Registered Dietitian: The home failed to meet the requirement of having a Registered Dietitian on site for a minimum of 30 minutes per resident per month, compromising residents’ nutritional and hydration needs.
Menu Planning: The home’s menu cycle did not include a choice of snacks in the afternoon and evening, risking poor intake among residents.

The facility was ordered to improve its Infection Prevention and Control (IPAC) practices, including education on PPE usage and ensuring proper signage and PPE availability for residents on additional precautions.

🔍 January 2022: Complaints Inspection

The inspection for Tendercare Living Centre focused on complaints related to staffing and resident care, as well as an Infection Prevention and Control inspection. The inspection team included Diane Brown.

Staffing Issues: The facility did not have a sufficient backup plan for nursing and personal care staffing for situations when staff cannot come to work. This led to increased resident-to-staff ratios, negatively impacting resident care. The Executive Director and the Acting Director of Care were unaware of unfilled PSW shifts and the lack of a written backup plan for staffing. The staffing clerk indicated that approximately 50% of the time, all shifts could not be filled, with agency staff not being utilized for PSW staff replacement.

The lack of staff replacement, particularly for personal support workers (PSWs), resulted in larger staff assignments, impacting the quality of resident care. This included delays in morning care, residents missing meals in the dining room, and compromised oral hygiene.

The facility was ordered to ensure that their staffing plan includes a backup plan for nursing and personal care staffing that addresses situations when staff cannot come to work.

🔍 January 2022: Critical Incident Inspection

The inspection for Tendercare Living Centre examined three critical incidents related to resident falls resulting in hospital transfers and significant changes in health status. The inspection team included Diane Brown.

Policies and Procedures: The facility failed to comply with provincial regulation, which requires adherence to established plans, policies, protocols, procedures, strategies, or systems. Specifically, after a resident fall with injury, the registered nurse did not follow the ‘Fall Prevention and Management Policy’, which led to a delay in medical attention and contributed to a resident’s death.
Plan of Care: There were multiple instances where the facility did not ensure collaboration among staff in assessing residents and integrating their care plans. The care provided was not consistent with the residents’ specified plans, particularly regarding falls prevention, resulting in significant injuries and fatalities.
Falls Prevention Equipment: The licensee did not ensure that equipment, supplies, devices, and assistive aids for falls prevention were readily available. This lack of availability was directly linked to an incident where a resident fell and later passed away.

In the first compliance order, the licensee must ensure compliance to the ‘Fall Prevention and Management Policy’. In the second compliance order, the licensee is required to ensure that care outlined in the plan of care, especially for falls prevention, is provided as specified.