The Saskatchewan ombudsman's investigation into the death of a 74-year-old woman concludes that nursing homes are under strain and there are gaps in long-term care.

Mary McFadyen's report released on Wednesday said there is a culture of distrust between staff and management at the care home where the woman lived. It also said care aides described a stressful environment.

"Many staff reported that their work schedules result in burn out and increased sick leave," the report said. "Some stated that when they tried to raise issues, management was either unavailable, or unsupportive and blaming."

The report also said there are no immediate consequences for care homes that fail to meet provincial standards.

Health Minister Dustin Duncan said he wants to implement all of McFadyen's 19 recommendations, which range from improving communication with families to publicly reporting on whether facilities are meeting guidelines.

"We know that this isn't isolated to an individual facility or to a region," he said.

Medical records show Margaret Warholm, who lived at the Santa Maria Senior Citizens Home in Regina, reported losing 30 pounds in a year and had compression fractures in her spine.

She also had a large bedsore on her back that her family believes could have been prevented. Warholm died days after being admitted to hospital in October 2013 following a bad fall.

McFadyen's report pointed to problems with Warholm's care, including inconsistencies in treating her fragile skin and contradictions in her care plan that were noted in a medical chart.

She said Warholm's case isn't unique and her office has received 89 other complaints about long-term care since she launched her investigation in November.

"Bluntly put, most people who contacted us simply said that all they wanted to know was whether their mother or father was safe, clean and properly fed," she said. "That in my opinion is not a lot to ask for."

McFadyen said issues included poor communication, lack of accountability and no clear way for families to complain about the care of loved ones.

"They felt then afterwards that their mother or father was not being treated as well when they left so they were afraid."

The Opposition NDP has been criticizing the government's position on seniors care for months. The New Democrats are calling for a seniors advocate, higher staffing levels and minimum-care standards.

NDP Leader Cam Broten said the ombudsman's report shows that the system failed Warholm. He said there is a seniors care crisis in the province.