Staffing issues, neglect found in past inspections at Windsor LTC home in COVID-19 outbreak

A Windsor long-term care home experiencing a major COVID-19 outbreak holds a number of infractions, some of which include neglect, insufficient staffing and improper hygiene services.

The Village at St. Clair has 147 COVID-19 cases

'We are strong' posted in the windows at The Village at St. Clair long-term care home as the facility continues to see a major spread of COVID-19. (Darrin Di Carlo/CBC)

A Windsor long-term care home experiencing a major COVID-19 outbreak has been cited for a number of infractions in recent provincial inspections, related to neglect, insufficient staffing and improper hygiene services. 

As of Monday, the province is reporting 147 cases — 97 resident cases and 50 staff — along with five resident deaths, at The Village at St. Clair — a long-term care home in Windsor operated by Schlegel Villages. The Windsor-Essex County Health Unit (WECHU) declared an outbreak at the home on Dec. 8. 

WECHU's website is reporting 68 resident cases and 50 staff cases as of Monday. 

According to a website that publicly reports inspections at long-term care homes, The Village at St. Clair was struggling with staffing levels prior to its outbreak and has violated several rules under Ontario's Long-Term Care Home Act, including poor staffing plans, failure to provide proper hygiene services such as bathing and incidents of resident neglect. 

CBC News reviewed the four complaints inspections and five critical incident inspection reports of the home in 2020. Of these reports, the home was found to have at least 20 infractions where they fail to comply with the province's Long-Term Care Home Act rules. 

A recent complaints inspection completed at the end of October, found that the home was struggling with staffing. 

Appropriate staffing levels at long-term care homes across the province has been a struggle throughout the pandemic

In the last few days, family members of residents in the home have told CBC News that they are concerned about the care of their loved ones and worry about staffing levels as dozens are off sick. 

The home has told CBC News in emailed statements that it is filling staffing vacancies and doing all it can to protect residents and staff by providing all personal protective equipment and going through a second round of testing. 

In a statement to CBC News Monday, VP of Operation West Joanne Potts said "The residents we serve are at the centre of all we do ... In any instance where a Ministry inspector identifies an area of improvement, our team takes action to resolve or correct the matter.

"In terms of staffing, The Village at St. Clair was fully staffed prior to the pandemic. With the current outbreak at the home, we are working to increase our staffing levels. The efforts from our dedicated central recruiting team from our support office continues to yield new hires, including a nurse practitioner and the onboarding of nurses and PSWs from our agency partners."

It continued to say that team members from other Villages locations have come to help out that that staff are running weekly virtual recruitment fairs to onboard more team members. 

'Pattern of compromised care'

The home's infractions, according to associate social sciences teaching professor at Ontario Tech University and long-term care researcher Vivian Stamatopoulos, are "very serious" and its track record shows a "pattern of non-compliance." 

"I think it's very clear reading these inspection reports that this home has had issues for a long time," she said. "There is a pattern of compromised care and the pandemic only aggravated what clearly is a disorganized and fragmented home." 

Social sciences associate professor at Ontario Tech University Vivian Stamatopoulos says the home has many complaints and critical incident inspections that show a clear pattern of 'compromised care.' (Jennifer La Grassa/CBC)

In one of four complaints inspections performed this year, the home was found to have insufficient staffing levels at the end of October. 

After a review, the inspection noted that "the home was not at full PSW compliment for a number of days with varying number of shortages, for the day, evening and midnight PSW shifts."

As a result of this, "specific care had been missed on occasion" for certain residents and the home did not try to get agency PSWs to fill the empty shifts. 

It continued to say that an interview with the general manager "confirmed that the current staffing mix did not meet the current needs of the residents." 

Stamatopoulos said while she hasn't looked at all other inspection reports from care homes across the province, the amount listed for The Village at St. Clair looks like what "more than the average home receives." 

The home has also not had a Resident Quality Inspection (RQI) since 2018, which director of geriatrics at Sinai Health System and University Health Network in Toronto Dr. Samir Sinha says were essential, until the government decided to switch to a complaints-based inspection system in the last few years. 

It's not the only one to have lost this. Sinha said that in 2019 only 27 of Ontario's 626 long-term care homes got an RQI, with that number dropping to 11 this year, as of Oct. 15. 

Between 2018 and 2019, Sinha said the complaints and critical incidents double for the home, which is the year it loses the RQI — a random check in on the home that assesses its operations and care. 

"One of the challenges that we see is that over the last few years like this is a classic home where we're seeing the number of individual complaints skyrocket after not seeing an RQI anymore," Sinha said.

"The argument might be that if you were actually were continuing to do these RQIs you might not have [a] significant increase in the number of other critical incidents and other complaint inspections occurring." 

In 2019, the home saw 10 critical incidents and complaints inspections and was ordered in March to improve its infection control measures as it failed to properly monitor and document resident symptoms related to an illness. 

In response to this, the home told CBC News in an email that it "created an electronic surveillance record protocol that has now been rolled out in all of our homes." 

Stamatopoulos also said that earlier this year the owner of Schlegel Villages, James Schlegel, became a member of the province's Long-Term Care Staffing Study Advisory Group to provide "strategic advice on staffing in the long-term care sector across the province," according to the government's website

Schlegel also sits on the province's Incident Management System Long-Term Care Table, which is a group that makes decisions with issues related to staffing, infection management and resources during the COVID-19 outbreak. 

"[There's] this record of poor performance in his homes, yet he is, at the same time, advising our government on how to protect residents that he seemingly cannot protect in his own home," she said. 

Local politician demands government action

NDP MPP for Windsor West Lisa Gretzky wrote a letter to Ontario Premier Doug Ford Thursday "demanding the province take over the management" at the home. 

According to Gretzky, over the weekend family and employees told her that some floors had one worker to 33 residents. But she added that Hotel Dieu Grace Healthcare hospital has sent some of their workers to temporarily fill in the gaps. 

The letter asks the premier to ensure the following: 

  • Properly fitted N95 masks. 
  • Additional PPE for every staff member
  • More staffing support as more staff become ill. 
  • Issue orders along with penalties to the company for any noncompliance. 

Last week, the home told CBC News that staff have been equipped with all the necessary PPE and given universal-fit N-95 masks. 

NDP MPP Lisa Gretzky says the Ford government should take control of the home immediately. (Chris Ensing/CBC)

She said what has stood out for her this past week is the "fear" the "desperation" from family members. 

"My office has been flooded with calls and emails and I've talked to some people myself ... and it's the same with the staff, it is fear and it is desperation, they really need some support, some extra help in there," she said.

"Looking at how quickly the numbers are rising in that home and looking at the other issues such as residents not being able to communicate with the family members and all that uncertainty, I believe that it's at the point where the province needs to step back in to take over management of the home."  

As of Monday, 14 long-term care and retirement homes in Windsor-Essex are in outbreak, with the largest outbreaks being at the following locations:

  • Berkshire Care Center in Windsor, 28 residents and 28 staff sick
  • Extendicare Tecumseh in Tecumseh, 32 residents and 13 staff sick
  • Chartwell St. Clair Beach in Tecumseh, 39 residents and 8 staff sick

About the Author

Jennifer La Grassa


Jennifer La Grassa is a reporter/editor for CBC Windsor. Email:


To encourage thoughtful and respectful conversations, first and last names will appear with each submission to CBC/Radio-Canada's online communities (except in children and youth-oriented communities). Pseudonyms will no longer be permitted.

By submitting a comment, you accept that CBC has the right to reproduce and publish that comment in whole or in part, in any manner CBC chooses. Please note that CBC does not endorse the opinions expressed in comments. Comments on this story are moderated according to our Submission Guidelines. Comments are welcome while open. We reserve the right to close comments at any time.