Shalom Village and Blackadar fined after not resolving issues raised in past inspections
Two Hamilton long-term care homes have been fined by the province for failing to fix serious issues raised in past inspections.
Blackadar Continuing Care Centre in Dundas has to pay $5,500 and Shalom Village in Westdale owes $1,100 after Ministry of Long-Term Care inspectors issued administrative monetary penalties (AMP) in March.
The homes are the only two Hamilton long-term care facilities to receive AMPs in the last year - no other local facilities were issued such fines in 2022 or so far in 2023.
The administrator at Blackadar has resigned after two inspection reports in 2023 found significant issues.
The first inspection from Feb. 22 detailed how the home needs a long list of maintenance and a good cleaning. It described dirt, mould, leaks, rooms in disrepair and residents left for more than 13 hours without power because the home had no guaranteed access to a generator for blackouts.
The other inspection report from March 30 resulted in the penalty over repeated failures since 2021 to properly care for wounds such as bed sores.
New leadership has been hired at the 60-bed for-profit home at 101 Creighton Rd. that is managed by Extendicare, a large chain that manages or owns more than 80 Canadian seniors' homes. Blackadar is owned by Elite Developments and H & S Holdings.
The Ministry of Long-Term Care's inspection process plays an important role in ensuring quality of care for residents across the province," Extendicare said in a statement. We view inspection findings as learning opportunities to improve processes. We have put in place an action plan to support Blackadar in addressing care quality issues and will continue to provide clinical supports to staff and leadership at the home."
Shalom Village is also under new leadership after Pat Morden was named interim CEO in September of the 127-bed non-profit home founded by the Jewish community at 70 Macklin St. N. Morden was previously CEO from 1989 to 2011 when she left to live on a farm she owns near Owen Sound.
Since her return, she says the home has been in the midst of a transformation" to resolve troubling failings brought to light in two inspection reports in 2022 that raised allegations of abuse - one report on Feb. 28 and the other on Oct. 31. A third inspection report on March 5, 2023, found the home failed to comply with two orders from the 2022 inspections, resulting in the fine.
Change doesn't happen overnight," said Morden. We've been working really hard to get the right people in place and doing the right thing."
The fine issued to Blackadar was the result of a failure to do weekly assessments of five residents with skin breakdown, pressure ulcers, tears or other wounds.
One resident went 13 consecutive weeks with no checks on a wound, while another was never assessed again after a wound was initially discovered. The three others also missed multiple checks, including a gap of 31 days for one.
It resulted in a compliance order being issued on March 30 to prepare, submit, and implement a plan to ensure weekly wound assessments are done going forward.
The fine was added because a previous inspection report from Oct. 27, 2021, found similar failings with wound care at Blackadar. AMPs can be issued when a home has had at least one other compliance order for the same problem within the previous three years.
The aim of an AMP is to encourage compliance and increase home accountability through appropriate, fair and consistent monetary penalties that increase significantly with repeated noncompliance," the Ministry of Long-Term Care said in a statement.
The other reason for an AMP is when a compliance order is not followed, which is why Shalom Village was fined. The home had been ordered in October to review its reporting policy after Shalom Village failed to investigate allegations that a resident was often being denied ordered pain medications by a staff member. The complaint by the resident and their family members was also not reported to the director.
The home had until Dec. 1 to comply but had no signed declaration that the review had been done when inspectors returned in February and March.
The work had actually been done, but the person didn't do the paperwork correctly," said Morden. Do I wish the person had kept better records and did I think they would have? Yes, but they didn't. We were wrong. We fixed it."
Inspectors found Shalom Village also failed to comply with an order from Feb. 28, 2022, but didn't issue a fine. The order was to ensure all staff, including new hires, were trained on the most current version of the policy to promote zero tolerance of abuse and neglect of residents by May 2, 2022.
The order stemmed from allegations of a personal support worker (PSW) sexually abusing two residents. In both cases there was no documentation in the residents' charts about the alleged incident or whether they were assessed afterward. The accusations were not reported to the director immediately and the police were not contacted right away. For one of the residents, the physician was not notified.
The PSW no longer works at the home and Morden says the staff training was done. However, attendance records showed only 80 of 181 staff had completed the education.
It's a huge priority for us, talking about a culture of respect and making sure that everyone here - the residents, the staff, the families - can come to Shalom Village and feel that they will not be abused, that they will be listened to and heard," said Morden. It wasn't that it wasn't important to us ... We just didn't have the paperwork complete."
Morden says the fine is unfortunate as she'd rather put the money toward the residents - the cash can't come from ministry funding.
I don't know why people take out a big stick," said Morden. They weren't happy with us that we didn't have the right records ... I think they wanted to say to us, You have to dot your i's and cross your t's. You have vulnerable people in your care and we expect you to have that kind of attention to detail.' That's how I'm taking it. I don't disagree with them. I wish they hadn't because I'd rather spend the money on something else."
The ministry found a number of other issues that are detailed in the March inspection reports for Blackadar and Shalom Village.
Noncompliance with Ontario long-term care legislation was found 13 times at Shalom Village, including an order issued to follow COVID-19 screening requirements.
This is stuff we knew about. This is stuff we had processes in place to fix," said Morden. Shalom Village is moving toward who they want to be."
Noncompliance was found 16 times at Blackadar during the inspection over multiple days in January, February and March, including the order and fine over wound care.
We have received and reviewed the recent inspection report ... and will be working with Extendicare to ensure that all necessary actions are taken to address the report and concerns raised therein," Haidar Sakhi, CEO of H & S Holdings, said in a statement.
The future of Blackadar is unclear as the owners had a redevelopment plan for the site in 2021 that would see the long-term care home close and be replaced with a nine storey, 226-unit residential building. The adjoining retirement residence has already shut down.
However, the province announced in 2022 that Blackadar would be significantly expanded and rebuilt into a 192-bed home.
Joanna Frketich is a health reporter at The Spectator. jfrketich@thespec.com