Following a spate of claims of abuse by a former nurse at the Mount Hope Centre for Long Term Care, the Ministry of Health has released its report into the scandal.
Nineteen patients along with some co-workers issued allegations of verbal and sexual abuse against Susan Muzylowsky.
Earlier this year, London police launched an investigation into the instances of abuse at the hands of Muzylowsky.
Police received the complaint from the owner of Mount Hope, St. Joseph's Health Care in June.
The investigation came two years after management at the home learned that Muzylowsky abused and mistreated residents physically and mentally.
CEO and President Dr. Gillian Kernaghan told CTV News that at the time, staff made the judgement call that there was no criminal intent in her actions.
The Ministry of Health and Long Term Care's re-inspections of Mount Hope took place on May 26, 27, 30, 31, as well as June 1-3.
During the inspection, 10 written notifications, nine director referrals, as well as one compliance order and a voluntary plan of correction were issued.
According to the Ministry, Mount Hope failed to comply with the Long-Term Care Homes Act's policy to promote zero tolerance of abuse and neglect of residents.
The report states, "The licensee has failed to ensure that there was a written policy that promoted zero tolerance of abuse and neglect of residents and that it was complied with."
In the report, the Ministry quoted Mount Hope's (St. Joseph's) own July 2014 Abuse and Neglect of Residents: Zero Tolerance policy.
"When any incident of alleged, witnessed or suspected abuse or neglect of a resident occurs, it is mandatory that the person who becomes aware of the abuse report the incident immediately to the Registered Nurse who will notify the Coordinator or Clinical-on-Call."
A review of the home's investigation notes failed to identify that specified allegations had been investigated.
The report also says that residents who brought forward the allegations of abuse were not protected from acts of retaliation.
Also in the report, the Ministry says Mount Hope had a history of noncompliance with the Abuse Policy, as non-compliance orders were issued in 2014, 2015 and 2016.
In a news release issued Wednesday, Dr. Gillian Kernaghan, President and CEO of St. Joseph's Health Care apologized for the treatment some residents received.
"Since 2014 the journey of improvement at Mount Hope has been an ongoing priority for the organization’s leadership team. We are committed to ensuring our practices and policies support a culture of accountability for our staff and ensure safe and quality care for our residents. We recognize and apologize for any distress this has caused residents and families as well as our staff and the community."
"Some of the areas would include making sure that we have real clarity around our policies and making sure that we are on a regular basis, educating our staff regarding reporting anything that they may see that would be inappropriate in the environment," adds Kernaghan.
To view the Ministry of Health and Long Term Care inspection reports of St. Joseph's and Mount Hope, click here: http://publicreporting.ltchomes.net/en-ca/homeprofile.aspx?Home=c596&tab=1