Are Hamilton’s long-term-care homes as scary as they might seem?

The pandemic has focused public attention on long-term-care homes, retirement homes and the quality of care received by seniors, many of whom are vulnerable and alone.

It's an area of health and social services that's often been overlooked.

But not now.

Horrifying stories have emerged from the sites of some of Hamilton's worst COVID outbreaks.

The letters published recently from workers at Grace Villa on the Mountain outlining the frightening conditions at the home during the height of the crisis are heartbreaking to read. More than 140 residents at the long-term-care home became infected with COVID and 44 have died.

Meanwhile, former staff and family members described similarly wretched conditions at the Rosslyn Retirement Residence near Gage Park, where 16 people died and virtually all of the 66 residents had to be evacuated to hospital in May. The home, owned by the Martino families, is now closed and its licence has been revoked.

Outside of Hamilton, there were similar stories of horrific conditions and overwhelmed staff at long-term-care homes in Ontario. People were shocked and angry when the armed forces were called in during the spring to assist at seven hard-hit homes across the province.

At one Scarborough home, 73 seniors died from COVID. At a Pickering home, 70 more died - nearly one of every three residents in the home.

There's a growing perception, it seems, that long-term-care homes have become death traps for the elderly, that frail and vulnerable seniors are being warehoused in awful conditions and places, that they've been poorly cared for or even neglected.

And yet, that's not exactly what the data shows, not for Hamilton nor the rest of the province.

Yes, there have been long-term-care (LTC) homes and retirement homes with high numbers of COVID cases and deaths. But the numbers show an overwhelming majority of the cases and deaths have occurred in a small fraction of the homes.

A little over 70 per cent of all COVID cases involving long-term-care residents in Hamilton occurred in just four of the city's 28 LTC homes.

Of the 506 LTC cases as of Jan. 21, there had been 144 residents infected in Grace Villa, 91 cases at Shalom Village, 64 cases at Chartwell Willowgrove in Ancaster, and 58 residents infected at St. Joseph's Villa in Dundas.

Of the four homes, two are for-profit (Grace Villa and Willowgrove) and two are non-profit (Shalom Village and St. Joseph's Villa).

It's the same story with COVID deaths. Those four homes accounted for 75 per cent of all deaths in Hamilton involving residents of LTC homes.

There were 119 LTC resident deaths as of Jan. 21, with 44 occurring at Grace Villa, 19 at Willowgrove, 17 at Shalom Village and nine at St. Joseph's Villa.

That means there was a total of 20 resident deaths at the other 24 LTC homes combined. Sixteen of the city's LTC homes had reported no deaths as of Jan. 21.

Cases in retirement homes

With Hamilton's retirement homes, the situation was similar.

There are 37 retirement homes in the city. Two of them - the Rosslyn and Cardinal Retirement Residence on Herkimer Street - accounted for 54 per cent of all COVID infections and 70 per cent of COVID deaths involving residents.

Two-thirds of the city's retirement homes have reported no COVID cases at all and 31 of the 37 homes had not recorded a single COVID-related death as of Jan. 21.

Two recent academic papers published by researchers at McMaster University and the University of Toronto show the results at the provincial level are even more lopsided.

One study shows that 92 per cent of all resident and staff COVID cases in Ontario's 770 retirement homes have occurred in just 10 per cent of the homes. Flip that around and it means 90 per cent of the homes have only accounted for eight per cent the cases.

With LTC homes, the study shows 86 per cent of all cases have occurred in just 10 per cent of the province's 626 homes.

Everybody gets painted with a bad brush," said Andrew Costa, a McMaster University researcher who is an expert in clinical epidemiology and aging, as well as one of the main authors of the two papers.

Everyone thinks their loved one in long-term care is at mortal risk because of the news and because there are really bad places where people have pulled family out and that's where the majority of deaths have been," Costa said. But if you look at the absolute risk, it's in the low percentage points in terms of being seriously affected by COVID."

Families shouldn't be freaking out here," he added.

Inspection reports

The Spectator's investigation also looked at the results from inspection reports of LTC and retirement homes - but there's not always a direct connection between COVID cases and deaths when compared to violations, citations and orders to comply.

Shalom Village, with 91 cases and 17 deaths, was issued 12 written notifications, nine voluntary plans of correction and three city violations related to infection prevention and control in the past year.

St. Joseph's Villa, with 58 cases and nine deaths, had been hit with 14 written notifications, two voluntary plans of correction, nine compliance orders and four violations for infection prevention and control.

On the other hand, Chartwell Willowgrove had no violations from LTC inspection reports in the past year and just two noncritical violations from the city's infection prevention and control inspections. Yet the home ended up with 64 cases and 19 deaths.

Grace Villa - with 144 cases and 44 deaths - had six written notifications and two voluntary plans of correction, but those were related to inspections that were carried out in February 2020 - before the pandemic had reached Hamilton. Yet during the height of the home's outbreak in December, a ministry inspection report dated Dec. 22 shows no problems were found with compliance at Grace Villa and no orders or other corrections issued at the home.

The Grace Villa situation suggests that the findings from inspection reports don't always tell the full story about the condition of a home. Most home inspections now look only at specific complaints that have been filed rather than a complete review of the facility.

Meanwhile, the city-owned Wentworth Lodge in Dundas had 30 citations last year, including three orders to comply, but no COVID cases and deaths.

Extendicare Hamilton had 29 citations, including two orders to comply, but also had no COVID cases and deaths among residents.

On the retirement homes side, it was the same muddled picture.

The Cardinal had one violation cited by the Retirement Homes Regulatory Authority (RHRA) in 2020, but 53 COVID cases and 10 deaths. The Village of Wentworth Heights had 19 cases and four deaths but no violations.

Aside from the Rosslyn, the other four Hamilton retirement homes owned by the Martino families had no COVID cases or deaths combined.

Yet those four homes - Cathmar Manor, Dundas Retirement Place, Montgomery Retirement Home and Northview Seniors Residence - had 51 RHRA violations combined, all of them had conditions on their licences and all of them are facing the revocation of their licences on June 1.

Why are some spared?

Why do some homes have large deadly COVID outbreaks while others are spared? Why is there sometimes a mismatch between outbreaks and the conditions in the home, at least as reported on paper?

One possible explanation might not sit well with people who have lost loved ones to COVID or been affected by a deadly outbreak in a long-term-care setting. It's possible, Costa said, that some of the serious outbreaks are the result of bad luck - a bad event that happened at just the wrong time.

Basically there's a degree of chance to this, and that's just the reality," Costa said.

Some of the places that are struggling operationally have so far made it through," he added, and some of the places that you expect would do all right got severely hit."

But time will catch up with the poorly run homes, Costa added.

Over time, the (poorly run) homes are at more risk, there's no question," said Costa. You dodge bullets if you're a poorly run place, but eventually your turn comes.

And if you're not prepared for it, you're not just going to have an outbreak, you're going to have a blowout because your staff is so demoralized, the culture is so horrible."

When things go bad," he said, they'll go bad quickly and you won't have a leg to stand on."

Dr. Nathan Stall, a University of Toronto researcher, has a different view than Costa, his co-author on the two papers.

Stall doesn't believe the worst outcomes can be attributed to bad luck.

I don't think this is chance," said Stall.

To manage the home in a way that prevents other residents from being infected and providing the care to residents they need to reduce their risk of death - that's not chance.

There are many homes that have had small numbers of cases multiple times throughout that have been able to contain those outbreaks and not lead to 44 deaths," Stall added.

Woeful inadequacies'

Meanwhile, the head of the Ontario Health Coalition warns that trying to make connections between the findings from inspection reports and whether or not a home had a deadly COVID outbreak is a fool's errand.

I think it's fair and true to say a small number of homes account for a large number of cases," said Natalie Mehra, executive director of the coalition. That does not mean, though, that all is hunky dory in the other homes."

Out of Ontario's 626 long-term-care homes, Mehra suggests at least 100 of them are very poorly run."

COVID-19 has cast a very sharp spotlight on existing woeful inadequacies in long-term care in a significant number of the homes," said Mehra.

We have to separate out COVID from the general conditions of homes," Mehra said. The very legitimate concern about the inadequacy of care is much more widespread than the homes that have been hit with terrible COVID outbreaks."

Mehra said a lot of systemic problems with long-term care have built up over decades, including a sharp reduction in the number of unannounced comprehensive annual inspections of homes based on a policy change by Doug Ford's government shortly after they took power in 2018.

Take the Grace Villa inspection conducted on Dec. 15 that found no problems even though the home was in the midst of a terrible outbreak.

The inspection was a so-called complaint inspection, designed to look only at the circumstances outlined in the complaint. It wasn't a comprehensive annual inspection, which hasn't happened at Grace Villa since November 2018.

Prior to fall 2018, comprehensive unannounced inspections occurred at least once a year for every LTC home. A CBC report last spring found there had only been 14 such inspections posted in 2019, compared to an average of 650 per year in the three previous years.

Over the last year, there really haven't been eyes in the homes to see what is going on and report on it," Mehra said.

The head of the Ontario Long Term Care Association (OLTCA) says her members are advocating for long-awaited system changes."

It will take all of us working together, across the health system and all levels of government, to address long-standing issues that contributed to the tragedy experienced through the pandemic so we can redevelop and expand the system to meet the needs of our rapidly aging population," stated Donna Duncan, CEO of the OLTCA.

The ownership factor

There is another factor that has attracted a lot of attention as the pandemic rolls on - the connection between COVID and the ownership status of long-term-care homes.

Nearly 60 per cent of Ontario's long-term-care homes are for-profit and those are the ones in the spotlight's glare.

A comprehensive report put out by the province's COVID-19 science advisory table on Jan. 20 stated that for-profit LTC homes had twice the proportion of residents infected in outbreaks and nearly 80 per cent more deaths than non-profit homes.

In Hamilton, for-profit LTC homes have had 14.8 COVID cases per 100 beds, compared to 12.4 cases for non-profit homes and 4.7 cases for the municipally run homes.

There have been four COVID-related deaths per 100 beds in the city's for-profit homes, compared to 2.2 deaths for non-profit homes and 0.7 deaths for the municipal homes.

But, again, the bulk of the COVID cases and deaths involving LTC residents have occurred in just four homes, two of which are for-profit and two that are non-profit, including St. Joseph's Villa, which is owned and operated by the large St. Joseph's hospital system.

Ten of the city's 18 for-profit LTC homes had no COVID cases and deaths as of Jan. 21.

There are fantastically run for-profit homes and terribly run municipal homes," said Mehra.

But across the board, what is irrefutable is that the staffing levels are lower, the pay is lower and the hours of care are lower in the for-profits versus the non-profits and the public homes," she said. That has remained true for years."

Stall, the U of T researcher, said it's more nuanced than all for-profit is bad, all non-profit is good."

I believe for-profit homes have had worse outcomes but it's not all of them," said Stall. It's not black and white."

We can't be totally blinded by ideology here," he said.

Stall and McMaster's Andrew Costa published a study last summer as anger was growing against for-profit homes. What grabbed public attention was this line: For-profit status is associated with the extent of an outbreak of COVID-19 in LTC homes and the number of resident deaths."

What got less attention was the very next line in the paper, which explained why.

Differences between for-profit and non-profit homes are largely explained by older design standards and chain ownership, which should be a focus of infection control efforts and future policy," their paper said.

It turns out that COVID infections and deaths are higher in homes that have more of the older design three-bed and four-bed rooms than homes that have more up-to-date one-bed and two-bed rooms. For-profit LTC homes have higher proportions of the older design model.

The for-profit homes also have higher levels of chain ownership, which can make the individual franchises slower to react in a crisis as they await direction from a centralized command structure.

COVID-19 impacted homes regardless of ownership structure," stated Duncan, the OLTCA head. Ontario's long-term-care homes advocated for Ontario's Long-Term Care COVID-19 Commission to understand how decades of underfunding and system neglect by successive governments created a perfect storm of issues ahead of the onset of the pandemic."

Duncan said the last major rebuild of the province's LTC homes occurred in the late 1990s and most of those renovated were municipal and non-profit homes.

Most of the privately owned homes at the time were not as old, and were expected to be rebuilt in the next tranche of government approvals," Duncan explained. But the government changed, as did the priority around investing in long-term-care infrastructure.

As a result, it is now a larger proportion of private homes that are older and in need of significant renovation or rebuilding to the new design standards of today."

We have asked for the approvals process to move much faster in order to meet demand," Duncan added. Many homes have been waiting years for approvals of their projects."

As COVID cases and deaths continue to increase in Ontario's long-term-care homes, there is a growing number of voices calling on the provincial government to abolish for-profit ownership.

That's easy to say, Stall noted, but I think you also have to ask yourself What does a different system look like?'"

How would you remove those people?" he asked. That's not something that's so evidently obvious."

Eighteen of Hamilton's 28 LTC homes are for-profit. Of the nearly 4,000 licensed LTC beds in the city, 2,100 are located in for-profit homes.

With the for-profit sector representing nearly 60 per cent of Ontario's homes and almost 42,000 of the 77,000 LTC beds, it's no simple matter to buy out the for-profit operators or revoke their licences.

In addition to the inevitable and expensive litigation, where would the money come from to take over those homes? Municipalities can't afford to run chains of LTC homes and there would have to be enough non-profit organizations with the cash to step in and fill the void.

On top of that, there's already a waiting list of 39,000 seniors in Ontario who require a long-term-care bed.

At the end of December, there were 5,600 people on Hamilton's waiting list. On average, just 86 LTC beds in the city come open each month.

I think we have to be very careful about the whole system collapsing when we've built this system where 60 per cent of the operators are for-profit," said Stall.

If they all walk away and leave, we're also screwed," he added. I don't know that we declare victory the day that happens either.

There are frail, vulnerable people living there and they need to be in a long-term-care home that's operational."

Steve Buist is a Hamilton-based investigative reporter at The Spectator. Reach him via email: sbuist@thespec.com

Long-term care in Ontario:

• There are 626 long-term care homes in the province with nearly 77,000 beds. In Hamilton, there are 28 LTC homes with about 3,950 licensed beds.

• 58 per cent of Ontario's LTC homes are for-profit ownership, 26 per cent are non-profit and 16 per cent are municipal. In Hamilton, 18 of 28 are for-profit, eight are non-profit and two are municipal.

• LTC residents receive personal and nursing care as well as subsidized accommodation under a publicly funded LTC program. Homes are under the jurisdiction of the Ministry of Long-Term Care.

• Most direct care in LTC homes is provided by personal support workers who make up 58 per cent of the LTC workforce, with nurses accounting for an additional 25 per cent of staff.

• 90 per cent of LTC residents have some form of cognitive impairment and 86 per cent need extensive help with daily activities, such as eating or toileting.

Retirement homes in Ontario:

• There are 770 retirement homes in the province which house about 56,500 residents. In Hamilton, there are 37 retirement homes with about 3,300 residents.

• Retirement homes are licensed by the Retirement Homes Regulatory Authority, a self-governing agency that administers the Retirement Homes Act on behalf of the provincial government.

• People who live in retirement homes generally require less medical care than LTC residents.

• Residents pay the full cost of their accommodation and any care services they purchase, such as nursing assistance, dementia care and the provision of medications.

The COVID connection:

• As of Jan. 21, 722 out of 8,543 COVID cases (8.5 per cent) in Hamilton involved residents of long-term-care homes and retirement homes.

• As of Jan. 21, 156 out of 231 COVID-related deaths (68 per cent) in Hamilton involved residents of long-term-care homes and retirement homes.

• 52 per cent of Hamilton's COVID-related deaths have involved long-term-care residents, compared to 61 per cent for Ontario.

• 74 per cent of all COVID-related deaths in Hamilton involving LTC and retirement home residents occurred in just six of the 65 LTC and retirement homes.