Newly released Manitoba nursing home inspections show nurses working 50 consecutive days

An inspection of a personal care home in Northern Manitoba done in the midst of the province’s second wave revealed staff shortages so severe that nurses worked 12 hour shifts for 50 consecutive days and water temperatures so low, residents were unable to properly sanitize their hands.

Inspection of Nisichawayasihk personal care home found severe staffing shortages, poor infection control

The Manitoba government proactively released almost 40 nursing home inspection reports on Thursday, including one that showed nurses working for over 50 straight days. (Lighthunter/Shutterstock)

A recent inspection of a personal care home in northern Manitoba revealed staffing shortages so severe that nurses worked 12-hour shifts for more than 50 consecutive days and water temperatures so low residents were unable to properly sanitize their hands.

The Oct. 8 standards review of Nisichawayasihk Personal Care Home — located in Nelson House, about 700 kilometres north of Winnipeg — found a litany of deficiencies with the 24-bed nursing home, including broken hot water tanks that meant the water in residents' rooms could not get hot enough to kill germs.

Of the five nursing positions, two were vacant and one nurse was being trained on the floor during the inspection. 

And the other two had worked at least 12 hours per day for the previous 50 days straight. 

"Across long term care it seems that understaffing is causing so many issues," said NDP Leader Wab Kinew. 

"The staffing issue needs to be addressed and I hope we maintain the political will and public interest to fix the staffing shortages."

The inspection found that health-care aides were acting as cooks and the sole maintenance position had been vacant since July.

This meant nursing staff were forced to change light bulbs, repair failing equipment and install hand sanitizers. The report notes shortages were a problem even before the pandemic hit. 

"Call bells, lifts, and tub chairs were described as unreliable and only one of three hot water tanks was reportedly working," stated the inspection.

The inspection is just one of the 38 inspections proactively released by the Manitoba government on Thursday.

Opposition NDP Leader Wab Kinew said the reports show a lack of resources and chronic understaffing at nursing homes. (Ron Boileau/CBC)

However, it was the only one released that was conducted during the second wave of COVID-19, which is when the overwhelming majority of nursing home outbreaks and deaths have occurred.

The outbreaks have caused staffing shortages across the province as nurses and aides are mandated to only work in one home or are absent due to contracting the virus or needing to isolate after an exposure. 

After the inspection, the licensing branch learned the CEO had quit, as did one of the three nurses.

"The LCB (Licensing and Compliance Branch) is not aware of a human resources plan for the PCH to ensure adequate staffing levels are maintained," the inspection stated.

More inspections in coming weeks

The inspection represents one of the dozens of nursing home inspections that have been conducted in Manitoba since the onset of the coronavirus pandemic.

According to a spokesperson for Manitoba Health, the 38 inspections released are the initial "launch" and inspections from 2019, 2018 and the remainder of 2020 will roll out in the coming weeks.

As of Thursday, almost 40 nursing homes had active coronavirus outbreaks. Nisichawayasihk PCH has not had any reported coronavirus cases. 

The nursing home is a non-profit, run by a board appointed by Nisichawayasihk Cree Nation's chief and council. It gets funding from the Northern Health Region and the federal government.

The inspection made some positive points about the home, noting that social distancing was occurring between residents, proper personal protective equipment was being used and "interactions between elders (residents) and staff as observed during the review were positive, personable and appropriate."

In a written statement from the Northern Health Region, where Nisichawayasihk nursing home is located, a spokesperson said following the inspection they have worked with the home to bring in more staff, including nurses and maintenance workers. She did not say how many new people were hired.

"While the results of the standards reviews indicated issues, the Northern Health Region is confident that necessary changes were made immediately and that the PCH is operating and providing appropriate care," wrote Twyla Storey.

Chief Marcel Moody of Nisichawayasihk Cree Nation said that a director of care and a new maintenance worker have been hired and are starting Monday. 

His concern is the lack of resources the Cree nation has, noting it desperately needs more funding for the nursing home to entice workers to come to Nelson House. 

His priority is keeping the virus out of the nursing home and the community at large.

"We are trying our absolute best but, I mean, I'm scared that it might come into the community," he said.

"We want to protect our people as best we can … especially the people in the personal care home, because it could be tragic and it could be devastating."

Inspections of privately run homes now released

CBC has been fighting for the release of these reports since 2019, when officials with the Winnipeg Regional Health Authority said it would cost over $1,000 to release them.

When some were finally released under freedom of information laws, owners of private nursing homes such as Revera Inc. and Luther Home Corporation were allowed to refuse their release, citing privacy concerns, sparking the CBC to file a complaint with Manitoba's ombudsman.

"I can see why the government was reluctant to release these reports," said Kinew. "It does seem that chronic underfunding has put our seniors at risk."

A provincial spokesperson says they are now committed to releasing these reports to the public on their website, even for private care homes. 

The inspections are typically done every two years in order to license Manitoba's 125 nursing homes. The reviews make sure they are meeting the standards set by the Manitoba government.

However, because of the pandemic the government says all 125 homes will be inspected this year. 

The oversight of each home is the responsibility of the health authority where the nursing home is located. 

According to the provincial government, the nursing home will be required to submit an action plan within the next 100 days. 


Kristin Annable is a member of CBC's investigative unit based in Winnipeg. She can be reached at