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The report says 31 written notifications, including 18 compliance orders, have been issued regarding Brucelea Haven. County officials say they are working to satisfy the requirements of those orders.

Colameco’s report says even though 80 nursing staff members at the home worked 2,512 overtime hours from Jan. 25 to March 27, the home was unable to maintain its staffing plan levels for registered nurses, registered practical nurses and personal support workers.

Over that same 60-day period, the home did not have a full PSW complement on 57 of those days.

As of April 5, three permanent part-time PSW positions and eight temporary positions had not been filled.

The report outlines the many ways the staffing shortages impacted resident care.

Residents are supposed to be transferred by two staff members, but the shortage results in only one employee being available to do the move.

One case highlighted in the report says a resident was transferred on three separate occasions by one employee, despite their care plan requiring two-person extensive assistance. The resident was injured each time and died within a short time of the last injury. The person’s death certificate notes falls with injury as a contributing factor.

The inspection also found Bruce County failed to ensure the home’s staffing plan promoted continuity of care by minimizing the number of different staff who provide care to a resident.

The report mentions a case where, due to a shortage of staff, an RN who had not completed their orientation cared for a resident they were unfamiliar with while on a unit they had not worked on before. The RN incorrectly processed palliative care orders for the resident and it wasn’t until the regular RPN returned to work a few days later that the resident was assessed for a possible respiratory infection. The RPN recognized the resident was not palliative but displayed symptoms of an infection. The resident’s death certificate stated the cause as respiratory infection with approximate interval between onset and death as one week.