'Disaster': Inside the Extendicare nursing home outbreak where 42 people died

Warning: This story features distressing details.

Twelve days after a COVID-19 outbreak was declared at Extendicare's Parkside nursing home in Regina, one of the first two doctors to step inside the buildingsince the beginning of the pandemic wrote the Saskatchewan Heath Authority about what they had just seen.

"We have a critical situation," the doctor warned. "Why can't we stop the spread?Eightypatients is a disaster!"

Things only got worse.

By the end of the outbreak, all but four of thehome's 198 residentscontracted COVID-19, along with 132 Parkside workers.

Forty-two of those infected residents died between November 2020 and January 2021 39of COVID-19 and three of other causes.

An ombudsman report released last weekconcluded thatExtendicare, the private company that operates Parkside,was "woefully unprepared"for the outbreak, which was declaredafter some staffworked shiftswhileexperiencing symptoms of COVID-19.

But there were earliersigns that all was not well at Parkside,according to the report.

Plans to replace Parkside which was built in the 1960s, long before modern infection control practices stalled despite a decade of documentedtalks between the province and Extendicare.

Concerns aboutParkside's crowded four-person roomswere again flagged early in the pandemic, yet no major action was taken to reduce the number of occupied beds until after the outbreak took hold, the ombudsman's investigationalso found.

Drawing on a trove of more than 20,000emails, letters, meeting summaries, reports, policies, agreements, audits, training materials, contact tracing recordsand other documents, the ombudsman's report showed thatSaskatchewan health officials had many concerns with Extendicare andParkside in the months leadingto the outbreak, including the company's refusal "for no good reason" to follow the province's continuous masking policy.

Still, the Saskatchewan Health Authority (SHA) only took overat Parkside weeks into the outbreak, when 11residents had already died.

"There were warnings of a second wave. There were public health orders and measures to protect residents in long-term care from COVID-19. So, what happened?" the ombudsman's office asked.

What follows is a detailedtimeline of the outbreak and the events that led to it, culled from the ombudsman's 120-pagereport.You can read the full report here or at the bottom of thisstory.

Note: None of the people who spoke to the ombudsman's office were named in the report. All were referred to by their job titles.

PART ONE:AN OUTBREAK-PRONEBUILDING

(2010 to March 2020)

Officials with the SHAtold the ombudsman's office that Parkside consistently had more outbreaks of all kinds year-over-year compared toother facilities because it had four residents in many rooms and cramped conditionsthat were not conduciveto disease control, according to the report.

In the first sevenmonths of 2020, 13 non-COVID outbreaks were declared atParkside: 11 respiratory, one vomiting/diarrheaand one involving scabies.

Some familiessaid that even before the COVID-19 pandemic, Parskide conditions were "terrible,"according to the report. Complaints included"dirty, towels strewn, and garbage left in areas." Even as recently as June 2021, Extendicare was storing its personal protective equipment (PPE) outside in sea cans, according to the report.

Fruitless talks

2010: Extendicare's efforts at lobbyingthe Ministry of Health to replaceParkside date back as early as this.

April 2012: The replacement was approved in principle, but nothing concrete came of it.

Oct.16, 2013: "Extendicare may be nearing the point of deciding whether they will remain in the province, given the state of their facilities," an official informedthe deputy minister of health.

The next day, the frustrated president of Extendicare complainedto the ministryabout his company'sunsuccessful "three-year effort."

Extendicare may be nearing the point of deciding whether they will remain in the province, given the state of their facilities.- October 2013 Ministry of Health email

Dec. 5, 2017: A business plan prepared for the health authoritynoted that Parkside was in "critical" need of replacement.

February 2019: Extendicare did not submit a proposal when the SHA sought requests for proposalsfor new long-term care homes in Regina.

Sept. 23, 2019:The Ministry of Health told top Extendicare officials that replacing Pioneer Village in Regina a long-term care home that, unlike Parkside, is ownedand operated by the SHA "was its top priority," according to the report.

PART TWO: RED FLAGS

(March 2020 to October 2020)

The Parkside outbreak didn't happen until November 2020 eight months into the pandemic but there were early warning signs about Extendicare'sstate of preparedness for such a crisis, according to the report.

COVID-19 arrives in Saskatchewan

March 2020: Saskatchewan announcedits first case of COVID-19.

April 14, 2020: The health authority issued its continuous masking policy, requiring all long-term care home workers who came into contact with residents to wear a mask at all times. This meant a minimum of four masks per person per shift.

Two days later, in a national memo to its workers, Extendicareunveiledits own policy,which would provide"all staff with [one]mask and a clean breathable storage container for the mask (such as a paper bag)," per shift.

'Human capital became scarce': Extendicare

April 17, 2020:The Ministry of Health ordered that long-term care staff work in onlyonehealth-care facility during the pandemic. This decision led to Parkside losing more than 100 part-time staff to other organizations, according to Parkside's administrator. Some staff were cohorted to SHA-owned facilities.

"Human capital became scarce," the Parkside administratorsaid.

The loss of so many staff, coupled with many infected workers having to stay home to self-isolate,iswhat later resulted in the SHA taking over Parkside"to handle the outbreak," according to the report.

This way there is no wasting of masks.-An Extendicare administrator writing in April 2020of the company's policy of providing workers with one mask and one paper bag to store it inper shift

April 20, 2020:An Extendicare senior administrator defended the company's conflicting mask policy.

"This way there is no wasting of masks," they said.

Four days later, an SHA public health nurse wrote Extendicare out of concern.

"I know we are in unusual times and there is a need to be judicious in our use of [PPE] but the described approach could be causing more harm than good," the nursewrote, adding that the company should contact the SHA if more PPE was needed.

April 29, 2020: Parksidewas the only Extendicare facilityin Reginathat had not completed a COVID-19 readiness checklist to ensure "it had the necessary PPE supplies and resources on hand to deal with an outbreak, or a human resources plan to maintain required services when working with reduced staff,"according to an internal update by the SHA.

Early warning about 4-bed rooms

April 30, 2020:An SHAmedical health officer warned that homeswith four residents per room had been "a challenge in the past for outbreak management and prevention."

May 7, 2020:The health authority put a planin placefor privately-run homes like Parkside to regularly order masks from theSHA, free of charge. It required Parksideto update the SHAevery two weeks about how many masks it was using.

"Parkside ordered masks from the authoritybased on its staff's actual usage (one mask per shift unless it become soiled), not on the authority's continuous masking principles and guidelines (four masks per shift)," according to the ombudsman's report.

June2020: Extendicare was alsomulling overthe issue of crowded rooms. The company's regional director told administratorsto start thinking about three-to-four-bed wards and how they could be reduced.

"You can share with your [directors ofcare] if you want but no one else," he wrote. "These discussions have far reaching implications and we don't have much to share.In a vacuum, people may make their own narratives."

Rapid testing requested

June 19, 2020: Extendicare asked the Ministryof Health to provideasymptomatic testing of long-term care staff at its Saskatchewan homes, sayingthe practicewas successful in limiting the spread of COVID-19 in Ontario. The ministry countered thattesting was universally available at its public testing sites.

Not until after the Parkside outbreak began and Extendicare lobbied the minister further did rapid testing become available at Extendicare's Moose Jaw home. The tests wereeventually usedat Parksidebeginning on Dec. 8, the day the SHA took over the building.

Premier Scott Moe later said the province's overall supply of rapid test kits"should have been dispersed sooner."

August 2020: Extendicare begantaking steps to have only two residents per room in Ontario but notin Saskatchewan, according to the ombudsman's report.

The company's "Ride the Wave"campaign educated staff about procedures to follow during an outbreak, including the use of PPE.

Financial concerns about reducing the resident count

Aug. 13, 2020: The health authority toldExtendicare that in order to free up some space at Parkside, a transitionalconvalescent program was being halted. Extendicare's regional director asked why.

"To minimize risk, keep [COVID-19]out of thehomes and, if we do have a positive situation, to mitigate risk and reduce scope of impact," an SHA official replied.

A week later, aftermore talk ofreducing the number of occupied beds, the regional director told the SHA, "Any bed reduction strategy would need to be supported with funding to ensureas an organization we don't experience any financial risk and are 'kept whole.'"

Oct. 13, 2020: Speaking after a record 106 Saskatchewan residents tested positive for COVID-19 over the Thanksgiving weekend, Dr. Saqib Shahab, Saskatchewan's chief medical health officer, announced anew rulecapping private indoor gatherings to 15 people.

"It is very hard to physically distance four people in an average room, let alone 15," he said.

Any bed reduction strategy would need to be supported with funding to ensureas an organization we don't experience any financial risk and are 'kept whole.'- Extendicare's regional director, Aug. 21, 2020

Oct. 27, 2020:After some prodding from the SHA, Extendicare submitted its pandemic operational plan readiness spreadsheet, but it had "quite a few outstanding items," according to the SHA.

For example, the form asked the company to confirm it was socially distancing people in communal areas and dining rooms.

"Infrastructure does not allow this to happen on a regular basis.We are doing the best we can," Extendicare wrote back.

Nov. 5, 2020:Saskatchewan reportedits first ever triple-digit daily increase in COVID-19cases and announced it was limiting indoor private gatherings to 10 people.

The revised public health order that took effect the next day also required everyone to wear masks in special carehomes like Parkside, although residents were not required to do so when in their rooms, which were considered private residences.

"Neither the Ministry of Health nor theSaskatchewan Authority initially made it clear to Parkside, nor did Extendicare ask, for clarification about how to apply the order to residents specifically if it meant they had to wear masks when outside their[bedrooms]," according to ombudsman's report.

This would have implications later.

PART THREE: OUTBREAK

(November 2020 to January 2021)

The Saskatchewan Health Authority's final outbreak notification report often cited higher infection numbers than the daily figures reported by Extendicareduring the outbreak. This was because not all test results were known at the time Extendicare reported its estimates.

This story uses the final figures established by the health authority.

Patient zero

Early to mid November:A direct care worker assigned toParkside's main wing worked in close contact with residents on Nov. 9 and Nov. 10, before beginningto feelsymptoms of COVID-19, the workerlater told contact tracers.

By Nov. 11 and Nov. 12, the direct care worker beganfeeling a cough, headache, dizziness anda lost sense of taste. This, according to the ombudsman's office, wasthe first person at Parksideto have experiencedsymptoms in the lead-up to the outbreak patient zero.

The personlived alone, had not travelled, had not attended any mass gatherings,wore a mask while out in public andhad not been inknown contact with a COVID-19 positive person.

"Their doctor told them to get tested for COVID-19, but they did not," according to the ombudsman report.

Still no action on masks

Nov. 12, 2020:The Saskatchewan Health Authority wrote Parksideto ask why, for the number of beds it had, Extendicare was reporting havingfewer staff than other homes.

"The authority thought this might be why [Extendicare]was not ordering what the authority believed were enough masks and was almost out before getting new orders every two weeks," according to the ombudsman's report.

Four days later,aspreadsheet indicated that Parkside was still using one or two masks per shift per person.

"While the authority balked at Extendicare's defiance and made it clear to Extendicare's local and regional managers that its facilities should be using four masks per day, the authority did not take any steps to enforce [the rules]," the ombudsman's office concluded.

• Do you have a story about the Parkside outbreak to share? Email Guy at guy.quenneville@cbc.ca

Unmasked in the break room

Nov. 12 to 18, 2020:Patient zeroworkedeight more shifts while symptomatic. The worker wore a mask when dealing withresidents in their rooms and during meals whenresidents were not wearing masks, according to the report.

"This direct care worker also reported sitting unmasked within sixfeet of other Parkside staff who were also not wearing masks during breaks."

The worker never toldmanagement about their symptoms,the report added.

Nov. 16, 2020:Parkside's administrator asked the health authoritywhether he could call in volunteers or family members "when we were in a COVID outbreak."

"This suggests that he was just then four days before the outbreak was declared and while some of its staff were coming to work with COVID-19 symptomstrying to figure out how [Extendicare]could replace some of its staff," according to the report.

LISTEN | CBC Saskatchewan's political panelbreaks down the Parkside report

The first resident dies

Nov. 15 to 18, 2020: A different direct care worker than patient zero socialized at a co-worker's house along with three other employees for three hours on Nov. 15, then drove unmasked for 20 minutes the next day with another Parkside worker, before working a full shift on Parkside's south wing on Nov. 16, according to the report.

Like patient zero, this worker wore a mask while dealing with residents but took if off on break.

During their next shift, on Nov. 17, that worker reported having a headache, body aches and chills.

"Their temperature was normal, so they said they took some pain medication and kept working," according to the report."While masked, they worked closer than two metres from three of their masked co-workers."

The ombudsman's office concluded that on the same shift the workerreported their symptoms, theyhelped transfer a patient who had been found unconscious.On Nov. 18, just oneday after being taken to the hospital, this resident would be the first of 39 Parkside patientsto die from COVID-19 during the outbreak.

Alot of people really didn't believe that COVID-19 was really a thing.-Parkside Extendicare direct care worker

Workerslater toldombudsman staff they had worked while symptomatic and taken their masks off in the break room, that there were often more than 10 people in the break room, that it was not possible to socially distance (the room was also used for storage)and that screening of workers before the outbreak was inconsistent.

"We ended up having to get security because staff were not compliant with taking their temperatures," the ombudsman's office was told.

"This is just my perception: a lot of people really didn't believe that COVID-19 was really a thing," one worker said.

The SHAlater learnedstaffwere"harassed" if they needed to stay home because they were symptomatic,according to the report.

Outbreak declared

Nov. 19, 2020:The second Parkside resident to show symptoms was isolated. The day before, the resident had been in a car with their family, where they wore masks but pulled them down frequently, the ombudsman's office heard.

Nov. 20, 2020:Public health officials declared an outbreak at Parkside. The home had 198 residents "still too many," according to the report.

Patient zero was finally swabbed for COVID-19.

Nov. 21, 2020 16residents and 15 staff infected: All residents were isolated to their rooms.

Parkside's administrator asked the SHA for a very large order of PPE, including 10 cases of masks"to keep [Parkside] afloat for about 5 days?"

The Red Zone

Nov. 22, 2020 16 residents and 20 staff infected:Extendicaremovedall known infectedresidents together into the building's main wing, contraryto the company's plan to cohort them in the 600 hallway of the north wing, which couldbe closed off from the rest of the home.

"One staff member told us that, in their mind, this made no sense because it meant everyone had to walk through the COVID-19 positive hallway in the main wing to get to the south wing," according to the report.

The main wing became known as the"Red Zone," although, as the ombudsman's office reported, "over the next few daystest results revealed that there were COVID-19 positive residents throughout the building."

Extendicareultimately convertedits north wing into a COVID-19 unit.

"Honestly we probably should have left everybody where they were," Parkside's director of care said. "I think the more we moved them around, the more we moved the virus around."

Residents who had not tested positive sat in the hallway as staff tried to get rooms cleaned, one worker said.

"It was a whole lot of chaos," they said.

Not all residents being moved wore masks, several Parkside workers told the ombudsman's office.

Much later more than a month after the outbreak was declared, and after the health authority took over Parkside Extendicare'sregional director clearly did not realize thatall residents in Extendicare's Saskatchewan homes were supposed to bewearing masks when outside their bedrooms since the revised order on Nov. 6., according to the report.

Nov. 23, 2020 17 residents and 23 staff infected: Extendicare's director of care complained about the company getting mixed messages from public health officials. Some symptomatic staff who tested negative were told they could return to work in 48 hours. Others who tested negativewere told they had to self-isolate for 14 days.

"Different rules each time we turn around," the director of care wrote.

Nov. 26, 2020:An infection prevention and control official with the SHA instructed Parksideto staggerbreaks, usedifferent break rooms for staff workingin different wings and requireworkers to sign in and out of break rooms.

"These recommendations need to be enforced!" she wrote.

'Cycle of transmission will continue uncontrolled,' SHA warns

Nov. 27, 2020 39 residents and 30 staff infected:Ahealth authority official flagged Extendicare'spractice ofisolatingnon-positive residents together in two- to four-person rooms,saying the "cycle of transmission will continue uncontrolled" and that it was better to place all uninfected residentsin private rooms.

"I think Parkside is likely to present us with our most extreme outcomes," she said.

Later in the day, Parkside's frustrated senior administrator vented in anemail, "I am struggling with the constant change of direction or opinion of change of direction from Public Health."

Nov. 28, 2020 49residents and 31 staffinfected: Fifty-five Parkside staff had either tested positive or were self-isolating, forcing Extendicare to deploy workersbetween wings.

"A direct care worker told us they were moved from working with positive residents on the main wing to working with positive residents on the north wing, but two days later they were moved again to work with non-positive residents on the south wing," the ombudsman's office reported.

Nov. 30, 2020 81 residents and 46 staff infected:More mass testing was done, resulting in a big bump in numbers.

Parkside's director of caresaid that while she realized the SHA was very thin on resources, she needed officials to get back to her in a timely manner regarding testing, contact tracing and messaging to staff about when they were able to return to work.

Dec. 2, 2020 88 residents and 58 staff infected: Infection control and safety officialsfrom the Saskatchewan Health Authorityvisited the Parkside home, after staff complained about not having enough PPE and other infection control practices.

The assessment turned up significant concerns, including staff saying they were still only allowed one mask per shift, a concern that not all staff were regularly replacing their masks, and continued difficultiessocially distancingin the break room "given Parkside's infrastructure limitations."

"We need to allow Extendicare staff the opportunity to have reasonable workloads and do their work safely," one SHA official wrote.

The doctorwho visited the home that day called the outbreak a disaster and said Extendicarestaffwere"tired and just surviving."

"We are watching the bus running away from us," the doctor wrote.

We have a critical situation, and I don't think we are not responding enough! Parkside is our first big outbreak. Why can't we stop the spread? 80 patients is a disaster! Is it PPE, is it staff fatigue?We need people on the ground to figure it out. Why are we not adding more resources to the outbreak? We need to have our go-team up and running by next week!Why are we waiting? We are watching the bus running away from us.- Dec. 2 email to SHA from doctor who visited Parkside that day

Over the ensuing days, the SHA provided Extendicare with advice andmoreworkers, and alsoconfirmed the home had adopted the province's masking policy.

Death after death

Dec. 4, 2020 101 residents and 74 staff infected, three residents dead: A wave of resident deaths began, beginning with the second and third residents to die of COVID-19.

Dec. 5, 2020 104 residents and78 staff infected, five residents dead:A Parkside manager who had been home isolating said that when they returned to work, it felt like walking into a war zone.

A total of 25 residents begangetting transferred toPioneer Village, another care home. Extendicare wasn't aware at the time, as test results were not yet known,but 19 of those people were already infected.

The SHA still noted some problems among Extendicare staff, such as skippinghand hygiene steps while donning and doffing PPE.

Two more residents died.

Dec. 6, 2020 105 residents and 83 staff infected, eight residents dead:Authority officials left a meeting that nightconcernedthat"Extendicare's corporate leaders were taking an arm's length approach and were providing only minimal corporate support to its local staff," according to the report.

Extendicare then asked for more PPE and staff.

Three more residents died. Thenanother threedied on Dec. 7, bringing the total death toll to 11.

The health authoritytakes over

Dec. 8, 2020:By the time the Saskatchewan Health Authorityassumed command of Parkside, 246 people at the home 149 residents and 97 staff already had COVID-19.

A12thinfected resident died that day of COVID-19.

Extendicare's chief medical officer called on the Ministry of Health to allow Parkside'sasymptomatic COVID-19-positive staff to immediately return to work to care for positive residents given "the critical staffing situation."

The company's request was, in part, "precipitated by its lack of planning before the outbreak about how it would replace its staff that were put into self-isolation," the ombudsman's office found.

The requestto shorten the isolation period for COVID-19 positive Parkside workers was granted the next day.

"Some [families]felt that Parkside waited too long to ask the authority for help," according to the report.

Dec. 10, 2020, to Jan. 20, 2021:

Twenty-seven more Parkside residents ultimatelydied of COVID-19, andanother three infected residents died of other causes, before the outbreak was declared over in January 2021.

Staff at Parkside were required to begin wearing N-95 respirators on Dec. 12 because a consultant foundresidents' rooms "did not meet relevant ventilation standards," according to the report.

OnDec. 31, Extendicareconfirmedits four-bed rooms now housed only two residents. The ombudsman's office estimated this willcost the company$1.2 million in annual revenue from resident's feescompared to if Parkside was operating with all 228 of its beds occupied.

Everett Hindley, Saskatchewan's minister responsible for seniors, announced on Jan. 14 that the government was seeking an independent investigation of the outbreak by the ombudsman's office.

The findings werereleased last week.

"There is no question that from the beginning of the pandemic, the ministry, the authority and Extendicare were aware that Parkside would be in serious trouble if it were to have a major outbreak," the report said of Parkside's crowded conditions.

"They have known of these issues for years and years."

Read the full ombudsman report below. Don't see it? Click here.