Ottawa·CBC Investigates

Serious, repeat violations at city-run nursing home

A CBC investigation has found 105 violations against the Long-Term Care Homes Act occurred at the Peter D. Clark Centre over the past five years. That places the facility in the top 10 per cent of Ontario care homes with the most violations. 

Families say they’ve witnessed and documented complacent care at Peter D. Clark Centre

Retired acute care nurse Lorraine Thomas says she was shocked to see her husband's conditions when she was once again allowed to visit him at the Peter D. Clark Centre in Ottawa. (Francis Ferland/CBC)

Despite a serious COVID-19 outbreak and several deaths in his unit at the Peter D. Clark Centre, Helairie Thomas has so far evaded the illness, but his wife says he hasn't gone unscathed. 

"He was on death row, and he survived," said Lorraine Thomas. "Based on how he's deteriorated in the six months of being 'incarcerated' there, he may not survive the next wave, which we're in." 

Thomas, a retired acute care nurse at the Civic campus of The Ottawa Hospital, was shocked by her husband's condition when her daily visits resumed this fall.

"His toenails have fungus and they're practically gone ... He has a stage two, diabetic ulcer and those can turn gangrenous. It's darkened," she said. 

Thomas, whose husband has dementia and has lived at the Ottawa facility for three years, has been critical of issues she's witnessed at the home, and she's not the only one to have filed official complaints.

There's too much complacency.- Diana Pepin

A CBC Marketplace investigation has found that 105 violations against the Long-Term Care Homes Act occurred at the Peter D. Clark Centre over the past five years. That statistic places the facility in the top 10 per cent of Ontario care homes with the most violations. 

The analysis of reports from Peter D. Clark also showed 25 repeats of the most serious offences, including abuse, inadequate infection control, unsafe medication storage, inadequate hydration, and poor skin and wound care, among others. 

3rd outbreak this year

Right now, the Peter D. Clark Centre is experiencing its third outbreak. Three staff members tested positive for COVID-19 in October. 

Despite the outbreak, essential family caregivers like Lorraine Thomas are now allowed inside the home.

Diana Pepin, whose mother Viola Surkan has lived at Peter D. Clark for six years, is also a retired registered nurse. 

Diana Pepin, left, is a former nurse and essential caregiver to her mother Viola Surkan who lives at the Peter D. Clark Centre. (Submitted by Diana Pepin)

Having nursed together at The Ottawa Hospital decades ago, Pepin and Thomas were re-acquainted in recent years at the long-term care home. 

Pepin said she was horrified by her mother's condition when she was allowed back in this fall.

"I came back five months later to see her groin look like she had been scalded by hot water being poured over her," Pepin said, referring to the severe skin wounds likely caused by her mother lying in urine-soaked diapers.

"This didn't happen overnight." 

‘Something isn’t working properly’

3 years ago
Duration 0:56
Lorraine Thomas, a retired nurse whose husband lives in the Peter D. Clark long-term care facility, says the standard of care at the centre is inadequate and that her husband’s condition has deteriorated sharply in the last six months.

Repeat drug errors

The CBC Marketplace investigation found the Peter D. Clark Centre has been written up 12 times for medication error violations, the highest number of repeated offences for a single violation code in the province. 

They need to get in there now.- Lorraine Thomas

"This is only a tiny tip of the iceberg," said Pepin. "Probably the majority of [medication] errors happen unseen, unreported, unrecognized." 

One provincial inspection of the home in 2018 found 20 residents had been given an expired, 2017 flu vaccine in violation of the rules.

"I think there's too much complacency," said Pepin.

Surkan, a resident at Peter D. Clark, is still healing from serious skin wounds that developed during the COVID-19 lockdown at the centre. (Submitted by Diana Pepin)

Both Pepin and Thomas said they've complained to staff about drug errors they've witnessed, but they don't always  report to authorities. 

In those cases, Pepin said her complaints have been validated in reports. But two recent complaints about medication errors she filed last winter have yet to be investigated. 

Charged with non-compliance

In April 2019, Thomas said she arrived for a visit and found her husband slumped over a chair.

"I found him in the lounge, semicomatose. He was hot. He couldn't stand up. So nobody's paying any attention," said Thomas who called 911.

He had a perforated duodenal ulcer, an acute kidney injury and abdominal sepsis, she said. 

Helairie Thomas has dementia and has lived at the Peter D. Clark Centre for the past three years. (Submitted by Lorraine Thomas)

The province's Ministry of Long-Term Care investigated her complaint in July 2019, resulting in a written notice. The home was "requested to prepare a written plan of correction ... to be implemented voluntarily."

Dean Lett, the director of long-term care services at the City of Ottawa, said in a statement that the Peter D. Clark Centre takes issues of non-compliance very seriously.

"Currently, there are no outstanding issues of non-compliance," said Lett in the statement.

Since 2017, City of Ottawa care homes have added 43 full-time equivalent front-line positions, enhanced training on abuse prevention and updated medication processes, according to Lett.

'You have to look at them as humans'

Both Pepin and Thomas point to inconsistent staffing, under-staffing, a lack of proper training and an absence of the checks and oversight they adhered to at the hospital. 

"You have to look at them as humans," said Pepin.

Exhausted, with tears in her eyes, Thomas said she is worried her husband won't survive the second wave.

"[Premier] Doug Ford said that there will be an overhaul and no stone will be unturned. Well, I hope I'm not in my grave, because they need to get in there now."


Julie Ireton

Senior Reporter

Julie Ireton is a senior reporter who works on investigations and enterprise news features at CBC Ottawa. She's also the host of the CBC investigative podcast, The Band Played On found at: You can reach her at

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