Dr. Bartlett had done stringent due diligence before putting her mother, a daughter of Italian immigrants who loved to cook her special meatballs for her two granddaughters, at the Herron. She visited half a dozen nursing homes and interviewed Herron’s medical staff. She even consulted a specialist in placing seniors in homes. In the end, she decided on the Herron, which charged her mother 6,500 Canadian dollars a month. Dr. Bartlett was originally impressed by its diligent staff, and services that included a beauty salon.

Today, Dr. Bartlett laments that even her extensive research failed to turn up the criminal record of the residence’s owner, Samir Chowieri, who in the 1980s served 15 months in prison for drug trafficking and had been convicted of fraud. One of his retirement homes was later the subject of a money-laundering investigation by the Royal Canadian Mounted Police. “Had any of this criminality been exposed I would’ve never put my mom there,” she told me.

But there was a reason for the lack of a paper trail: In 2014, Mr. Chowieri was successful in obtaining a pardon and having his criminal record expunged. The Quebec premier, François Legault, this week said it was “unacceptable” that a person convicted of serious crimes ended up running a home for the elderly, and asked why there were rigorous background checks for employees of long-term care facilities in Quebec but not for owners.

Dr. Bartlett said that while her mother’s care had initially been satisfactory, conditions at the residence deteriorated as the owners went on an aggressive cost-cutting spree and struggled to find qualified staff.

She attributed the 31 recent deaths to the fact that, as Covid-19 spread and the residence was locked down, relatives of families were not able to visit and act as advocates for their loved ones. That in turn helped create a “perfect storm of neglect,” when overstretched and depleted health care workers, fearful of the virus and lacking sufficient protective equipment, fled.

Yet Dr. Bartlett said it was hard to fathom that the body bags leaving the residence did not raise alarms sooner. “Why didn’t anyone scream at the top of their lungs?” she asked.