Inspectors of Cedarwood find cases of elder neglect among other things


Cedarwood Lodge of 860 Great Northern Road is under the gun again after inspectors found about a dozen cases on non-compliance by the Ministry of Health and Long-Term Care under the Long-Term Care Homes Act of 2007.

These include: one critical incident submitted to the Director related to an allegation of staff to resident neglect; two critical incidents submitted to the Director related to resident to resident abuse, one critical incident submitted to the Director related to resident falls, one critical incident submitted to the Director related to improper care of a resident; and, four complaints submitted to the Director related to the care of residents.

This inspection was conducted on the following date(s): September 18-22, and 25-29, 2017. The report was not made public until just recently.

The purpose of this inspection was to conduct a Resident Quality Inspection.

During the course of the inspection, the inspector(s) spoke with the Administrator, Director of Care (DOC), Life Enrichment Manager, Dietary Services Manager, Registered Dietitian (RD), Physiotherapist, Resident Assessment Instrument (RAI) Coordinator, Registered Nurses (RNs), Registered Practical Nurses (RPNs), Personal Support Workers (PSWs), Food Service Worker (FSW), family members and residents.

The inspector(s) also conducted a daily tour of resident care areas, observed the provision of care and services to residents, observed staff to resident interactions, reviewed relevant health care records, staff personnel files and reviewed numerous licensee policies, procedures, and programs.

Written Notification #1: The licensee has failed to ensure that there was a written plan of care for each resident that set out clear direction to staff and others who provided the direct care to the resident. The licensee has failed to ensure that the resident, the resident’s substitute decision-maker, if any, and any other person designated by the resident or substitute decision-maker was given the opportunity to participate fully in the development of the resident’s plan of care. The licensee has failed to ensure that the care set out in the plan of care was provided to the resident as specified in the plan. A Critical Incident (CI) report was submitted to the Director on a specific date, for an incident of abuse that occurred a number of days prior. During a health care record review, it was identified that resident #009 had experienced a number of falls over a 19-day period.

A compliance order was issued.

Written Notification #2: The licensee has failed to ensure that a person who had reasonable grounds to suspect that any of the following had occurred or may occur shall immediately report the suspicion and the information upon which it was based to the Director: abuse of a resident by anyone or neglect of a resident by the licensee or staff that resulted in harm or a risk of harm to the resident or improper or incompetent treatment or care of a resident that resulted in harm or a risk of harm to the resident. A Critical Incident (CI) report was submitted to the Director on a particular date, for an incident that had occurred a number of days prior. The CI report submitted under Improper/ Incompetent treatment of a resident alleged that a staff member improperly transferred residents #010 and #011. Inspector #542 reviewed a Critical Incident (CI) report that was submitted to the Director on a particular date, for an alleged incident of abuse that had occurred on a particular date. The CI report indicated that resident #016 performed an action towards another resident.

A second compliance order was issued.

Written Notification #3: The licensee has failed to ensure that residents were protected from abuse by anyone and that residents were not neglected by the licensee or staff.

A third compliance order was issued.

Written Notification #4: The licensee has failed to ensure that when a resident had fallen, the resident was assessed and that where the condition or circumstance of the resident required, a post-fall assessment was conducted using a clinically appropriate assessment instrument that was specifically designed for falls.

A fourth compliance order was issued.

Written Notification #5: The licensee has failed to ensure that the following requirement was met with respect to the restraining of a resident by a physical device under section 31 or section 36 of the Act: staff apply the physical device in accordance the manufacturer’s instruction. On September 21, 2017, Inspector #542 completed a health care record review for resident #015. The care plan included documentation to indicate that the resident was to have a specific device in place when using their mobility aid. During an interview with RN #112 on September 28, 2017, they stated that registered staff were to sign off on the Restraint Monitoring Record every eight hours. RN #112 stated that the purpose of them signing was to ensure that the PSW’s documented their hourly checks. No hourly signatures were in place on four specific dates in eight hour periods. If signatures from the PSW’s were missing, they were responsible to notify the PSW’s to complete their documentation on the sheet. RN #112 further stated that PSWs should have identified and documented what they had done with the device such as applying, monitoring and releasing.

A fifth compliance order was issued.

Written Notification #6: The licensee has failed to ensure that the policy promoting zero tolerance of abuse and neglect was complied with.The statement identified that on a particular date, staff found resident #012 sitting in a unclean bed. The statement identified that resident #012 was upset stating that they required assistance and no one would help them.
Furthermore, the letter identified that RN #108 commented to the staff that resident #012 was yelling the “entire time” and when approached to ask why the resident was left in that condition RN #108 stated “what did you want me to do about it?”.
Inspector #679 reviewed a document dated on a particular date, which indicated that RN #108 was terminated from the home on specific grounds.
In an interview with the DOC on September 26, 2017, they indicated that the neglect was substantiated and that RN #108 was terminated from the home

The other eight written notifications mandated a voluntary plan of correction.


  1. Okay let’s shut it down yeah people that’s a good idea, then tell me where these resident’s would go? You people are so quick to bash other’s just because of some others don’t give a shit. Yes i agree that some people are in it for a pay cheque but i’m telling you that’s not the case here. How do i know well i’m a resident here. And these girl’s are the most caring and have such a big heart and compassionate people you ever want to meet. I have been here right from when the place first opened and yes their were problem’s but they moved on and worked on problems but because of a rotten apple or two they came back and it has been takin care of.So let’s stop blaming the whole staff for a few Dog F**cker’s who don’t care!!!!

    • Well said Chris.
      And from a resident no less.
      Unfortunately, media is designed for this.
      To report the negative. Gossip.
      Bad news makes the news.
      Nobody ever gets credit. Such as these psws who do care, yet they cover the bad reports allowing others to say how “disgusting” it is and get to condemn people and say how much better they need to be. Yet, sault online does a write up about how Canadian Tire is giving snow tires to expecting moms! But not to the ones who do care for the life and wellbeing of other’s loved ones in a home. No, focus on the bad. It just shows what a joke this site is and what a joke their reporters are.

  2. My mother is there and she is soon to be relocated elsewhere. There is abuse going on and fortunately, my mother is not one of them. Everyone needs to be accountable who works there. They see and know what’s going on. For evil to grow- good people say and do nothing. How sad for our elders to be treated like they don’t matter. I’m putting a cam in my mom’s room, until she is transferred.

    • How sure are you that abuse isn’t happening where your mom is going? i get it, we want to protect our loved ones but take your time to read other LTC homes report in SSM and you will be surprised, stop blaming the staffs cause most people work their ass off, yes there is no excuse for neglect or abuse. why not blame the ministry itself or infact the management.

  3. Here so everyone can read about all the LTC homes in sault ste marie and the inspections. Maybe this reporter can write up five more stories instead of targeting one home. Other LTC home inspections are worse instead of protecting them because they are Extendicare

  4. Cedarwood is the Canary in the coal-mine! Government is finding seniors are a bottleneck in the Health System.
    They have were not prepared for so many of us, and still are not facing the problem. We have had no new
    beds for ALC residents in the Sault since 2004!!!!!!!!!Seniors are pushed sometimes into housing that is not of their choice. Seniors are living longer with more complex health issues, and staff are not properly trained for these issues ( no fault of their own) such as dementia and violent behaviour. Most staff are caring but they are also short staffed and their opinion is not respected.Consequently many seniors are dying ahead of their time through lack of care and inadequate medical attention. The health system is set up to hasten our demise. This is not the gentle exit from this realm we were led to believe, but were getting the big push due to too many of us and no planning. Government has put money ahead of people. We all have to voice

  5. It is interesting how this home appears in the news, yet when you check into the Ministry of Health listings on all the nursing facilities inspections in the Sault, the others have as many or more. Why do they not make the news. Are Soo Today and Sault Online pressured to not report on them due to their corporate ownership? Extendicare Mapleview, FJ Davey Home, VanDale, etc. Ministry of Health has inspection reports on all of them.

  6. Very few have compassion…. I stand with them…. For the Dog F##kers that are paycheck grabbers, and don’t give a shit…. Please… Find a New Career… These elderly people represent where we came from, they pointed us in directions we never thought possible… Never did they think that in their final Years, things would come to this

  7. we can say whatever we want or blame him or her fr this or that, it wont replace the dignity nor the loved one who is gone- these people were placed there in their care-care wasn’t provided -the directors are responsible

  8. The Problem is…. these people working there, just dont give a shit…. Wish it was me watching them… I delivered Prescriptions, there for years, and every time I went in there… I was sad when I left, Never saw any staff, always had to look for the RN to sign for scripts… always found her doing nothing, but hiding from the reality of her job…. ITS YOUR JOB….. DO IT AND BE GRATEFUL YOU HAVE A JOB….

    • Ron, this home has only been open a couple of years, so not sure where you have been delivering the prescriptions, maybe that it why you could not find anyone to sign for them

  9. What are the ministry set standards? 1 psw to 12-14 residents? and only 5 minute care per resident ….
    Always the psws blamed.
    Whether you “work to the bone” or not.
    You get yourself ready in 5 minutes and see if you’re not looking kinda neglected.
    Shut it down! Let’s trash the psws!
    But never fault the ministry, right?

  10. This is a complete ######## article.
    As a psw myself that has worked in homecare. I have visted many homes, and none are perfect. Far from it. I love how as a community we’re so quick to jump down others throats when reading something reported by a painter…
    I don’t know. Is it fair to blame the employees who are constantly working short staffed? Is it fair to not credit the psws in the home thar are doing a good job? No residents are ever interviewed. Their opinion never seems to come into play. There’s good and bad no matter where you go people.
    You’re basing the whole staff on the action of some who do not do their jobs.
    Truth is people there are people in every home that see your loved ones as nothing more than money on a cheque, and some that go above and beyond. In every home.

  11. I’ve been a HCA/PSW since 1990 and there is NO excuse for any of this!! Back then, things were different. I had never witnessed any of this at Van Daele Manor, nor the Tendercare. Things used to run smoothly, and although we had many clients to tend to each day, we pulled together to ensure that they all received proper care if we happened to be behind schedule. We were complimented for constant care and compassion by family members and the DOC. It’s crazy to see that this is happening in today’s world … and someone mentioned that there is a total of 50 patients? Wow .. we had double that amount for sure back then!

    • You’re serious? Tendercare was disgusting.
      Students in my class were complaining of ants. My great aunt was in there. In the 90s. And tendercare was terrible. It should have been shut down. I wouldnt send an enemy there let alone my loved ones.

    • Ran smoothly? They used restraints like crazy back than too many had table tops and seat belts whether they needed them or not, and were in their chairs from morning till night left in hall ways I had a family their was their often. Most times in larger homes many things are swept under the carpet.

  12. That place needs to hire more staff immediately if they are so understaffed that the current staff can not provide the care they are supposed to be providing. Is it going to take an event such as a resident ‘dying from lack of proper care’ before the owners of that place will hire enough staff? The owners should be fined a huge amount of money as a deterrent to acting so greedily that ghey do not have the sense to hire suffiient staff to handle the number of patients they house. Shameful that the jgnorant RN was not named!!

    • Its the Ministry/government to blame not the owners they only provide funding to hire one psw per 12 (min) residents (Ministry set standards) , it should be goverment funded to hire 1 psw per 8 residents max to ensure proper care and time can be given to also avoid burn outs and book offs.

  13. Understand that understaffed isn’t an excuse.
    WE MUST BE PREPARED TO WORK OUR FINGERS TO THE BONE because we’re well aware that there are those who simply refuse to.
    We must be willing to pick up slack without hesitation, or blame towards the innocent bystanders, not saying we should be silent about the slack, just saying that the elderly didn’t ask to grow old, and be cared for by us… They lived in a time where it wasn’t a question of how much you did, rather an insistence that you just DO until you can’t…
    Which they did.
    Just like fostering/adopting.. If you foster/adopt some children whether able or DISABLED,
    These children didn’t ask you to care for them, they simply require care and compassion that they’re most likely lacking. Don’t treat them the same way or worse than they were at home…. They’re not commodities they’re the future RNs that’ll be carrying our silly asses to bed and feeding our faces when we cannot reach…. What that woman said about it comes back.
    She’s one hundred percent correct. It will, incidentally the young grow up and the RNs and psw and fosters will ALLLL grow old…. Who’s going to wash your arses when you’ve shat yourself? Hopefully someone who won’t throw your nappie into your face because you did it to someone they loved in the past…. Oh wait. Perhaps this is occurring .. .Hmmmm… Now I gotta rethink

  14. Cedarwood always quick to get thrown under the bus, so i’m just here wondering, why always this home? have you all seen public report on Maple View?? Tons of abuse and neglect but why don’t they ever make it to the news? Cause Extendicare? Well Sault online, your headlines are pathetic and i see what you guys are doing, keep it up!

  15. I agree the names should be released so they can’t get hired some other place to repeat what they have done. It does make me sick o my stomach too and the place should be shut down. They have to remember they will be seniors some day and what goes around comes around! They should be treated the same way then, but people have hearts ♥️

    • Very few have compassion…. I stand with them…. For the Dog F##kers that are paycheck grabbers, and don’t give a shit…. Please… Find a New Career… These elderly people represent where we came from, they pointed us in directions we never thought possible… Never did they think that in their final Years, things would come to this

  16. Wow….. Names of the apparent RN should be released to the public, as many people seek RN assistance for their loved one’s that reside in their own homes and aren’t supervised on a constant basis unless by way of camera… Just like babysitters… If we abuse a helpless person, we should be well known. .
    Innocence and helplessness doesn’t permit attack… So many instances I have seen with my own two eyes, abuses against the most helpless and I was too young to speak up…. I’m not anymore so BEWARE (those who have acted in such aforementioned ways are well aware that I am speaking to them)

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