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County-run home fined for not complying with wound care standards

County of Simcoe says progress being made to bring home into compliance; this is the second $5,500 fine issued this year for ongoing non-compliance
2022-06-27 Sunset JO-001
Sunset Manor is a long-term care home in Collingwood operated by the County of Simcoe.

The county-operated long-term care home in Collingwood has received its second fine this year related to ongoing non-compliance identified by provincial inspectors. 

The County of Simcoe, as the operator of Sunset Manor Long-Term Care Home, has been fined $5,500 by the province for failing to comply with provincial requirements for skin and wound care. 

In August, the county received the same administrative monetary penalty of $5,500 for not meeting provincial requirements for medication management. 

The communications team confirmed the county will be complying with the penalty. 

In a statement issued to the families of residents living in Sunset Manor, the county said it was pleased to report “continued improvement” at the home with “just two compliance orders remaining in place, an overall decrease from eight.” 

The remaining compliance orders are the same two that prompted the province to issue the fines: skin and wound care, and medication management. 

The most recent report and administrative monetary penalty issued by the Ministry of Health and Long-Term Care is the result of inspections that took place at the home in June. Incidents and observations recorded in the report show residents with wounds did not receive complete assessments once a week as provincial legislation requires, and wounds showing signs of deterioration and infection were not always referred to a physician in a timely manner. 

The report detailed one case of a resident with a stage-three pressure ulcer that got worse. An assessment completed one day noted the changes, but didn’t flag it for a physician follow-up. The next assessment seven days later did flag it, and the physician saw it the day after it was flagged and ordered a new treatment for it. 

The delay potentially caused the infection to be worse than it might have been had it been treated when the changes were first noted. Therefore, the delayed reporting to the physician likely caused the resident further harm, according to the inspector’s report. 

Other inspector notes indicated some, but not all, skin and wound assessments were incomplete, and did not include pertinent information including the measurements of the wound, indications of infection (such as swelling), a description of the wound bed, and the presence of odour.

Some residents went 12 days without an assessment, instead of the required maximum of seven.

“The residents exhibited altered skin integrity, including skin breakdown, pressures, skin tears, or wounds, and the licensee did not ensure that those residents were re-assessed at least weekly,” states the ministry report. “In cases where re-assessments were done, many of them were insufficient as they did not assess for important issues related to the skin/wound.” 

The county was given a compliance order by the province in the spring after inspectors noted other shortfalls in the home’s wound and skin care. The previous order was set with a compliance deadline of April 29, but according to the province, the county asked for an extension to May 20, 2022. 

Since inspectors found further non-compliance with skin and wound care in the home in June, the province issued a fine because the non-compliance was repeated within a three-year period. 

As the licensee for Sunset Manor, the county is required to take several actions ordered by the ministry, including conducting audits to make sure skin and wound re-assessments are completed weekly and the assessments must document the required information. 

The statement issued by the county lists multiple actions the county says it is taking to address the remaining two areas of non-compliance, including training and education for staff, daily auditing of staff compliance, additional registered practical nurse (RPN) resources, a resource nurse dedicated to overseeing the skin and wound program, and securing an external enterostomal therapy nurse to support skin and wound care assessments and treatment protocol. 

Enterostomal therapy nurses specialize in caring for patients with ostomies, and also treat wounds. 

There were no findings in the most recent report related to medication management. 

There were seven written notices, which are issued when an inspector investigates a matter at a long-term care facility. 

Among those notices is a finding of non-compliance with bathing requirements. 

In one case, a resident refused a bath seven times, and did not have a bath for four weeks. 

The findings of the inspector noted the three residents investigated identified a preference for a bath in a tub, but they received showers or bed baths. Residents are supposed to be bathed twice a week.

“One resident may have been refusing to be bathed because they were not being bathed as per their preference,” stated the inspector’s notes.

The latest report also noted two outstanding compliance orders were considered met. They were related to a pain management program and having the proper written policies for medication management. 

“The scrutiny on our home, new protocols and inspections have been challenging; however, our team, our residents and their families know first-hand that Sunset Manor is a great place to work and live,” the county said in its statement. 

There are currently 102 residents at Sunset Manor, but the home is equipped with 148 beds.

Sunset Manor has been under a new admissions ban since June 2021; the ban was ordered by the Ministry of Long-Term Care after several reports of non-compliance dating back three years and documented in inspection reports.  

The county has challenged the admissions ban in court, alleging it was an excessive response prompted by the reports of an ex-employee who is now a provincial inspector. 

The province has countered that the ban was and is still necessary based on multiple reports by multiple inspectors before and after the ban was put in place. It is the province’s position that the admissions ban would have been warranted even without any of the evidence presented by the former Sunset Manor employee.

“It is our top priority, and goal, to reopen admissions to our home as soon as possible,” reads the county statement. “We know the community needs these beds open and the county requires the ongoing support of its partners to continue to move forward. County council has given direction to do everything we can to reach compliance and welcome new residents.” 

The County of Simcoe operates four long-term care homes in Simcoe County, including Sunset Manor, Simcoe Manor (Beeton), Georgian Manor (Penetanguishene), and Trillium Manor (Orillia). 

The county is currently hiring for multiple positions related to long-term care and seniors care. There is a job fair at Sunset Manor on Thursday, Sept. 29 from 10 a.m. to 3 p.m. Applicants are encouraged to come prepared for on-the-spot interviews. 

You can read the most recent inspection report by the Ministry of Long-Term Care on Sunset Manor here.


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Erika Engel

About the Author: Erika Engel

Erika regularly covers all things news in Collingwood as a reporter and editor. She has 13 years of experience as a local journalist
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