Inspection reports found mouse feces, neglect, abuse at Ontario long-term care homes before COVID-19

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Coronavirus outbreak: Ontario deploys inspectors into senior homes following CAF report
WATCH ABOVE: Ontario deploys inspectors into senior homes following CAF report – May 28, 2020

WARNING: This story contains graphic details some readers may find disturbing. Discretion is advised. 

Past inspection reports of the five long-term care homes in Ontario named in a troubling military report released Tuesday show many concerns similar to those raised by Canadian Forces members were present at the facilities months before the novel coronavirus pandemic started. 

These include allegations of improper care, neglect, poor record keeping, failure to dispense medication properly and abuse. 

Global News reviewed inspection reports going back to the beginning of 2019 for the five care homes that Canadian Forces teams were dispatched to in April: Orchard Villa in Pickering, Altamont Care Community, Eatonville Care Centre and Hawthorne Place in Toronto, plus Holland Christian Homes’ Grace Manor in Brampton.

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The reports, completed by inspectors from Ontario’s Ministry of Long-Term Care (MLTC), included findings of mouse feces found in a resident’s dresser drawer and closet, a resident who died in hospital after being struck by a staff member who admitted they were improperly moving a piece of furniture at the time of the incident, plus other violations, including failure to prevent abuse and not making recommended safety repairs after a fire.

Emails and affidavits from staff released by their union as part of a labour relations board investigation also claim management at two of the facilities, Altamont and Eatonville, failed to provide adequate personal protective equipment (PPE) as COVID-19 started spreading in their buildings in March and April. 

The labour relations board responded by ordering the companies to “make all efforts to immediately obtain appropriate PPE” and by requiring mandatory weekly inspections at those facilities. 

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On Tuesday, Ontario released the military report that included observations from the five homes where troops are stationed.

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Allegations in the report included a “blatant disregard” for infection control measures to prevent the spread of COVID-19 at the homes, cockroach infestations, rotten food and residents being left in soiled diapers.

Global News contacted the MLTC for comment on the past inspection reports of the five long-term care facilities. 

A ministry spokesperson said the province provides “regulatory oversight” of the homes but added that the facilities are independently run and operated.

“Licensees are responsible for ensuring that the homes they operate are in compliance with the (Long-Term Care Homes) Act and Regulations,” Gloria Yip said in a written statement.

“The ministry uses a rigorous inspection framework to ensure and review this compliance.”

Premier Doug Ford has said it took the military going into the homes and reporting what they observed before he realized how bad things were. 

He also said he takes “full responsibility” for the state of these homes, while adding that long-term care in Ontario has suffered from decades of neglect and mismanagement.

Altamont Care Community

Altamont Care Community, which is managed by Sienna Senior Living, was named in the Canadian Armed Forces report, which alleged that most residents didn’t receive three meals a day, a significant number had pressure ulcers and cited concerns regarding clinical skills of staff.

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In a November 2019 inspection report, a ministry inspector issued 14 written notifications for non-compliance, eight voluntary plans of correction and two compliance orders.

The report said staff failed to ensure prescribed drugs were administered to residents as required.

In one instance, Altamont’s medication documentation indicated that a registered practical nurse gave six times the prescribed dose of a drug to a resident all at once, according to the report. The nurse was fired immediately after the incident.

In another incident, a resident was standing in a hallway waiting to enter the dining room when they fell after coming into physical contact with a staff member carrying a recliner, the report showed.

“The resident was transported to the hospital, where they were diagnosed with an injury,” the report read.

”The home was notified that the resident died while in the hospital.”

According to the report, there were two staff members moving the recliner. The staff member who made physical contact with the resident was moving the recliner backwards down the hallway and said they didn’t see the resident before they fell. They acknowledged moving the recliner with only two people was unsafe, and that in the future they would “take precautions to ensure resident safety when furniture in the home was being moved.”

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In an interview with the inspector, Altamont’s environmental services director said staff were required to submit a maintenance request to have furniture and other large items moved in the home.

“The (environmental services director) indicated that in this case, maintenance staff would have moved the furniture while residents were in the dining room to ensure that residents were not in the hallway,” the report read.

Altamont’s care director also said the two staff members should have submitted a maintenance request to move the recliner, according to the report.

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Canadian military arrives at Ontario long-term care home to aid during COVID-19 pandemic

Another incident led a family member of one of the residents to complain to the home that a nurse “refused to assess and send the resident to hospital when the resident was in distress.” 

The home completed an investigation, which found that the nurse didn’t complete an assessment when the resident was showing certain symptoms and that Altamont’s physician wasn’t notified immediately when the resident’s condition got worse.

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“The family member of the resident called (registered practical nurse) #131 to assess the resident,” the report read.

“The (nurse) did not respond immediately and the family member took the resident to hospital themselves.”

Altamont determined that the nurse neglected the resident, and the nurse was disciplined, according to the report.

In an email, Natalie Gokchenian, communications and stakeholder relations director at Sienna Senior Living, said the organization is “deeply saddened” by the effects of COVID-19 on long-term care facilities.

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“Our commitment to our residents, their families, and our team members is to make sure the issues identified by the Canadian Forces are all dealt with immediately and permanently,” Gokchenian said.

“Altamont has continuously evaluated and implemented additional measures, processes, and protocols in line with provincial and public health direction and requirements, to care for and protect our residents and staff during this crisis.”

Gokchenian also said staffing challenges in the long-term care sector “must be addressed.”

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But the union representing workers at Altamont disputes the company’s characterization of the situation, alleging management failed to provide adequate personal protective equipment (PPE) before many staff got sick.

In a response to the union’s claim, Sienna said the company has “acted in compliance with health guidelines and applicable legislation, including those relating to the use of personal protective equipment.”

“Any incident or complaint is handled swiftly and resolved to ensure not only alignment with ministry standards, but also the wellbeing of our residents,” Gokchenian said in an email.

Hawthorne Place Care Centre

Hawthorne Place, administered by Rykka Care Centres, was the source of several of the more serious allegations contained in the military’s report — including forced feeding, insect infestation, residents going unbathed for weeks and delayed changing of soiled residents, which led to skin breakdown. 

The home was also subject to six compliance orders, nine voluntary plans of correction and 17 written notifications from MLTC inspectors in 2019.

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A November 2019 report said an inspector found mouse feces in a resident’s dresser drawers and closet. The same resident also had 12 “alterations in skin integrity,” including several that were not properly assessed and that had no recorded treatment plans.

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This finding was confirmed by the home’s environmental services manager, who said pest control measures, including setting of traps and repairing a hole in the baseboard, were completed earlier in the year. Two staff members interviewed by the inspector also said they were unaware of the feces, but had they known they would have reported it.

These findings were made following complaints from family members, including claims the resident was left unattended laying in their own excrement.

“The complainant indicated they were concerned when they found resident #004 soiled without an incontinence product, and a staff member indicated that they would return after break to care for the resident,” the inspection report said.

According to the report, the resident was not properly assessed after returning from the hospital to reflect changes to their bowel movements. The home’s director of care confirmed this finding and the home agreed to ensure resident care plans are based on an accurate assessment of needs. 

Staff at the home also said the resident was treated for skin alterations, despite these treatments not being noted in the medical records.

“(The nurse) indicated in an interview that treatments for resident’s alterations in skin integrity should be entered directly into the electronic documentation system by the wound care nurse,” the report read.

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The same resident was given medication by a nurse to treat loose bowel movements that was not prescribed by a doctor, the report read.

“The physician orders for resident #004 were reviewed in the chart and electronic medical record, and no active orders or medical directives were found for the above identified medication,” the report read.

The same inspection found other issues with improper dispensing of medications at the home, including medicine being given hours after it should have been and a nurse who routinely handed out a double-dose of medication to a resident who refused to take the first dose earlier in the day.

“(The nurse) indicated that when that occurred they would save the first scheduled dose and administer it together with the second scheduled dose,” the report said. 

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“The RPN indicated they should have communicated this to the physician and documented the resident’s preference in a progress note.”

According to the report, the home’s director of care said it is policy that medications should be dispensed as directed. The inspector issued an order telling the home it must comply with these rules in the future.


Eatonville, operated by the same company as Hawthorne Place, also has a history of critical incident reports prior to being taken over by the government Wednesday.

A report from January showed the home failed to provide care to residents as laid out in their specific care plans, a violation of the long-term care act. 

The report found three residents with a history of falling were not wearing an “injury protection device” as specified in their care plans. According to the report, staff from the home acknowledged the residents should have been wearing the devices and could not explain why they weren’t.

According to the report, one of the residents said staff members “occasionally forgot to apply” the devices.

The home agreed to a voluntary correction plan to ensure the devices were properly applied in the future, the report read.

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The report also found the home was not a “safe and secure environment” for residents because staff failed to make repairs as recommended by the fire marshal.

Following a fire at the home, which resulted in residents being evacuated, the fire marshal determined the cause of the blaze was an electrical outlet in the kitchen. 

The fire marshal said the home’s electrical panel should be immediately relabelled because some of the tags on the breakers were either illegible or missing. This caused a delay in shutting off the home’s electricity at the time of the fire, the report read.

However, during a later visit, an MLTC inspector found maintenance staff had not relabbled the electrical panel as recommended by the fire marshal. 

According to the report, the home’s executive director confirmed that leaving the breakers unlabelled “poses risk and creates an unsafe environment for staff and residents.”

The director indicated the breakers would be relabelled immediately.

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In a written statement, a spokesperson for Responsive Management, which represents Hawthorne Place and Eatonville, said they have worked tirelessly to ensure the homes they manage have the resources and tools needed to provide a safe and comfortable environment for residents, adding that most of the homes they manage have “been successful at keeping COVID-19 at bay.”

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However, the response acknowledged that both Hawthorne Place and Eatonville had been “significantly impacted” by the virus.

“We received the CAF report (Tuesday). Reading the findings in this report were devastating to our leadership team and to each member of our care team,” said Linda Calabrese, vice president of operations for Responsive Management. 

“To complement the action being taken by the Ministry of Long-Term Care, we are initiating a third-party independent review of all the CAF’s findings. We will not rest until our residents and their families have confidence that residents are getting the best care possible.”

Calabrese said the company understands the government’s decision to take control of the homes and will work closely with provincial inspectors to ensure proper care and public confidence in the homes are restored.

“There are long-standing systemic issues facing long-term care in Ontario and Canada,” she said.

“Fixing these systemic issues will require the involvement of the federal government and others, working in collaboration.”

However, internal emails and statements from employees and management filed as part of a labour relations board hearing indicate the company was already aware, before the military arrived, that it needed to take stronger measures to prevent the spread of COVID-19.

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In a statement sent in April, Calabrese said that management at Eatonville were pleased to reach an agreement with the union at the labour board hearing and that the company remains committed to ensuring staff have appropriate protective equipment available at all times.

Orchard Villa

Orchard Villa, which is managed by Southbridge Care Homes, was also included in the Canadian military’s report. The document stated that there had been cockroaches and flies, as well as a “rotten food smell” at the facility, inappropriate use of personal protective equipment, unsafe medication errors and a lack of training for new and agency staff.

Three inspection reports were filed in December 2019. In those reports, ministry inspectors issued a total of eight written notifications of non-compliance, four voluntary plans of correction and two compliance orders.

According to one of the reports, a registered practical nurse witnessed a personal support worker allegedly abusing three residents on separate occasions. The nurse failed to report the first incident right away, but did report the other incidents immediately after they occurred, the report read.

 “(The nurse) indicated that they were disciplined for not reporting and completed additional education,” the inspection report said.

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The home has a zero tolerance policy of resident abuse and neglect, which in part states that anyone who witnesses or suspects abuse or neglect must immediately notify management, the report said. 

However, after the nurse underwent additional training, they indicated in an interview with inspectors that they didn’t report another incident of alleged abuse toward a fourth resident.

“During an interview with the (director of care), they indicated that based on the training and retraining of (registered practical nurse) #103, that both incidents referenced above should have been reported immediately to the supervisor,” the report read.

The report said the care director indicated that they would submit a critical incident report and follow up with the nurse, however four days after the inspections wrapped up at Orchard Villa, the inspector reviewed the MLTC’s online reporting portal and didn’t see any reports related to the incident.

It isn’t clear in the inspection report what happened to the personal support worker who allegedly committed the abuse.

Global News reached out to Southbridge Care Homes for comment on the past inspection reports, but didn’t receive a response by time of publication.

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However, Southbridge’s executive director, Jason Gay, previously said in a statement to Global News that COVID-19 has created “an unprecedented challenge” in the home and that Southbridge’s duty of care to residents is its “most important responsibility.”

Grace Manor

Holland Christian Homes’ Grace Manor was identified in the military’s recent report, which alleged staff moved between the COVID-19 unit to other units without changing contaminated personal protective equipment. The report also contained allegations about staff leaving food in a resident’s mouth while they slept and aggressively repositioning a resident.  

As a result of an October 2019 critical incident report completed by the MLTC, Grace Manor was issued three written notifications and agreed to three voluntary plans of correction.

The inspection report found the home failed to properly inform staff and others who provide direct care to residents about details of their care plans. 

The report also said a personal support worker mentioned in the report did not have access to either a physical copy or electronic record of a resident’s care plan who had a history of “responsive behaviours toward other residents.”

The home also failed to prevent abuse by not properly supervising this resident, according to the report.

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“A family member observed resident #001 exhibiting inappropriate behaviours towards resident #002. (A nurse) noted that resident #002 was crying during the incident and the residents were subsequently separated,” the report said.

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The home violated the rules by not immediately reporting the abuse to the MLTC, the report said.

And this wasn’t the first incident of abuse by this resident the home failed to prevent, according to reports.

A critical incident report from two months earlier said the home was ordered to ensure residents were “protected from abuse” after staff witnessed the resident abuse two other residents and attempt to abuse a third resident on the same day.

The report found that despite a history of abusive behaviour being documented in the resident’s admission records, there was no mention of this behaviour in the resident’s care plan or in the daily log used to communicate important information to staff members.

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A registered nurse on duty the day the three incidents occurred confirmed there was “no highlighted monitoring” of the resident that day, the report said. 

The nurse also said the resident who committed the abuse was new to the home.

However, according to the report, proper monitoring procedures for new residents were not followed and no specific monitoring of the resident was initiated until after the three separate incidents occurred.

The report said the home agreed to prepare voluntary plans of correction to address the resident’s behaviour, including a plan to minimize the risk of potentially harmful interactions among residents. The home also agreed to create a written plan to ensure staff members, including temporary staff, have proper access to patient records.

In a written statement, a spokesperson for Grace Manor said the ongoing health, safety and well-being of residents and staff is its top priority.

“Findings contained in previous inspection reports have always been treated with the same care, attention and diligence as those identified more recently in the military’s report, and all were cleared within mandated time frames,” said Ken Rawlins, CEO of Holland Christian Homes.

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Rawlins also said he welcomed the deployment of military personnel “at a time when their services were greatly needed.” 

“We will be forever thankful for their like-minded dedication to our residents, sense of humanity and compassion, professionalism and noted expertise,” he said.

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