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At Chartwell, a chain of 27 homes, chief operating officer Karen Sullivan said the pharmacy that services the chain, MediSystem, pays for "many additional valued-added services" such as employee education, nurse leadership sessions and conferences for leaders of homes. MediSystem also pays for Wi-Fi systems and therapeutic care equipment at the homes, Sullivan said in an email. The Star asked pharmacies what they are told the money is used for. Among the responses from pharmacies were "staff education," "resident programs" and payments toward Wi-Fi systems. Classic Care, a pharmacy, said the money it pays covers monthly rent of an area in the nursing home, staff education, technology and "donations and sponsorships" for conferences and other training. Other pharmacies, such as Rexall, say their fees have paid for diabetes education, for example. The largest pharmacies serving long-term-care homes in Ontario include Medical Pharmacies Group, MediSystem (owned by Loblaw), Classic Care (Centric Health) and Rexall. The fees are not new. Pharmacies have willingly offered money or agreed to demands for years. But there's a growing outrage among some who say homes are more interested in "inducements" than "clinical excellence" that pharmacies can provide seniors. Last year, after the Ontario government cut each dispensing fee by $1.26 (it is now $5.57 per prescription in nursing homes), sources said some pharmacies wanted to stop paying the fees. The problem was, the sources said, that the homes refused to give up the extra cash flow and other drug companies were willing to pay, so nothing changed.

It's usually the larger companies that can afford to pay. One insider said smaller pharmacies now ask the homes, "Do you want the money or do you want good service? Because we can't afford to give both." Sources said the Ontario Ministry of Health and Long-Term Care knows the money changes hands but does nothing to stop it. Instead, pharmacies are "held hostage" by the homes, the source said. One home that no longer charges the fees is John Noble Home in Brantford, a municipally operated 156-bed facility. The Star obtained a 2010 request for proposals (RFP) that noted "only proposals with a minimum rebate of $20,000 annually will be considered for the project." A spokesperson for the city said the RFP "references a previously approved practice employed by several long-term care homes." A recent RFP did not ask for a rebate, though some offered to pay. The city spokesperson, Maria Visocchi, said it chose a pharmacy that "demonstrated qualifications and experience, project understanding, approach and methodology, medication system processes and quality control." This pharmacy did not offer a rebate. Not all pharmacists pay. Teresa Pitre runs Hogan Pharmacy Partners in Cambridge and serves long-term-care homes that don't ask for money. Instead, she signed contracts with several homes in the People Care chain to provide a "highly personalized approach." Pitre sends a registered pharmaceutical technician into each home daily to relieve nurses of much of their work regarding medication, confusion over communications and extensive paperwork. Her company also puts a bookshelf-sized dispensing machine in each home, which holds medication (pain relievers, antibiotics or insulin) that residents need on short notice but, in the traditional system, often can't get for hours. "I really wanted our pharmacy to be a partner with homes instead of servicing them and just meeting the requirements," she said. Meadus says the added cost of bed fees means pharmacies have no reason to reduce their rates, either by lowering dispensing fees or not charging the $2 co-payment.

A recent Star story revealed that pharmacies serving nursing homes typically charge dispensing fees for drugs once a week, rather than once a month as they typically do in a community pharmacy. Long-term-care pharmacies told the Star they charge the weekly fee because the medication for frail residents can change weekly. That was a claim hotly disputed by some family members the Star spoke to, including Margaret Calver, who has spent years documenting the costs of dispensing fees at Markhaven Nursing Home, where her husband is a resident. "This needs oversight and that's the problem," she said. "Nobody is doing the checks and balances." Moira Welsh can be reached at mwelsh@thestar.ca.

35 buyouts of hospitals or chains of facilities in the last two and a half years by private equity firms

Among the secrets to HCA’s success: It figured out how to get more revenue from private insurance companies, patients and Medicare by billing much more aggressively for its services than ever before; it found ways to reduce emergency room overcrowding and expenses; and it experimented with new ways to reduce the cost of its medical staff

HCA decided not to treat patients who came in with nonurgent conditions, like a cold or the flu or even a sprained wrist, unless those patients paid in advance.

In one measure of adequate staffing — the prevalence of bedsores in patients bedridden for long periods of time — HCA clearly struggled. Some of its hospitals fended off lawsuits over the problem in recent years, and were admonished by regulators over staffing issues more than once.

inadequate staffing in important areas like critical care

Many doctors interviewed at various HCA facilities said they had felt increased pressure to focus on profits under the private equity ownership. “Their profits are going through the roof, but, unfortunately, it’s occurring at the expense of patients,” said Dr. Abraham Awwad, a kidney specialist in St. Petersburg, Fla., whose complaints over the safety of the dialysis programs at two HCA-owned hospitals prompted state investigations.

One facility was fined $8,000 in 2008 and $14,000 last year for delaying the start of dialysis in patients, not administering physician-prescribed drugs and not documenting whether ordered tests had been performed.

Claiming he provided poor care, the other hospital did not renew Dr. Awwad’s privileges. Dr. Awwad is suing to have them reinstated.

“If you were a for-profit hospital with investors and shareholders,” said Paul Levy, a former nonprofit hospital executive in Boston unaffiliated with HCA, “there would be a natural tendency to be more aggressive and to seek more revenues.” Executives at profit-making hospitals are “judged in greater measure by profitability” than the administrators of nonprofit hospitals, he said.

some of HCA’s tactics are now under scrutiny by the Justice Department. Last week, HCA disclosed that the United States attorney’s office in Miami has requested information about cardiac procedures at 10 of its hospitals in Florida and elsewhere.

HCA’s cardiac business is extremely lucrative, and the Justice Department has requested reviews that HCA conducted that indicate some of the heart procedures at some of its hospitals might not have been necessary and resulted in unjustified reimbursements from Medicare and other insurers.

Small and nonprofit hospitals are closing or being gobbled up by medical conglomerates, many of which operate for a profit and therefore try to increase revenue and reduce costs even as they improve patient care. The trend toward consolidation is likely to accelerate under the Obama administration’s health care law as hospitals grapple with what are expected to be lower reimbursements from the federal and state governments and private insurers.

Columbia/HCA became the target of a widespread fraud investigation in the late 1990s, which led to one of the largest Medicare settlements ever.

HCA wanted to attract more patients to its emergency rooms, and it did. Annual visits climbed 20 percent from 2007 to 2011. But while emergency departments are often a critical source of patient admissions, they are frequently money-losers because many patients do not have insurance. HCA found a solution: it figured out how to be paid more for the patients it was seeing.

Nearly overnight, HCA’s patients appeared to be much, much sicker.

No one has accused HCA of up-coding, or billing for more expensive services that were not needed — one of the complaints made against it a decade ago.

The acting head of Medicare is Marilyn B. Tavenner, a former HCA executive who left there in 2005 to become the secretary of Health and Human Resources in Virginia.

Several former emergency department doctors at Lawnwood Regional Medical Center in Fort Pierce, Fla., said they frequently had felt compelled to override the screening system in order to treat patients.

When the doctors failed to meet the hospital’s goals for how many patients should be considered emergencies, “they really started putting pressure on.”

Regulators in several states have taken HCA hospitals to task over screening out patients too aggressively, including situations where the screening missed serious conditions.

“Staffing is critical,” said Courtney H. Lyder, the dean at the UCLA School of Nursing and an expert on wound care. “When you see high levels of wounds, you usually see a high level of dysfunctional staff,” he said.

HCA owned eight of the 15 worst hospitals for bedsores among 545 profit-making hospitals nationwide, each with more than 1,000 patient discharges, tracked by the Sunlight Foundation using Medicare data from October 2008 to June 2010.

an examination of lawsuits shows bedsore problems have been persistent at several HCA facilities

The hospital was cited twice by Florida regulators, in 2008 and 2010, for having inadequate numbers of nurses on its staff to oversee wound care for patients.

Nursing homes that underwent chain-related transactions such as mergers and acquisitions experienced a larger number of deficiency citations both before and after transactions than nursing homes that did not change ownership.

The research, led by David Grabowski, professor of health care policy at Harvard Medical School, measures the implications of corporate ownership changes, which policymakers have long worried negatively impacts nursing home quality of care. The findings are published in the May issue of the journal Health Affairs.

emergency-room doctors and patient advocates blast the policy as potentially harmful to patients

the consumer group Families USA, said the tactic lets hospitals turn away uninsured patients who often fail to pay their bills and are a drag on profits.

There is no data on how many who leave the ER without treatment follow up with visits to doctors’ offices or clinics.

“It seems the point of the policy is to put a financial barrier between the patient and care,” said Anthony Wright, executive director of Health Access California, a consumer advocacy group

The U.S. Centers for Disease Control and Prevention says that about 8 percent of ER visits are for non-urgent problems that could be treated less expensively in a doctor’s office or clinic

Hospital officials say the upfront payments are a response to mounting bad debt caused by the surge in uninsured and underinsured patients, and to lower reimbursements by some private and government insurers for patients who use the ER for routine care. In the past year, for instance, Iowa, Tennessee and Washington state reduced or eliminated Medicaid reimbursements for those visiting ERs for specified non-urgent conditions, such as sore throats or warts.

The HCA payment policy excludes children 5 and younger, pregnant women and those 65 and older.

the company owns more than 160 hospitals in 20 states

Other large chains that have followed HCA’s example include Florida-based Health Management Associates and Franklin, Tenn.-based Community Health Systems.

The upfront payments for non-urgent ER visits are also used by nonprofit hospitals.

the 320-bed hospital has seen a 10 percent drop in people visiting the ER with non-emergencies and a big drop in bad debt

The price cuts don't apply in Canada where Valeant doesn't have similar distribution agreements with pharmacy retailers such as Shopper's Drug Mart, Jean Coutu or the Rexall Group. Valeant's pricing practices have been under investigation by U.S. authorities, including Congress, since the company dramatically hiked prices for some specialty products this year.

The company has also come under fire as the result of a civil suit by a small U.S. pharmacy that shed new light on Valeant's distribution agreements and practices. "We have listened and we've taken positive steps to respond," Valeant chairman and CEO Michael Pearson said in a news release Tuesday, a day before he's scheduled to hold a conference call with industry analysts.

The distribution agreement with Walgreens - a chain with more than 8,000 retail outlets - follows Valeant's decision to sever ties with mail-order pharmacy Philidor Rx Services. That relationship came to light as a result of a court battle between Valeant and another mail-order pharmacy. Valeant says the Walgreens agreement will be used as a model for distribution deals with independent retail pharmacies. After losing 73 per cent over the past few months, Valeant's shares closed up nearly 16 per cent in Tuesday trading on the Toronto Stock Exchange.

Guelph University microbiologist Keith Warriner conducted the tests for Marketplace and found alarming results. “I wasn’t expecting [bacteria] to be so prolific,”

Comforters were the most consistently contaminated spot, rating a "fail" in 23 out of 51 tests

faucets in hotel rooms were quite dirty themselves, with 16 fails out of 54

Over 70 per cent of remote controls tested were rated a caution or fail.

Other major hot spots included bed throws, bathroom sinks, toilet bases and telephones.

a pillow with so much bacteria it has “its own life story.”

Overburdened hotel staff is the main reason that many rooms are so filthy

Canada’s hotel union tries to enforce a cap 15 to 16 rooms cleaned per shift, giving staff approximately 30 minutes per room. Ruiz says that isn’t enough.

many housekeepers work unpaid overtime to reach their daily targets, but many still use time-saving “shortcuts” like not dusting or vacuuming.

The Teamsters represent the orderlies, who earn up to $6 an hour less than they would in the public sector, as well as the nurses and nursing assistants, who also earn less than their peers in the public sector. However, these workers all have the same skills, the same training and virtually the same duties.

However, there are concerns. Organ solicitations have been criticized as unfair, because they enable donation to identified recipients rather than to a recipient on a waiting list. Celebrity status and access to resources clearly provide increased opportunities to find a donor. A person with a high profile or more appealing story may be perceived as getting ahead in the transplant system, which could influence the public against organ donation.4 Recipients who are computer literate, social media savvy or English-speaking have enhanced access to potential donors beyond their local community and are more likely to find a donor than those without these characteristics.2 Publicity surrounding personal stories involving organ solicitation can be misleading and encourage offers to the solicitor, without considering donations to those with greatest need.5 However, all living donation is inequitable in that the donor chooses to whom to donate — generally someone they know — without any requirement to donate to the wait-list recipient with the greatest need.

One concern with public solicitations for organs is the potential for exposure of the recipient to harms from a donor who is unknown to them, which may in turn damage the reputation of transplant programs.3 Canadian law requires a minimum donor age for living donors, voluntary consent and no exchange of goods for an organ.6 Public solicitation may increase the potential for exchange of valuable considerations for an organ, because the donor is unknown to the recipient.

Two recent, well-publicized Canadian cases focused attention on these issues. The owner of the Ottawa Senators hockey team, who needed a new liver, used his public profile to solicit an anonymous donor.7 In the other case, the family of a young girl who needed a liver transplant made a public appeal through a Facebook page.8 The solicitation was fuelled by media attention surrounding this touching story, whereby the child’s twin had received liver tissue donated by their father, who could only donate once. The solicitation received more than 500 responses from people willing to donate.8 These two public solicitations for organs received markedly different public responses: one faced criticism9 and the other garnered sympathy. The difference in public perceptions was likely due to the different recipient profiles. In both cases, anonymous donors came forward, were screened and donated a part of their livers.

There are no guidelines for public solicitation of organs in Canada. Canadian transplant programs have had to address this issue on a case-by-case basis, often without consensus. Within Canada, different responses to organ solicitation by potential donors may be producing inequity of access to organs. Transplant programs and their patients could benefit from guidance on how to address the challenges raised by public solicitations. Many transplant doctors would be comfortable with public solicitation only if the donor became a nondirected altruistic donor, by which the organ is allocated to the next suitable recipient on the waiting list rather than to the actual solicitor (unpublished survey data, July 2015). Transplant doctors consider the next best thing to be to ensure that a relationship existed between the recipient and the solicited donor before donation occurs.

Donors who respond to public solicitations should be considered for transplantation. However, transplant programs must ensure that the motivation for donation is based on altruism rather than secondary intention, and that donors meet medical and psychosocial criteria for living donors, provide informed consent and agree to meet the requirements of the program regarding contact with the recipient. Although they should not be dissuaded from donating to the intended recipient, solicited donors should be made aware of alternatives such as donating to the recipient with the greatest need. A model is Canada’s National Kidney Paired Donation program. This program is the best option for candidates who have living kidney donors who are willing to donate and medically able, but who are incompatible with their intended

recipient. The program coordinates a chain of multiple transplants so that a willing donor’s organ can find its way to a compatible recipient while the intended recipient also receives an organ.10 This system allows the most people in need of an organ to get one. Even if the solicited donor and recipient are compatible, they can still choose to enter the National Kidney Paired Donation program as a pair, to benefit the greater transplant community, because a critical number of pairs are required for the overall success of the program.10 Whether donors from a public solicitation should remain anonymous to their recipients is a decision best left to the transplant program.

Donations of living organs are valued. Solicited organ donation helps to identify willing donors. It is an important facet of living donation and should be promoted. However, solicited organ donors should be encouraged to consider anonymous nondirected organ donation within systems, such as the National Kidney Paired Donation program, to maximize the number of patients in need who receive a transplant from a willing altruistic donor.

However, according to Jain, it was SteriPro who initiated the proceedings to bring the contract to a close. "It was SteriPro that took Trillium to task," says Jain. "We filed a change inquiry notice, and according to our agreement, the next step would have been arbitration, and we would have won a very, very large compensation from Trillium if we had gone to arbitration." Rather than going through arbitration, SteriPro opted to begin negotiations to terminate the contract. "We got compensated a significant amount of money by Trillium to enter into this termination agreement. So, it's not that they terminated the contract. We terminated it."

Jain explains that rather than being dissatisfied with SteriPro's service, the hospital instead had carried on along a trajectory of increasing demand for those services, but neglected to honour the contract elements that mandated further talks about increasing compensation along the same lines. "There were some issue in the contract that enabled us to increase our compensation with increased volume," says Jain. "When a hospital's surgical case volume goes up by 70 per cent, you would expect that our compensation would increase by 70 per cent, but it went up by zero per cent over the last four years, and that's because Trillium did not engage in the discussions that were dictated in the agreement to enable us to increase our compensation for the extra work and the extra labour force that we needed to employ the work that needed to be done."

For Jain, the notion that it was the hospital who terminated the SteriPro contract is factually incorrect, but the added idea that that decision would have been made because of lapses in quality runs counter to the high mark that he sets for his company, and which is attested by the level of accreditation they've received.

"We are the first private facility accredited by Accreditation Canada, which looks at all your work. We've been accredited strictly for reprocessing, Which is a very stringent and highly controlled and monitored service that meets all the standards set by the CSA." With regards to the company's contract with Pembroke Regional Hospital, two main concerns were raised by CUPE representatives during their March media event: that prolonged turnaround time on instruments needing cleaning could lead to shortages at critical times, and that the 400-plus kilometre one-way trip to Pembroke from the SteriPro facility could result in compromises to the sterilization of the equipment. On the topic of instrument inventory, Jain points out that the issue was raised during the preliminary portion of contract talks with the hospital, and to mitigate that concern, SteriPro agreed to cover the cost of an augmentation to the hospital's existing inventory with brand new equipment so that they would always be sufficiently well-stocked to deal with routine and unforeseen situations.

When it comes to the notion that distance presents an insurmountable hurdle to assuring the sterilization of treated instruments, Jain points to his company's provision of service to a trauma centre in Newfoundland, and their various other contracts, as his main response. "If we can service a major trauma centre on the East Coast, we can service anyone from coast to coast. We consider ourselves the experts in sterile transport, because we have developed the methodologies and the techniques, and we've tested them out, to ensure that instruments can be transported safely by road or by air. We currently transport instruments to major hospitals throughout the GTA, and we transport them safely."

In addition, Jain says that SteriPro has a number of detailed tracking and data systems to ensure that every step in the process is wellsupervised and documented. "We have temperature and humidity-controlled and monitored trucks, which have GPS monitoring on them as well. If there was a particular case that had an infection, we can pull out all the records on that particular tray of instruments and provide the data to show when it was sterilized, by whom, and under what conditions that sterilized set was kept. So the chain of sterility from the time that it comes out of the sterilizer to the time when it goes on the shelf in the storage room in Pembroke is completely documented, and we are practically the only ones in Canada who can do that, and we maintain all that data in our database forever. If there was a case that was done 10 years ago where, say, an orthopaedic implant which became infected 10 years ago, we can provide the hospital all the records they need to prove that sterility was not the issue." Over the past few months, SteriPro officials have been working to get the necessary underpinnings of their service to PRH in place, and they are expecting to be fully operational for surgical equipment reprocessing by the end of April. rpaulsen@postmedia.com Twitter.com/PRyanPaulsen

Ontario seniors homes have the worst fire fatality record in North America with 45 deaths since 1980.

Four private members’ bills and three inquests have all recommended sprinklers.

Residences built after 1998 must have sprinklers but the devices are still not required in 4,000 older “care occupancies,” which house more than 200,000 seniors and other vulnerable people across Ontario including the intellectually challenged. The frail, elderly are more likely to die in fires than any other age group, experts say.

Madeleine Meilleur, Minister of Community Safety and Correctional Services

“Sprinklers are not the only answer. They are important, but nothing will replace the staffing levels and how they are trained in case of fire,”

There are never fire deaths in homes with sprinklers except in the rare case where a person who caused the fire is overcome by injuries, said Sean Tracey, of the U.S.-based National Fire Protection Association.

Ontario fire chiefs are frustrated with the province’s refusal to force homes to install sprinklers that would protect the elderly. The fire chiefs say their study is the latest effort in a long campaign to convince Queen’s Park.

an early draft said most respondents (more than 230 comments came from firefighters, retirement homes, municipalities and advocates) agreed that sprinklers should be mandatory in all care homes.

Oak Terrace long-term care home, a government-licensed nursing home operated by the Revera chain, failed a test in October 2010.

After fire officials sent a letter to each member of Revera’s board of directors, the home decided to install sprinklers

Revera has installed sprinklers in 85 per cent of its 200 retirement and nursing homes across Canada

Homes that fail mock evacuation tests are hit with legal orders under the Fire Prevention and Protection Act, telling them to hire enough staff to be able to safely evacuate 24 hours a day — or install sprinklers.

Sprinkler installation costs roughly $3 a square foot. That translates to $40,000 for a 30-person home or about $110,000 for a 155-person home.

Fragile residents, combined with inadequate staffing and the fiery nature of materials in modern furniture, like the foam padding in couches, are a recipe for disaster.

In 2010, a year after the Orillia fire killed four residents (and left two brain dead), the government began a consultation on fire safety. Meilleur said she expects the report will be released in June.

Here is how the chiefs did the study: Firefighters visited a retirement or nursing home — sometimes without advance notice — and performed a mock evacuation based on the number of overnight staff when few employees are on shift. Firefighters ordered staff to conduct a fire drill. Using a stopwatch, they tested staff’s ability to move residents out of the building or behind a firewall

“If 45 children had died in fires would we still be waiting for the government to take action?”

residents, some drugged for a night’s sleep

Former NHS hospitals, free to generate half their income from private patients, will dedicate their staff and facilities to that end, making it impossible to monitor what is public and what people are paying for.

Billing, invoicing, marketing and advertising will add between 30% and 50% to costs compared with 6% in the former NHS bureaucracy.

some of HCA's American hospitals are under investigation for refusing care and performing unnecessary investigations and treatment, including cardiac surgery. A decade ago it paid the federal government $1.7bn to settle fraud charges, while former chief executive Rick Scott – now the Republican governor of Florida – managed to avoid prosecution.

Unitedhealth, which is currently providing services to the NHS, paid hundreds of millions of dollars in settlement of mischarging allegations in the US; Medtronic paid $23.5m for paying illegal kickbacks to physicians to induce them to implant the company's pacemakers and defibrillators; GlaxoSmithKline and Abbott paid $4.5bn in fines relating to improper marketing and coercion of physicians to prescribe antidepressants and antidementia drugs respectively. Novartis, AstraZeneca, Pfizer and Eli Lilly have all paid large fines for regulatory breaches.

The areas being looked at are: health records, registration and booking, laundry, payroll, central sterilization, food service, human resources, information technology and telecommunications, library services, general administration, finance and supply chain and material.

The consulting firm is being overseen by a steering committee made up of senior staff from the province’s district health authorities. However, no one representing the province’s front-line, health-care workers is on the steering committee.

The unions believe that cleaning staff may be the first to go and they fear that might lead to superbugs in hospitals.

Mr. Manji puts the average current Amica resident at about 82. He predicts that age will drop to the mid- to late-70s in the coming decade

For Toronto-based operator Chartwell Seniors Housing REIT, which offers accommodation ranging from independent living to long-term care, future growth is also about providing intriguing activities to occupy increasingly-active seniors.

Amica, which caters to the wealthier subset of the market

the $3,500 to $6,000 in monthly fees charged by their residences

“Over the last decade or so, we’ve witnessed a paradigm shift to creating environments that are no longer places where you go to die, but … offer the equivalent to cruise ship living on land.”

An elderly woman with a broken thighbone in a Pickering nursing home suffered for days without treatment.

A Brantford home was so short staffed that residents frequently missed their weekly baths.

Eight years after an Ontario government promise to revolutionize nursing home care, the elderly are still suffering neglect and abuse.

The Star’s investigation draws from material uncovered by a new inspection system created by the Ministry of Health and Long-Term Care in July 2010. It has since investigated 2,993 complaints and critical incidents, like broken bones or assaults. We analyzed more than 1,500 of those inspection reports and found at least 350 cases of neglect where residents were left in soaking diapers, suffered untreated injuries, bedsores, dehydration, weight loss or were put at risk from outdated care plans that ignored changing medical needs. Other reports, scrutinized for Thursday’s story, focused on abuse. Today the Star probes the issue of neglectful treatment of home residents. The reports reveal that many families have no idea what their loved ones are subjected to. Inspectors found that some homes do not disclose problems to the ministry or police.

Diaper shortages can be found in many of Ontario’s 627 homes, said Sharleen Stewart president of the union representing front-line nursing home staff. “Our members tell us the shortages leave residents with rashes and sores,” said Stewart, of the Service Employees International Union, which represents 50,000 Ontario health care workers, including 22,000 nursing home employees.

Last November a ministry inspector wrote, “Five different nursing staff members working the day shift from all home areas… indicated they are only provided with one (diaper) per (eight hour) shift for the resident and frequently have to go to another home area to try and borrow products.”

The report also described a resident with an open sore whose diaper was soaked in the morning. Since staff could not find a replacement, the resident was only given a paper insert to keep urine from the senior’s wound.

Two months later, in January 2011, the ministry was back at the same home, this time investigating a complaint from a family who said their loved one was wearing the same diaper from the previous day and it was “heavily soiled.”

Ko dismissed allegations that a Revera home in north Etobicoke rations diapers. But one current and one former resident of Westside Long Term Care on Albion Rd. told the Star residents are only given one diaper per eight-hour shift.

She praised the staff, saying they scramble to find an extra diaper if one’s needed. “They’re embarrassed that I’m embarrassed.”

Two employees at Westside said the home locks up diapers and staff have to sign them out. The workers at Westside spoke on the condition of anonymity, saying they are afraid of being fired. One worker said she is so worried about leaving residents in wet diapers that she places towels and plastic garbage bags under them to prevent urine from soaking their bed sheets.

Revera was “shocked” to hear allegations that makeshift diapers were being used and she has both launched an investigation and is conducting educational sessions for staff

Westside workers say their bosses warn staff they will be fired if they tell residents’ families the home is rationing diapers. Whistleblower protection in Ontario homes only helps staff who divulge problems to their nursing home supervisors or the health ministry. It does not protect the jobs of workers who warn residents’ families that their relatives are being neglected, complain to their union or speak to the media.

The new inspection report system often hides bad care from public scrutiny. The public report is often stripped of details. A private version for the home’s management, on the other hand, gives precise information about each violation. It took Lorraine Henderson 11 months to obtain copies of these private reports through access to information legislation.

The Star’s analysis of inspection reports found more than 50 cases in which elderly residents fell and got injured, many times when they were left unassisted by caregivers or dropped from mechanical lifts.

The hospital appears to have taken advantage of Medicare rule changes that authorized bonus payments for treating patients with major complications.

national data shows about 5 or 6 percent of Medicare patients have acute heart failure as a primary diagnosis

the chain, based in Ontario, is the target of a federal investigation for suspected Medicare fraud involving "upcoding"

That probe, by the U.S. Department of Health and Human Services, was requested by two lawmakers in response to the chain's high rate of blood infections known as septicemia

several former Prime doctors and coders have contended that Prime's founder and board chairman, Dr. Prem Reddy, urged aggressive coding of routine medical conditions to obtain enhanced Medicare payments

Earlier this month Prime sued Kaiser and the Service Employees International Union, accusing them of conspiring to drive Prime from the Southern California health care market in violation of antitrust laws.

Sandy Barber, a coding supervisor who worked at Prime's Desert Valley Hospital in Victorville in San Bernardino County, testified in a 2005 employment lawsuit that Reddy convened meetings where he "ordered" coders to engage in illegal upcoding to boost reimbursements from Medicare.

It's a 126-bed facility that Prime obtained in 2004 after the prior owners, a physicians group, went bankrupt.

California Watch, the state's largest investigative reporting team, is part of the independent, nonprofit Center for Investigative Reporting.