A failure to make safety upgrades to their buildings in the past two decades appears to have left many long-term-care homes particularly vulnerable to the deadly spread of COVID-19.
Since the pandemic began earlier this year, almost half of Ontario's long-term care homes have suffered outbreaks. For some facilities, a handful of residents fell ill and eventually recovered. For others, as many as 45 per cent of their residents died.
Data analyzed by Marketplace reveals the structure of the buildings themselves may be a contributing factor that helps explain this disparity.
Ontario changed its structural safety standards back in 1998 — mandating, among other things, that nursing home bedrooms should house no more than two residents.
Homes that didn't meet the new standard were allowed to keep running as-is, with an expectation they would upgrade eventually. The vast majority of homes that haven't yet upgraded are run by for-profit companies.
While non-profit and for-profit homes have been equally likely to experience outbreaks, those outbreaks have proven deadlier in for-profit homes.
Only a third of the 78,163 beds in Ontario facilities remain at the 1972 standard, referred to as C, but they account for 57 per cent of the province's 1,691 reported COVID-19 deaths (as of Tuesday morning) in long-term care homes.
Buildings that operate at the C standard may have four-person shared wards and communal dining rooms where hundreds of people are brought together for meals.
'I have to do something'
Experts say such out-of-date features make infection control much more difficult.
Diana Anderson, a medical doctor and architect from Montreal who has worked on hospital design projects in the U.S., Canada and Australia and specializes in environments for geriatric patients, says the four-person wards, in particular, pose a number of risks.
"You're bringing more pathogens in from the outside based on how many people are coming in and out of that space," she said. "Not only do you have staff, you have family members and loved ones of the three other roommates with you."
She says sharing a washroom means more opportunities to spread viruses between residents in the same room, plus it makes staff less likely to wash their hands between patients when they aren't passing by a washroom each time.
The four-bed wards are one of the main reasons Dilys Patterson, 62, pulled her 93-year-old mother, Joan, out of Camilla Care Community in Mississauga, Ont. She did so immediately after the first case of coronavirus was confirmed there on April 6.
Now, 67 residents are dead — the second highest death toll in a long-term care home in Ontario. Of the 297 homes in the province that have had an outbreak, Camilla has the 11th highest death rate, with 28 deaths per 100 beds. And Camilla is still dealing with an active outbreak.
"I got a call saying that there was one case and I couldn't sleep that night because I know the facility is very crowded," Patterson said. "I woke up and I just said, 'I have to do something.'"
Patterson has had to take a leave of absence from her job in retail to take care of her mother full time, but she won't be able to stay home with her forever. She's hoping to get her mother into a newer home, she said.
"I would like her living in something much safer, but then the problem is there's no beds there, right? How do you stomach putting your loved one in a place that you know is dangerous?"
Camilla Care's parent company, Sienna Senior Living, told Marketplace in a statement that it hasn't upgraded the facility because of the cost. The company said it has been advocating for increased funding from the government, as "construction funding has remained mostly unchanged since 2014, with no annual adjustments for inflation or rising construction costs."
Four-person rooms have been considered below standard since 1998. However, the updated rules only applied to new homes being built. Since then, standards were upgraded again in 2002, and most recently in 2015. Beds that exceed the 1972 standard are classified as "B", "A" or "New" depending on how far they are from meeting current standards. There are approximately 1,300 Ontario beds that don't meet the 1972 standard, which are classified as "D" beds.
"Politicians have said they are committed to change, but they've been sitting on this for 22 years," Patterson said. "That doesn't show me that they're very interested in addressing these issues."
She said she is concerned not only about the close quarters typical in older homes, but also the time and effort that's required to feed everyone in a big dining hall.
"At Camilla, everyone had to go downstairs to get their meals, and it was just chaos," she said. "Everyone had to gather in front of the elevator and get taken down, they had to be received at the dining room, at ground floor, and then the whole process had to be reversed again.
"[That's] a lot of time and energy for staff — devoted staff — just schlepping people around."
How design can affect health
When Marketplace reviewed data from homes that lost 20 per cent of their residents or more to the coronavirus, it found 65 per cent of those homes had C-level accommodations.
The fact that so many Ontario homes only meet a 1972 structural standard is an "interesting timeline," said Anderson, the doctor and architect.
She said it wasn't until the 1980s that architecture shifted to what's called evidence-based design, which means incorporating research on the relationship between physical space and health into the design of a structure.
In geriatric settings, she said, studies have shown building design has an impact on health outcomes for infection control and fall prevention.
"There is quite a convincing data set for the move toward single rooms," she said, pointing to a medical journal study published in 2019 that showed the benefits of the single-room model for hospitals in slowing the spread of infections.
In 2010, long-term care homes in Ontario were given 15-year licences based on the structural standards they had at the time. Many homes have upgraded since then, with non-profit homes accounting for only 12 per cent of the province's 24,695 beds still classified as C level, with another eight per cent in long-term care homes owned by municipalities.
However, 80 per cent of the C-level beds that remain are run by for-profit homes. Those beds account for 49 per cent of the total for-profit beds, meaning almost half of the beds in for-profit facilities are still at the 1972 standard or below.
Why the delay?
So why do for-profit companies own the vast majority of beds in older facilities, and why haven't more of them upgraded their facilities?
It depends on who you ask.
The Ontario Long Term Care Association, which represents 70 per cent of care homes in Ontario, is advocating alongside Sienna and others for more funding for redevelopment. The association said in a statement that current funding "does not reflect historic increases in the cost of construction."
However, the Ministry of Long-Term Care said in a statement it has invested $1.75 billion "specifically to bring aging long-term care homes up to modern standards and build badly needed new capacity."
"We are putting our money behind this," the ministry said.
It's about money, lawyer says
In the view of elder advocate and lawyer Jane Meadus, it really comes down to profit.
Meadus has been specializing in long-term care issues for 25 years. She says that when the Long-Term Care Homes Act came into law in 2010, there was an expectation that in the following 15 years, the older homes would all upgrade to meet modern standards, and while many non-profit homes have done so, many for-profit homes have not.
"They would have to use some of their profits to rebuild," she said. "They're able to keep their homes occupied at a high rate ... and so there isn't any particular impetus for them to build because they fill their beds anyway."
She said more pressure needs to be put on these homes to meet modern standards.
"We have building codes for everything else," she said. "And when you look at the profits that are coming out, frankly, the amount of money that is being paid to the executives, you know, they're doing it on the backs of people, and on the province's dime."
The provincial government has called for a commission into Ontario's long-term care system to understand the impacts and responses to the COVID-19 outbreak. It is scheduled to begin in July.
The ministry said there are currently 686 older long-term care beds in the construction phase of redevelopment, and an additional 11,727 at various stages of planning for redevelopment. It also continues to receive applications to redevelop older beds under the most recent call for applications, the ministry said.
In the meantime, the OLTCA says, it is asking the ministry for immediate support to make emergency renovations to older buildings to make them "better suited to the level of infection control required for a pandemic."
It says the changes under consideration include removing carpeting, creating larger spaces for physical distancing in common areas, and converting three- and four-bed rooms to one- and two-bed rooms only.
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The data about deaths in the province's long-term care facilities was pulled from Ontario's COVID-19 website on Friday, June 5, and compared to the profit status for each home available on Ontario's long-term care reports website, as well as structural classification data that was obtained by CBC from the Ministry of Long-Term Care.
Where death numbers were indicated as <5 on the provincial website, they were corrected to 1. As of June 9, the total confirmed long-term care deaths listed on the provincial website is 1,720, as reported by the Ministry of Long-Term Care, and 1,575 as reported by the Public Health Ontario daily epidemiologic summary. The total deaths that are assigned to specific homes on the website as of June 9 is 1,691, so that is the death number used to calculate percentages.
Structural data was compared on a per-bed basis. A small number of homes have more than one bed classification (i.e. one wing of "C" beds and one wing of "A" beds). We don't know which wing the deaths occurred on, so when analyzing death counts in C and D homes, we assigned the home the lowest standard of beds that were operational there.
Out of the 1,691 deaths, 12 fell into this category: 11 deaths at Chartwell Aurora, which is majority C-standard home, and one death at Craiglee, which has an even split between C and New beds with fewer beds in the A category.
With files from Joyita Sengupta