The Ontario seniors home with the most deaths related to COVID-19 has a lengthy history of failing to comply with provincial rules designed to protect long-term-care residents.

A Star review of Ministry of Long-Term Care inspection reports from the last five years found that Orchard Villa long-term-care home in Pickering has faced a litany of citations for non-compliance with regulations and previous ministry orders, including those around ensuring living areas are kept clean and sanitary; protecting residents from staff abuse; meeting residents’ continence and toileting needs; and preventing falls.

To date, more than 200 residents and staff of the 233-bed Orchard Villa have been infected with COVID-19, while 52 residents have died from the virus.

April Beckett, a spokesperson for Southbridge Care Homes, owner of Orchard Villa, told the Star the company’s full attention is focused on the needs of its residents as it works to manage the COVID-19 outbreak at the home and it could not commit resources to address specific details of its inspection history.

Beckett said the company has “made significant progress” since taking ownership of the home in 2015, adding that it “co-operates transparently with the ministry in all inspections and work(s) to quickly resolve any areas noted for improvement or required action.”

Last week, Durham Region’s medical officer of health, Dr. Robert Kyle, ordered Orchard Villa to “address the immediate risk of COVID-19 to residents and staff of this home,” and a team from Lakeridge Health was sent in to lead the home’s response to the outbreak.

The home is one of the facilities where members of the Canadian Armed Forces were sent to assist staff.

Beckett, in her statement to the Star, said resident complaints or incident reports are immediately filed with the ministry to ensure potential issues are recognized early.

“We abide by all legislative requirements for hiring qualified staff. That said, there has been a chronic challenge to achieve adequate staffing in long-term-care homes across the country for a number of years,” Beckett said. “It is an issue that COVID-19 has highlighted, but it is one we have been actively working to address for some time with government partners, provincial associations, and through collaborative efforts with other providers in the sector.”

“Our commitment, now and always, is to our residents and providing the care we know they expect of us,” she added.

The Star reviewed inspection reports from December 2019, the most recent to be made public, back to July 2015, around the time when Southbridge Care Homes took ownership. During that time, Orchard Villa underwent 34 ministry inspections, two dozen of which led to a combined 127 notices of failure to comply with the Long-Term Care Homes Act and its regulations. Among them were two incidents in which doctors were not notified immediately after patients were injured and found bleeding. In one case, the senior died hours later.

All inspection findings were made before the COVID-19 outbreak at the home.

Seniors advocates say long-term-care facilities’ records of compliance or non-compliance with provincial legislation raise questions about the ability of some homes to handle the exceptional challenges that come with a pandemic.

“I think that the inspections reports provide you with a window into issues that a home is having and allow the public, as well as the government, to see whether or not homes are able to provide the care as required under the legislation,” said Jane Meadus, a lawyer with the Advocacy Centre for the Elderly. “So if a home has a problem or many problems in a time of relative normalcy, its ability to manage a pandemic where there are far more problems and issues is going to be affected.”

In April 2019, following three anonymous complaints, Orchard Villa was cited for failing to ensure that a sufficient supply of clean linens, face cloths and bath towels was always available for residents’ use.

The inspection report indicates that the availability of clean linens and towels fluctuated at different times and in different areas of the home. On one occasion, an inspector found, in one resident home area, “four beds stripped to the mattress and there was no linen available to make the beds. No towels or face cloths in any resident rooms. There were no towels in the spa room. The linen cupboard contained bedspreads, blankets, and one flat sheet.”

The home was told to come up with a voluntary plan of correction to address the problem.

The Ministry of Long-Term Care conducts several different types of inspections: those based on complaints; reports of critical incidents — serious incidents affecting the well-being of residents, such as fires, unexpected or sudden deaths, missing residents, and disease outbreaks; and followup inspections to determine if past complaints orders have been addressed. It also conducts “resident quality inspections,” which it calls a “comprehensive inspection” of the home designed to take a fuller look at several aspects of resident life; these inspections involve interviews with random samples of residents.

The last time Orchard Villa was the subject of a resident quality inspection was two years ago.

“When you have companies that have two years of no full inspections, it’s really hard to know what’s going on in those homes and what is causing them to have a really bad problem,” said Meadus.

“If you’re not inspecting them, you don’t know how they’re doing.”

Gillian Slogget, a spokesperson for Minister of Long-Term Care Merrilee Fullerton, said every long-term-care home is inspected at least once a year and that the ministry completed 2,882 inspections in 2019.

“Ministry inspectors conduct inspections to ensure that long-term-care homes are safe and well operated, and are meeting all the requirements in the Act and Regulation while thousands of health-care providers in Ontario work to provide a high quality of care to residents,” said Slogget, who added that the ministry has redeployed inspectors “to use their skills and experience to best guide and support the long-term-care system through the COVID-19 crisis.”

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She added that resident quality inspections are just one type of inspection the ministry uses.

At the time of its resident quality inspection in 2018, Orchard Villa was cited for six compliance failures, and given one compliance order related to medication administration. The ministry ordered Southbridge Care Homes to ensure that three residents in particular “and all other residents are administered medications in accordance with the directions for use specified by the prescriber.” Inspectors noted that in one case, an incorrect dosage of medication was given to a resident, and, in two other cases, no medication was administered at all. The report notes that the residents did not suffer harm as a result.

Marie Tripp, whose mother, Mary Walsh, was a resident of the home over the last year, says she complained to Orchard Villa about the treatment her mother was receiving. Walsh died on April 20 at the age of 89 after contracting COVID-19.

“It started from lack of communication with one nurse, in particular, and she was not communicating through the log book,” Tripp alleges.

Tripp says her mother underwent skin cancer surgery while living at the home and was prescribed painkillers. She says she gave it to a nurse at Orchard Villa, but somehow the receipt of the medication wasn’t logged. Only after repeated questioning did the home log the medication, she claimed.

When asked about Walsh’s case, Southbridge Care Homes’ Beckett said the organization was not at liberty to disclose “private information” about any of its current or former residents to the media.

Tripp says that after the home was put in lockdown in mid-March, she visited her mom’s window every day. She and her two daughters put up notes and posters in the window and windmills in the bushes outside to cheer Walsh up.

After her mother died, Tripp says she began to go through Orchard Villa’s inspection reports but says she has no idea if her complaints were reported by the home to the Ministry of Long-Term Care.

“I honestly believe, just my opinion, that it was all dealt with internally, so it’s not on that list,” Tripp says.

An inspection report from April 2016 that issued 19 non-compliance notices found nurses at Orchard Villa failed to contact a doctor as required. The report details how two personal support workers were transferring a resident from a wheelchair to a bed using a mechanical ceiling lift when the resident’s medical equipment became entangled with the lift. The PSWs heard the resident “cry out” and observed the resident “was in discomfort and bleeding.” An hour and a half later the resident was found with “vital signs decreasing” and was taken to hospital and assessed by a specialist. Later that day, the resident was transferred back to Orchard Villa, where they were found dead four hours later.

The home’s director of care at the time told the inspector that the personal support workers assisting the resident weren’t following the home’s “Safe Lifting with Care Program” and that nursing staff should have contacted the resident’s physician when the resident continued to experience bleeding. The director of care also told the inspector that they were unaware that a sudden and unexpected death required an immediate notification to the ministry’s compliance branch director; it wasn’t until 15 hours later that the death was reported.

That same inspection report found Southbridge Care Homes failed to ensure that suspected abuse of a resident — namely financial abuse — was immediately reported to the ministry. The compliance problem was based on an interview with two residents in November 2015 who alleged that $270 and $40, respectively, went missing from their possessions. Inspectors found that there was a documented record of the missing money in one case, but not the other. The inspection report notes that the home administrator “confirms that he did not complete or submit a report” to the ministry’s compliance branch director as required.

In July 2015, the home was cited for failing to comply with the Act after a resident with a cognitive impairment fell and was found “on the floor in a pool of blood,” with blood on the bedside drapes.

The report notes that the resident was identified as having an “extreme high risk” for falls and had already fallen five times during the year. The inspection report notes that the physician was not notified of the fall and resulting injuries. Instead, nursing staff tended to the wounds with bandages that became “saturated with blood.” The Registered Practical Nurse on duty told inspectors the physician was not called because they were “fearful of waking the physician during the night.”

It took seven hours before the resident’s family was contacted, at which point the resident was transferred to hospital and treated.

Laura Tamblyn Watts, CEO of the national seniors advocacy group CanAge, said inspection reports can also reveal the lack of funding for infrastructure and staffing in the long-term-care system.

“When we look at inspection reports, we have to not just see what’s happening at that moment of time at that home, but we must take a step back and say, are we funding so that homes can meet the standards that are required?

“I say we are not.”