Families demand answers after losing loved ones in Winnipeg's most lethal care home outbreak

As all eyes were on the unfolding crisis at other nursing homes in Winnipeg last fall, Charleswood Care Centre was quietly experiencing a massive COVID-19 outbreak that would leave one-third of its residents dead. 

Now the families of residents who died during this period want answers into what happened during the outbreak that infected 70 per cent of its residents and left 45 residents dead.

Heather Castillo's father, Richard Zimmerman, died on Dec. 5, 2020, after catching COVID-19 at the nursing home. 

"We were in shock," said Castillo.

"At the beginning we were hopeful because he was younger. And he was a strong guy. So we were very hopeful that he would come out the other end of it."

Suddenly during her daily call to check on her 66-year-old father after the diagnosis, a worker casually mentioned on the phone he was receiving comfort care (often referred to as palliative or end of life care) — something the family had never requested or wanted. 

"Someone messed up, but we don't know who," she said.

"We spoke with the resident care manager and discovered that he was grouped into the wrong group."

Highest per-bed death rate in city

A CBC investigation released on Wednesday looked into the death rates at nursing homes, calculating how many residents died compared to how many beds were in the home.

It found Charleswood, the 155-bed for-profit care home owned by Revera Inc., had the highest per bed death rate in Winnipeg. 

It had more deaths per bed than Parkview Place and Maples Personal Care Home (both also owned by Revera), even though those homes received widespread attention, including a government-ordered external review of Maples.

Charleswood's outbreak was first declared on Nov. 20, about two weeks after a rapid response team was called into Maples after eight people died there in a 48-hour span. 

The month of December was particularly deadly for the home, with daily bulletins announcing sometimes three or four deaths in one day. There was a six-day span where at least one death at Charleswood was announced each day.

By the end of it, 107 residents were infected with the virus.

A further 42 staff members would test positive.

In a prepared statement, Revera acknowledged that Charleswood, Parkview Place and Maples had "very serious outbreaks."

"Our hearts go out to the families and friends of all the residents we lost to the pandemic," wrote Larry Roberts in a prepared statement

"Revera is very proud of the resilience and determination of the teams at all our homes in Manitoba in dealing with outbreaks of the pandemic in areas where community spread was very high."

'This should have never happened to him'

Castillo says her father was one of the first residents to contract the virus after the outbreak was declared in late November.  

His family says he was physically healthy and full of life, but required full-time care because of his vascular dementia. 

"This should have never happened to him," said Richard's mother, Renata Zimmerman.

"I say to myself, why him? He had enough issues already. Why him?"

When he first got sick, his daughter felt they had to advocate for their father to get adequate care, as the home became increasingly chaotic as more residents tested positive for the virus.

"We had to vouch for him and and say that … even though he was in a care home, he still had a vibrant life," said Castillo.

"I feel like people in care homes were more or less written off by the entire health care system."

It was around this time, around Nov. 27, that the WRHA sent in clinical leads to provide on-site support to the home.

Castillo doesn't know if the two days her father was on comfort care had an impact on his prognosis, but felt the two days he was in that group delayed his care. 

Soon after it was discovered he was in the wrong group, her father's oxygen levels dropped and he was rushed to the hospital.

Suddenly, the family was told he was in critical condition and he was put on a ventilator.

He died a week later on Dec. 5.

Renata Zimmerman, 90, said the last time she was able to see her son was in November.

"We weren't supposed to hug, but he said, 'Mom, come here,' and he gave me the biggest hug. Like he knew that something was going to happen," she said.

The family said there were early signs that not everything was right with Richard's care.

Often his room was messy, his mom once found a weeks worth of pills he had not taken and he started falling in early September — and once the family wasn't told about a really bad fall until a week later.

"We really question the level of care there, because he had bruising the size of a soccer ball on the side and bruising all over his arm, baseball-sized bruises," said his daughter.

"To not be told about that right off the hop was concerning, to say the least."

A spokesperson for Revera said they cannot comment of the specifics of any resident's care, citing privacy, but said if the family wishes to discuss things further they should directly contact the executive director of Charleswood.

Retired nurse sent into home to feed resident

Deborah Young is wondering if her best friend would still be here today if she had just paid more attention to what was happening at the nursing home.

"I question what I could have done differently," said Young, whose friend Frances Rowlin died on Dec. 14.

"Could I have kept on spending every night with her and not getting any sleep of my own?" 

Young found out her best friend of more than 60 years had tested positive on Dec. 12 and within two days, she died. 

As the outbreak at Charleswood grew worse, a retired nurse who was friends with Rowlin would come in every day, donning PPE, so he could make sure she ate and drank.

Young said it was clear the nursing home was short-staffed as more and more workers fell ill.

A directive from the government that nursing home workers were to only work at one nursing home had already lessened the pool for the care home staff.

"When COVID hit them so hard, the care deteriorated. There weren't people to check to be sure if she was eating," Young said. 

"There was all kinds of people dying there, there were all kinds of people getting it, there were all kinds of stuff falling by the wayside."

The retired nurse was there when Rowlin died, and had phoned Young an hour before so she could say her goodbyes.

"I said, you know, God's waiting for you. It's a beautiful place … why are you hanging around? You know, go and get ready for us when we come to join you," said Young.

"And she died about an hour later with him holding her hand so she wasn't alone."

The Zimmerman family wants the Manitoba government of Premier Brian Pallister to place more attention on long term care, so other families don't have to go through this.

"Maybe Mr. Pallister should go into these nursing homes to see what's going on?" said Renata Zimmerman.