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Saskatchewan’s ombudsman has found a Regina nursing home was “woefully unprepared” for a deadly COVID-19 outbreak last year.

The outbreak was declared in November at Parkside Extendicare, where 194 of the facility’s 198 residents tested positive and 39 died due to the virus.

A report from the ombudsman Mary McFadyen says the for-profit facility, which operates in partnership with the Saskatchewan Health Authority, was also lax in enforcing public health orders and implementing effective infection prevention and control measures.

The report, released Thursday, recommends Extendicare issue a formal, written apology to the families of the residents who died, collaborate with the health authority on a review of the outbreak and make sure Parkside has enough resources on-site so staff can take proper precautions for infection prevention and control.

In a statement, Extendicare said it is “deeply sorry for what happened” and intends to work with the health authority.

The report found that, before and during the outbreak, some staff did not consistently follow public health measures, including physical distancing and mask-wearing. While staff may have taken proper precautions when interacting with residents, they were less cautious on their breaks.

“It was like they thought COVID-19 could not enter the break room,” the report states.

The report also says the provincial government, the health authority and Extendicare all knew Parkside would be in serious trouble if it were to have an outbreak because of overcrowding.

“They knew it did not have adequate space to isolate more than a few residents during an outbreak without taking drastic measures (which ended up happening) such as displacing residents on an emergency basis into other facilities and turning an entire wing into what was essentially a makeshift field hospital,” the report says.

“They were also aware that this same overcrowding increased the likelihood of a major outbreak because it was impossible to maintain proper social distancing among its residents, for example, during meals.

“In fact, they have known of these issues for years and years, as exemplified by Parkside having consistently more outbreaks than other facilities over the years.”

During the COVID-19 outbreak, residents who had been in close contact with positive cases were isolated together in two- or four-bed rooms, which fuelled transmission in the facility.

Saskatchewan Minister of Seniors Everett Hindley called the report troubling and said the province is committed to making sure such an outbreak never happens again.

The province said it accepts the recommendations made by the ombudsman and is taking immediate action in response.

“We need to do better,” said Hindley. “The findings and recommendations in this report provide a clear path to do better.”

Hindley apologized to the families and friends of the residents who died.

The report found that, while the health authority did work to support Parkside during the outbreak, broader oversight was lacking.

The government said it has appointed the Saskatchewan Health Authority as the administrator of all five Extendicare long-term care facilities in Saskatchewan for a period of 30 days. It said the authority will then submit a report to the Ministry of Health regarding compliance with the ombudsman’s recommendations.

The government said that report will be used to evaluate the health authority’s agreement with Extendicare as a long-term care service provider in the province.

Opposition NDP Leader Ryan Meili said the deaths and infections at Parkside are an example of the Saskatchewan Party government’s “chronic failure to care for Saskatchewan seniors.”

“The ombudsman ... makes it clear that the problems in long-term care go far beyond this one horrific outbreak when she calls on the government to ‘make meaningful and lasting systemic and structural improvements to Saskatchewan’s long-term care system,”’ said Meili.

“The Saskatchewan NDP believes that should include the end to for-profit care in Saskatchewan.”

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