REGINA -- The Extendicare Parkside care home was unprepared for a deadly COVID-19 outbreak that left 39 residents dead, according to a report by Saskatchewan’s Ombudsman.

Ombudsman Mary McFadyen tabled her report on the outbreak in the Legislature on Thursday, detailing how COVID-19 spread through the facility in late 2020.

“This was a tragedy. 194 out of 198 residents got COVID-19 and 39 of them died of it. Three others who got it died of other causes. 132 Parkside staff also got COVID-19,” McFadyen said in a news release.

“It is important for residents and their families to know what happened. I hope our recommendations will help to prevent something like this from happening again.”

According to the Ombudsman, the “physical limitations” of the Parkside building were known to Extendicare early in the pandemic. The report states the Saskatchewan Health Authority (SHA) and Extendicare knew the facility would be in trouble if the virus spread throughout the home.

“… but instead of reducing Parkside’s population, so no more than two residents shared a room, the focus was on keeping a few rooms vacant to isolate COVID-19 positive residents. This was a mistake,” the report reads.

The investigation found Extendicare was not following some pandemic protocols, such as not consistently screening staff for symptoms and failing to ensure staff were physical distancing and wearing masks during breaks.

Parkside also gave staff only one new mask per shift, instead of the four masks recommended in the SHA’s guidelines.

“The Authority’s ‘hands off’ approach coupled with Extendicare’s ‘back off’ approach made collaboration on other issues more difficult,” the Ombudsman said in the news release.

Despite having a pandemic plan to isolate positive residents in its north wing, Parkside instead chose to isolate the first positive residents in its main wing where residents were staying. With the virus spreading, the home was forced to convert the entire north wing into a COVID-19 wing and move several residents at once.

“Its staff were not equipped to safely move so many residents at once. Positive residents were moved simultaneously with non-positive residents. Not all of them were masked and rooms were not fully disinfected between moves.”

Finally, a lack of a staff contingency plan created a “staffing crisis” early on in the outbreak, the report said.

Rapid testing was implemented at the facility on Dec. 8, 2020, but the Ombusdman said that was too late for Parkside residents.


Based on the findings of the investigation, McFadyen offered several recommendations for both Extendicare and the SHA.

She recommends Extendicare issue an apology to all the families of residents who died and any other residents whose lives were disrupted.

A “critical incident review” was also recommended to be done by the company, to try and prevent similar errors in the future. It is also asked to ensure administrators and staff follow rules laid out by Extendicare, the Ministry of the Health and the SHA; and to have resources on site to help staff comply with relevant infection prevention and control management.

The report states the SHA gave Parkside “reasonable support” during the pandemic, but oversight was still lacking in some areas.

McFadyen recommends the SHA stop allowing four-bed rooms in long-term care facilities immediately. It is also recommended that the health authority update its agreement with care home operators to make sure care-related policies, standards and practices are followed; and conduct annual reviews to ensure care homes are complying with rules.

Lastly, she recommends the SHA ensure communicable disease prevention and control management standards and practices are being followed, which includes completing, at-minimum, annual inspections of all long-term care homes.


Both the government and the SHA said they have accepted the recommendations and are taking “immediate action.”

Saskatchewan’s Minister Responsible for Seniors Everett Hindley said the Ombudsman‘s findings are very troubling, during a press conference Thursday. He added that the report concluded Parkside failed to protect its residents and that the SHA didn’t provide effective oversight in some areas.

“For that, on behalf of the government and the SHA, I want to apologize to the families, the friends of all those who died at Parkside as a result of COVID-19,” Hindley said.

The government appointed the SHA to oversee all five Extendicare care homes in the province for 30 days on Thursday.

The SHA will submit a report to the Ministry of Health at the end of the 30 days about compliance with the recommendations made in the Ombudsman’s report.

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

Minister Responsible for Seniors Everett Hindley said the government will do everything it can to prevent another outbreak in a long-term care home.

"In particular, it's my expectation that Extendicare Canada will accept these recommendations to provide the safest care possible to their residents," said Hindley in a press release.


In a statement, Extendicare said it extends condolences to residents, family members and staff who suffered because of COVID-19. The operator said the pandemic “has exposed weaknesses in our health-care system and, in particular, has made painfully clear the structural challenges that have burdened the long-term care sector for decades.”

Extendicare said it is focused on learning from the COVID-19 pandemic to “build a better future for seniors’ care.” It added it has launched its own multi-year plan to improve care across every home operated by Extendicare.

The care home operator thanked the Ombudsman for her efforts and said it will “carefully consider” the findings and recommendations in the report. 

More to come…