A long-term care home in Scarborough, Ont., where dozens of residents died from COVID-19, was cited 13 times by provincial inspectors for failing to comply with health and safety regulations that included not giving residents enough water or timely medication, staff improperly using protective gear, and a lack of infection prevention measures.
In early December, an outbreak of COVID-19 swept through Tendercare Living Centre killing 81 residents – more than any long-term care home in the province – leading North York General Hospital to temporarily take over management of the for-profit home on Dec. 25.
Two inspectors with the Ontario Ministry of Long-Term Care visited the 254-bed nursing home 10 times between Jan. 7 and 20 and issued 13 written notices, following a number of complaints at the home ranging from nutrition and hydration concerns, to a lack of staffing, to unexplained injuries. It is unclear from the report when exactly the violations occurred.
Their report paints a troubling picture of what was happening in the home, even after more than 1,000 people died in Ontario’s long-term care sector during the first wave of the novel coronavirus outbreak.
Inspectors found that the home “failed to ensure that staff participated” in its Infection Prevention and Control (IPAC) program which contributed to the spread of the virus.
“There was potential for possible transmission of infectious agents due to the staff not participating in the implementation of the IPAC program,” said the report which was filed on Feb. 11. “The scope of this non-compliance was widespread because the occurrences were on the two floors of the [long-term care home].”
Inspectors found repeated instances of staff not using protective equipment properly and several cases where personal support workers did not wear gloves when handing out meals, or wore protective gear between rooms.
In one case, the report said a staff member created a hole in their protective gown “for their right and left thumb on each sleeve by puncturing the gown with their thumb.”
“[An inspector] also observed the lack of leadership on the floors, and some staff were not clear on the appropriate IPAC practices,” the report said.
According to the report, the inspectors detailed how a severe staffing crisis during the COVID-19 outbreak in December meant that residents did not receive enough assistance while eating and drinking. These findings echo what some doctors said they saw when they went into the home in mid-December and issued urgent calls for help.
“The delay in assistance compromised the integrity of the food, becoming unpalatable for residents, which may have also potentially lead to a decrease in their food and fluid intake,” the report said, which could put residents at risk of dehydration.
The short-staffing also meant that in some cases medications weren’t given on time or documented properly, according to the report, which could result in “medication error incidents.”
Inspectors found that the home also failed to provide residents with sufficient continence care, and did not reposition residents frequently enough, leading to skin problems.
“A number of residents developed new alteration in skin integrity due to lack of turning and repositioning,” the report said.
Also concerning, was an allegation the Tendercare failed to ensure that staff complied with “it’s zero tolerance of abuse and neglect of residents.”
“[The director of care] further acknowledged that the staff did not comply with the home’s policy on prevention of abuse, as the staff did not immediately notify the home’s management regarding their allegations,” according to the report.
Tendercare did not respond to repeated requests for comment from Global News about allegations of neglect at the home.
Jane Meadus, a lawyer and institutional advocate for the Advocacy Centre for the Elderly in Toronto, said the report shows a home that was “completely overwhelmed.”
“There is clearly just not enough staff in the home,” she said. “The fact that we are almost into a year of [the pandemic] and the staff still doesn’t have IPAC training … it’s hugely concerning.”
“The middle of a pandemic is not the time to be learning about IPAC.”
Meadus said because the inspection was complaint-based, meaning it only responded to specific complaints, many other issues affecting how people were cared for in the home could have been missed.
“They only looked at the five residents that made complaints about feeding,” she said. “And I think to myself, well, those are probably only five people that have family members who are being very proactive.”
“How many other residents were not getting fed and hydrated during that period of time? And what was the impact on those people we don’t see out of the report?”
Tendercare has had a lengthy history of non-compliance with provincial regulations. Since 2015, the home has been cited dozens of times for issues like failing to report incidents of abuse, poor infection and prevention measures, and failure to properly treat skincare wounds.
Some non-compliance issues found in the latest Ontario inspection report were also in a Dec. 17, 2020 report that found resident rooms without personal protective equipment caddies for staff to wear PPE, and staff going room to room without changing gowns.
However, just one written notice was issued in the December report. Tendercare was ordered to ensure all staff practice proper infection prevention measures and to provide immediate education and training for staff who don’t.
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In the latest report from, inspectors issued seven plans of correction and five compliance orders, again calling for the home to ensure its staff are trained in infection control by Feb. 26, and ensure concerns related to resident care are addressed by March 11.
North York General declared the outbreak over on Feb. 1, a little over a month after it took control of the facility.
A spokesperson for North York General said the hospital could only respond to the issues at the home since it took control, but said Tendercare will meet the timelines laid out by the ministry for corrective actions.
“Over the last two months, all staff have been re-educated, trained and retrained on IPAC and outbreak management best practices including proper PPE and donning and doffing,” the hospital said in a statement. “A dedicated IPAC specialist has been hired and IPAC champions have been trained for each area of the home to support all staff and provide on the spot corrective feedback.
“Adjustments have been made to prevent future outbreaks including shifting from four-bed rooms to single-bedded and double-bedded rooms to reduce transmission,” the statement said. “Staffing, including nursing, physicians and PSWs, is now stable and there is less reliance on temporary agency staff.”
For Meadus, the tragedy at Tendercare is part of a systemic problem of the Ontario government’s reliance on for-profit homes. She said the government is often reluctant to take a firm stance against homes with a high number of infractions because they need the long-term care spaces to meet the demands of an aging population.
There are around 35,000 people waiting for a long-term care bed, according to the Ontario Long Term Care Association.
“If they close the home, where do the people go and live?” Meadus said. “They are reliant on all these homes to continue to provide care.”
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In Ontario, 3,730 residents in long-term care homes have died from COVID-19 since the pandemic hit. Eleven long-term care staff have also died.
Extendicare, which owns or operates 71 long-term care facilities in Ontario including Tendercare has been hit with a proposed class-action lawsuit that seeks more than $200-million in damages.
The claim, which has not been proved in court, alleges Extendicare was negligent in the care of residents and failed to adequately respond to the pandemic.
“The plaintiffs plead that the defendants behaved in a reprehensible and unconscionable manner by failing to implement an adequate COVID-19 response plan,” the suit alleges.
Extendicare said in a statement it would respond to the allegations through “appropriate legal channels.”
“Our focus at this time is solely on providing quality care to our residents, and supporting our families and team members,” the statement said. “Our hearts are with our community and those who have lost loved ones to this virus.”
The Ontario Ministry of Long Term Care did not directly respond to questions about the years of non-compliance issues at the home.
“The ministry takes all non-compliance orders extremely seriously, and expects all homes to be in compliance in order to ensure a safe environment for their residents and staff,” spokesperson Rob McMahon said in a statement.
“Near the completion of the management contract the ministry will work with the licensee and hospital to implement a plan to transition operations back to the licensee.”
McMahon noted that when a compliance order is issued as a result of an inspection, the ministry follows up to ensure the licensee acted to correct the non-compliance and followed the requirements of the order.
“Repeated non-compliance is a serious concern and can result in escalated measures and sanctions by the ministry,” said McMahon, which can include revoking the license of the home.
Meanwhile, North York General said more than 95 per cent of residents have now been vaccinated against COVID-19.
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