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The Blackadar Continuing Care Centre in Dundas, Ont., on Mar. 2.Fred Lum/The Globe and Mail

The call bells used to summon staff for help stopped working the instant the nursing home lost power during a major winter storm last Dec. 23. So did the electric ceiling lifts that people rely on to get into their wheelchairs. One person who requires a feeding pump couldn’t eat or drink.

Wind gusts of up to 110 kilometres an hour, snow and flash freezing knocked out power for nearly 60,000 people in the southwestern Ontario city of Hamilton, including those living and working in the Blackadar Continuing Care Centre. They went without essential services for 13½ hours, from 5 p.m. until 6:30 a.m. the next day when power was eventually restored.

Under Ontario’s rules, that is 10½ hours longer than residents in the facility should have been in the dark. All nursing homes must have guaranteed access to a generator that will be up and running within three hours of an outage.

Long-standing problems at the for-profit home exemplify the province’s lax enforcement of the sector. Premier Doug Ford promised to put an “iron ring” of protection around people in long-term care after COVID-19 tore through many homes, killing thousands of residents and laying bare weaknesses in the province’s oversight. Yet, despite beefed-up legislation introduced after the pandemic, homes continue to face few consequences for breaking the rules.

The government unveiled long-term care legislation in October, 2021, that doubled the existing maximum fine to $200,000, plus 12 months in prison for an individual convicted of a first offence under the Provincial Offences Act. A home can be fined up to $500,000.

But no nursing home or individual in Ontario has ever faced charges or fines under the quasi-criminal act. Nor has any home lost its operating licence. Since the new law came into force last April, the government’s enforcement actions have consisted entirely of administrative penalties – a total of $178,200 in fines handed out to 32 of the province’s 626 homes as of March 6.

“We actually have good legislation that has tough language,” said Samir Sinha, the head of geriatrics at Sinai Health System in Toronto. “But when you don’t enforce anything, this is what you actually see – homes that are allowed to run with a 13-hour power failure.”

Internal Blackadar e-mails, government inspection reports and complaints obtained by The Globe and Mail, including one that detailed the recent outage, show that this blackout wasn’t an isolated incident. Blackadar has repeatedly contravened the province’s long-term care legislation with impunity, a Globe investigation has found.

The home has endured three power failures ranging from five to 13 hours over the past 2½ years alone. During an outage on Nov. 15, 2020, three residents and a personal support worker were trapped in an elevator for 90 minutes until firefighters rescued them, according to a complaint sent to the Long-Term Care Ministry by a former employee. In response to that outage, the ministry asked Blackadar to guarantee the facility had generator access, according to an inspection report that does not mention the elevator incident. The home has failed to comply with that request.

The ministry is now ordering the home to ensure that it has a generator powerful enough to maintain a number of services, including the heating system, call bells, emergency lighting and life-support equipment.

Blackadar has until June 30 to comply, according to an inspection report posted this month on the ministry’s website. Although the home has a small generator – which is capable of powering only a few electrical outlets on the main floor, along with the telephone and fire alarm systems, the hot-water tank and magnetic door locks – it was out of service for several hours on Dec. 23 because of a frozen gas line, the report says.

Lack of access to backup power is not the only problem at Blackadar. Other issues include the run-down condition of the building itself, chronic staffing shortages and a lack of proper care for residents with skin tears or wounds, according to the records reviewed by The Globe, as well as current and former employees, and family members of former residents.

Blackadar was family-owned and operated for more than three decades, but that changed in 2012. That was the year Extendicare, one of Canada’s largest for-profit nursing-home chains, began managing the 80-bed facility on behalf of owners Dean Blackadar and his wife, Sandy.

In November, 2020, the family sold its shares in both the nursing home and a retirement residence on the same Creighton Road property for $3.7-million to Hamid Hakimi, chief executive of residential real estate developer Elite Developments, and Haidar Sakhi, CEO of building maintenance services company H&S Holdings, records show. Extendicare continues to manage the facility.

In response to questions about the December blackout, Extendicare spokesperson Laura Gallant said the company is responsible only for managing the facility, not making major procurements, and it has advised the owners of Blackadar to comply with the ministry’s order.

“We cannot force clients to buy new equipment, upgrade existing equipment or make capital investments. We cannot implement all recommendations we offer within homes we do not own, even if those recommendations are sound and clearly required by regulation,” Ms. Gallant said.

Mr. Sakhi, who responded on behalf of the facility’s owners, declined to comment on the ministry’s findings.

Problems at Blackadar predate the 2020 ownership change. According to inspection reports dating back to 2014, the home has been cited on seven separate occasions for not properly treating residents’ skin wounds. One person did not receive nine out of 15 weekly assessments of their wounds ordered by a physician, risking further deterioration.

An inspection report dated June 18, 2018, says the home contravened the rules by not having a registered nurse on duty at all times. An incident report dated May 28, 2022, submitted to the College of Nurses of Ontario highlights the same problem, noting there was no registered nurse on duty to supervise residents during dinner that day. One resident was left in the dining room alone for more than an hour after her meal because no one in the home was available to take her back to her room, the report says.

The report is referring to Dave Hunt’s aunt, Shirley Junkin. He told The Globe this happened to her more than once. One Sunday when he went to visit her after breakfast, he said, he found his aunt sitting in her wheelchair in the hallway. “They forgot about her,” Mr. Hunt said. “She was pretty upset.”

Ms. Junkin moved to another nursing home last May, well before the December power failure.

The Ontario Nurses’ Association (ONA), the union representing nurses in the home, filed grievances over that power failure as well as a five-hour outage on Good Friday last year.

“At what point are the owners going to pony up and deal with these serious situations?” Deanna King, the ONA’s labour relations officer, said in an e-mail dated Jan. 2 to Blackadar administrator Lauren Disch.

Ms. Disch responded in an e-mail the following day, saying the home’s on-site generator is able to run “certain resources,” but it did not “power up as planned” during the storm. She attributed the generator failure to a frozen gas line and said the problem had been fixed.

Prior to seeing the ministry’s inspection report, Mr. Sakhi, the home’s co-owner, said in an e-mail response to The Globe that the generator was up and running around midnight. In anticipation of the winter storm, he said, the home purchased extra flashlights, table lanterns, batteries and disposable dishware. It also printed copies of residents’ medication records.

“As a result of our management’s actions and service,” Mr. Sakhi said, “we believe that the negative consequences of the power outage were mitigated to the fullest extent possible.”

But the ministry did not share that view after its inspection. Ministry staff spent three days at Blackadar in early January, in response to multiple complaints from staff in the home.

When the power went out, there was no alternative lighting for residents’ bedrooms, the inspection report says. The home also did not provide instructions for managing residents’ hygiene and transferring them without electric ceiling lifts; monitoring temperatures inside the refrigerators; and cleaning cooking equipment without a dishwasher, the report adds.

If the home is not able to ensure it has sufficient working generator capacity by June 30, it will “face potential increased enforcement actions, including administrative monetary penalties,” said ministry spokesperson Patrick Imlay.

On two previous occasions when Blackadar lost power, in 2013 and 2020, the ministry issued what’s called a voluntary plan of correction – inspectors asked the home to ensure it has guaranteed access to a generator that could maintain essential services. A Blackadar official who is not identified by name in an inspection report dated June 1, 2021, acknowledged that the home did not have access to such a generator because “they were under the impression” that they could wait until 2025 – when the home’s operating licence expires – to have that in place.

The ministry has plenty of powers to force operators to follow the rules: Short of revoking a home’s operating licence or laying charges in court and issuing fines, it can order a home to stop accepting new residents or issue compliance orders.

Since the new long-term care act came into effect, the ministry has issued administrative penalties for various infractions to a number of facilities – but not Blackadar. One home has been ordered to pay penalties totalling $47,300 for not administering medications as prescribed and failing to provide proper wound care.

Another home fined $5,500 is one of only two facilities in Ontario ordered to stop accepting new residents, based on the ministry’s belief that there is “a risk of harm” to residents’ “health or well-being.”

Dr. Sinha, the geriatrician, said there should be serious consequences when a facility that houses clinically frail individuals fails to maintain essential services during a power failure.

“How is Ontario going to meaningfully ensure that its residents are actually living safely in these homes, because I don’t think they’re living safely in this home,” he said.

With a report from Stephanie Chambers