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Camilla Care Community – a cross outside of it seen here on April 13, 2020 – is owned by Sienna Senior Living Inc., one of Canada’s largest owners and operators of private, for-profit long-term homes.

Fred Lum/the Globe and Mail

Staff at Camilla Care Community were wearing plastic bags over their clothing as personal protective equipment, garbage pails were overflowing with discarded food and soiled diapers, and physicians, including the home’s medical director, were checking up on residents by phone instead of visiting in person, says a new report.

Trillium Health Partners, which has taken over management of Camilla Care under a mandatory order by the province, has documented its initial findings in a nine-page report sent to family members of residents on Monday.

The report chronicles problems ranging from poor hygiene standards – cockroaches were observed in the kitchen and on residents’ floors – and a lack of communication with family members who have not been able to visit loved ones during the pandemic, to leaders at the home who could not consistently identify who had been exposed to the coronavirus.

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Some residents in palliative care were not receiving an adequate supply of oxygen because of a shortage of oxygen tanks.

“It is important to note that for the staff to be successful in caring for residents in a safe and sustainable environment,” the report says, “key workplace changes will need to take place, including cultural change.”

Camilla Care is owned by Sienna Senior Living Inc., one of Canada’s largest owners and operators of private, for-profit long-term homes. To date, 68 residents of the 236-bed home have died of COVID-19, the respiratory disease caused by the virus, and 16 remain in hospital.

Sienna spokeswoman Natalie Gokchenian said in an e-mail Monday evening that the company is “deeply disappointed” by the observations made by Trillium. “We have reviewed the report and remain committed to making changes where change needs to happen,” she said, reiterating that Sienna hired former Ontario deputy attorney general Paul Boniferro last week to conduct a company-wide review of its policies and practices.

The report prepared by Trillium corroborates many of the allegations of elder abuse made by a whistle-blower, including forced feeding. The whistle-blower was part of a team from the hospital network sent to Camilla in late April to help deal with the outbreak of COVID-19. Peel Regional Police have launched a criminal investigation into her allegations.

Trillium has also hired Benard and Associates, a Cambridge, Ont., firm founded by former police officer and nurse Dean Benard, to conduct an internal investigation.

Four staff members of Camilla Care and one person who is a staff member at the hospital have been placed on leave while the investigation takes place.

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By the time staff from Trillium arrived at the home, the coronavirus had spread throughout the facility. In all, 186 residents tested positive for the virus, along with 60 staff members, ranking Camilla Care as one of the hardest hit seniors’ homes in Ontario.

Trillium’s report describes a home ill-equipped to prevent the highly contagious virus from spreading. Residents sickened with COVID-19 shared the same room with those who were healthy. The home’s leaders did not always know whether contact tracing had been completed on residents who had tested positive, and not all nursing staff were aware of how and when to swab someone for testing.

Leadership at the home ignored the fact that staff did not use face masks, gloves and other personal protective equipment properly, the report says. “Staff were initially observed wearing garbage bags over their clothing and on their feet as PPE, and keeping gloves on while washing their hands instead of changing gloves,” the report says.

The Trillium report also says a shortage of staff affected every facet of the home, from cleaning the premises to food preparation and care of its elderly residents.

Garbage cans were too small, and were overflowing with discarded personal protective equipment, food and soiled diapers. Only three staff were working in the kitchen preparing meals, down from a normal shift of nine. No supervisor was on site to ensure that residents’ dietary needs were met. Delivering meal trays to residents was disorganized, sometimes taking up to three hours.

The report says Peel Public Health declared the COVID-19 outbreak over at the Mississauga home on June 7. Pest control completed spraying for cockroaches on June 11.

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The Ontario government has ordered hospitals to take over two other homes owned by Sienna: Altamont Care Community in Scarborough and Woodbridge Vista Care Community in Vaughan.

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