At 6:41 p.m. on Dec. 10, an urgent email went out to families of residents at Tendercare Living Centre.
The long-term-care home warned of an escalating COVID-19 outbreak at the 254-bed facility in the eastern Toronto suburb of Scarborough.
“Residents who have Covid-19 will be moved to the 4th floor on December 11, 2020,” read the email, signed by Francis Martis, executive director and Esther Spencer, director of care.
“We have 20 vacant rooms on this floor and we will provide all services including nursing care, environmental services and meals to residents on this floor.”
But residents were never moved to the fourth floor.
By Feb. 1, 2021, the novel coronavirus had infected almost every resident in the home, killing 81.
“We all were scared,” said a personal support worker, whose identity Global News is protecting for fear of workplace reprisal.
”No one was prepared for this magnitude of people dying like that.”
A months-long investigation by Global News interviewed more than 15 people, including personal support workers, physicians and the families of residents, who provided first-hand accounts of how the outbreak unfolded, and obtained dozens of documents through freedom of information requests.
They provide a portrait of a home that was disorganized and unprepared for the virus, even though management had told public health agencies in writing, several months earlier, that it was ready for the second wave.
The witnesses to the Tendercare tragedy also explained how the home became a grim example of the situation in Canada’s long-term care sector, where close to 15,000 people have died since the first wave of the pandemic in March 2020.
“They told us time and time again, in case of anything, the residents would be moved to the fourth floor,” the personal support worker said.
But after the disease arrived at Tendercare, the home decided not to implement that emergency plan, according to the worker.
“It was a big, huge mistake by moving the residents back and forth, back and forth,” the worker said. “[COVID-19] kept spreading like that, more and more.”
The 4th floor
Images of the fourth floor inside Tendercare Living Centre.(Supplied)
Tendercare is a five-storey, grey building just to the east of Highway 404, north of Toronto. It’s managed by Extendicare Assist, a subsidiary of Extendicare, one of the largest owners and operators of long-term care homes in Canada, with more than 100 facilities.
The nursing home is classified by the Ontario Ministry of Long-Term Care as a “C” bed home, meaning it was built to design standards of 1972. Almost all the rooms at Tendercare are shared and many are three or four-person rooms.
About a month into the Global pandemic as nursing homes across Canada started to see multiple COVID-19 fatalities, internal notes from a Public Health Ontario checklist on April 2020 outlined Tendercare’s emergency plan to use the fourth floor.
“LTC able to set up unit same day,” said the document. “Equipment is already there.”
The first sign of trouble came on Dec. 4, when the home sent families an email about a “suspected outbreak” linked to an infected staff member.
Five days later, a team from Scarborough Health Network arrived and urged management to enact the fourth-floor plan and begin separating sick residents.
“We have agreed to move all residents positive with Covid-19 to our 4th floor on the east side,” Tendercare told families in an email on Dec. 10.
But as the number of infected staff and residents continued to rise, the intended isolation wing on the fourth floor remained vacant.
Exactly why residents were never moved to the fourth floor is unclear.
The support worker said management told staff that the floor wasn’t up to “code,” but they didn’t explain why the April plan still wasn’t ready.
“I don’t know why it was not prepared,” the worker said.
“They were just talking, but there was nothing being done.”
James Ha’s father was living at Tendercare and was among the families who began receiving the urgent emails advising of the growing outbreak.
“They relied completely on [agency staff] and that completely fell apart too, when every other long term care home was looking for the same thing,” he said.
“I think they basically hoped that the thing would go away by itself. Of course, we know that’s not how the virus operates.”
Images of the fourth floor inside Tendercare Living Centre.(Supplied)
The CEO of Extendicare and the owners of Tendercare declined or didn’t respond to repeated requests for an interview.
Extendicare told Global News in a statement that it didn’t have enough workers to carry out its plan to move infected residents to the fourth floor once the virus struck and “overwhelmed” the Scarborough region.
“The home’s staff levels were seriously reduced due to illness. As such, we did not have the resources to open the floor,” Extendicare said in a statement.
“Agency staff were used only when the home confronted the acute staffing crisis resulting from the outbreak, as large numbers of staff and management fell ill and we sought all options to maintain continuity of care.”
118 positive cases
By Dec. 18, Toronto Public Health issued a rare order, directing the home on how to manage the outbreak, which included separating infected residents and providing staff with training on infection prevention and control.
“These measures are to remain in effect until you hear otherwise from Toronto Public Health,” the document said.
There were now 118 residents infected at the home, and 38 staff members. Eleven residents had died.
James Ha’s father was still negative as public health officials intervened but he wished they had acted sooner.
“I think it was way too slow,” he said. “The rapid spread of the coronavirus back in March 2020 will tell you that one or two infections will lead to many more very, very quickly.”
“You need to segregate people. You need to isolate people. You need to move people, remove staff that are possibly infected.”
‘We don’t have any more Oxygen’
Dr. Vinita Dubey, Toronto’s associate medical officer of health, said public health received confirmation of a case of COVID-19 on Dec. 4. TPH notified the home and a suspected outbreak was declared. Dubey said TPH had verified that the original fourth-floor plan was viable.
“The facility submitted a cohorting plan to Toronto Public Health (TPH) on December 19, 2020 and the home began implementing the plan on the same day,” Dubey said in a statement.
Dr. Kate Greenaway, a Toronto physician, remembers walking through the doors of Tendercare at 10 a.m. on Dec. 20.
She had responded to a call for help on social media about the increasingly dire situation at the home where the virus had now sickened two staff physicians.
Greenaway said she was greeted by “frenetic” and discombobulated staff who were desperate to help dying residents.
She thought she was going to provide basic care for residents but quickly realized how grave the situation was. Greenaway immediately began to prescribe oxygen for those who had difficulty breathing and dexamethasone, an anti-inflammatory, which can help open up the lungs.
“I started seeing these people that were very ill,” she said. “Then at some point later in that shift one of the nurses just said, ‘well, we don’t have any more [oxygen].’”
Greenaway said it was “shocking” to see the state of the home — months into a pandemic — and said there appeared to be no “overarching plan of management from a medical perspective.”
She was able to source oxygen from the Scarborough Health Network.
Extendicare said the region was under “severe pressure” at that time, resulting “in a scarcity of resources and difficulty accessing them, despite our best efforts.” The company said it “categorically” disagreed with Greenaway’s assessment.
Looking back, Greenaway said she was heartbroken for the staff, residents and their families.
She was also furious that a long-term care home, which had months to learn from the mistakes of the first wave of COVID-19, was caught so off-guard.
“I feel a sense of frustration, anger that outbreaks weren’t prevented in a second wave, when we knew exactly what happens with a virus in a long-term care home.”
On Christmas Day, three weeks after the outbreak began and with 164 resident COVID-19 cases, North York General Hospital took control of the home after a request was approved by the province.
Dr. Kevin Katz, the hospital’s director of infection and prevention control, said when the team arrived at the home there was already “widespread transmission.” His team recruited over 50 additional doctors from Kingston to Windsor.
“At that point, the focus is just on pure stabilization,” Katz said. “Nearly every resident acquired it.”
With dozens of staff members sick, other workers also stayed home for fear of catching the virus, Katz said.
“It’s a large home and compromised individuals, elderly age group, lots of COVID. You put all that together and you end up with devastation.”
Ontario preparedness assessments
A man protests outside the Tendercare Living Centre long-term-care facility during the COVID-19 pandemic in Scarborough, Ont., on Dec. 29, 2020. The LTC home was hit hard by the coronavirus during the second wave.THE CANADIAN PRESS/Nathan Denette
In August, Ontario Health asked all long-term care homes to assess their own outbreak plans.
“[Long-term care homes] were all told formally that they were accountable for infection prevention and control,” Katz said. “But clearly they weren’t ready to manage what they experienced.
In the assessment obtained by Global News, Tendercare gave itself high marks in nearly every category — including infection and prevention control — stating that 71.5 per cent of staff had completed annual online IPAC training and there were regular audits.
“Internal audits include PPE use, set up of isolation rooms, cleaning and disinfecting of shared and designated care equipment and high touch surfaces, hand hygiene, accessibility of PPEs, and cleanliness of clean and soiled utility rooms,” the document said.
Tendercare preparedness assessment document. (Ontario Health)(Ontario Health)
At that time, some public servants questioned whether any of the assessments would be of use.
“I am trying to understand whether there is any validity to that darn preparedness assessment,” said Donna Cripps, a Transitional Regional Lead with Ontario Health in an email on Sept. 21, 2020.
“My gut tells me that we really need to treat every LTCH as a risk home.”
A senior government official echoed those concerns while noting, during testimony before a provincial inquiry examining how COVID-19 spread in nursing homes, that no public health authority was verifying the plans.
“There was, to my knowledge, no follow-up,” Olivia Dobush, an assistant deputy minister with Ontario’s attorney general, said.
Susan Kwolek, North York General Hospital’s lead at Tendercare, gave devastating testimony about what her team saw when they went into the nursing home.
Common spaces not being cleaned, clutter and supplies everywhere, some infestation, exposed drywall, and doors that had holes and were falling off their hinges, were among the problems listed.
“You would look at it and say, how could you let somebody live in this home?” she testified.
Kwolek also said that staff weren’t adhering to proper infection prevention measures and showed no signs of being ready for the second wave, apart from having some protective gear at their disposal.
“Theoretically, I’m sure they knew how to use it; practically, they weren’t using it appropriately,” she said.
She also said the home didn’t receive enough support early on in December from public health officials.
“Toronto Public Health and (Scarborough Health Network) had been in early December, had assessed the situation, made some recommendations around co-horting of staff or residents, but really didn’t provide additional support that was really needed at the time,” Kwolek said.
Many of the problems flagged by Katz’ team were also found by provincial inspectors who had visited the home prior to the outbreak.
Since 2015, inspectors cited the home more than 45 times for a range of infractions, including the failure to report incidents of abuse, inadequate infection and prevention measures, and the failure to properly treat skincare wounds.
In the middle of the latest outbreak, an inspector also identified other infractions on Dec. 17, 2020, including staff going from room to room without changing gowns.
And in January 2021, inspectors issued 13 written warnings for health and safety infractions. They included staff not giving residents enough water or medication on time, as well as inadequate use of their protective gear and inadequate infection prevention measures.
Extendicare and Tendercare said COVID-19 IPAC and pandemic preparedness training was conducted by the Scarborough Health Network for all staff at Tendercare during the First Wave.
“An outbreak the size of Tendercare’s resulted in large numbers of staff falling ill,” the company said. “The home is now back to a full staffing complement and the findings of the inspection report have been addressed.
“We take swift action to rectify issues raised in Ministry inspection reports.”
Extendicare also said the home has a weekly schedule for “regular, preventative maintenance, and took action in response to insect control needs as soon as they were detected.”
Several other personal support workers at Tendercare also shared harrowing stories about working in the midst of the deadly outbreak, with some even becoming sick themselves. Global News is protecting their identities so they wouldn’t be punished for speaking out.
“I took some time off from there because it was too traumatic to deal with all the residents that passed away,” one said, adding that they had to put “many residents in body bags.”
Another said they worked despite having a fever because they had no sick days left.
“I was feeling achy and I work because of the situation,” the worker said. “I don’t have sick days because I’m not a full time employee.”
A third told Global News the experiences left them heartbroken: “I did all the best for my residents.”
Extendicare said in a statement there were “no limits” to the number of sick days for staff if they became infected with COVID-19. But some workers said they were not aware of this policy.
“Staff were screened for symptoms upon every shift and are not allowed to come to work sick. If they were symptomatic, they were directed to stay home and were paid for their time away from work,” the company said in a statement.
Dr. Cyril Press, a doctor who worked at the home before contracting COVID-19, said it was an “exceptionally well-run home” before the December outbreak.
“It has an exemplary accreditation,” he said. “And I think everyone was extremely happy with the way things were going.”
But as the virus ravaged the home and its staff, Press said Tendercare didn’t receive enough help from public health agencies.
“When it spreads, all of a sudden you’ve got staff that are infected and staff that don’t turn up,” he said. “And so from being an exemplary home, it becomes a catastrophe.”
James Ha said he moved his father, Thanh Kim Ha, 83, into Tendercare after signs of dementia began to appear and did not characterize the home as exemplary.
He said his family started to see problems almost immediately after his father arrived in 2018.
These included cramped bedrooms, cases when physiotherapy wasn’t available, as well as staff failing to provide meals for Ha’s father.
“There were so many deficiencies, just the basic care type deficiencies,” he said.
Extendicare said it works with families to establish plans of care for all residents and asks that families notify the company of any issues so it can rectify them.
“Each resident’s care plan is individualized, which includes identifying needs for physiotherapy and mobility support through a physiotherapist assessment upon admission. These plans are monitored regularly by our care team thereafter.
“Resident meals are delivered at 8 a.m., noon and 5 p.m. daily, and this structure is adhered to by our care team daily.”
A family history
Tim Lukenda is a director at Tendercare Nursing Homes Ltd. He previously served as the president and CEO of Extendicare from 2008-2018. (Extendicare)
Tendercare and Extendicare have shared a family history that stretches back nearly 50 years.
According to corporate records, Tendercare Nursing Homes Ltd. was founded by Louis Lukenda, Christopher Doherty, and William Sullivan in Sault Ste. Marie in 1973. Lukenda served as chairman and CEO of Extendicare from 1990-2007.
Louis’ son, Tim Lukenda, took over the top job, serving as the president and CEO of Extendicare from 2008-2018, while also becoming a director of Tendercare in 2003.
Tendercare Nursing Homes is now owned by the children of its founders: John and Sheila Doherty, Suzanne Brescacin, and Tim Lukenda, who is also president of the Soo Greyhounds, a team in the Ontario Hockey League.
All declined or didn’t respond to repeated requests for an interview.
Tendercare president, John Doherty, deferred all questions to Extendicare, which had a net income of $54 million in 2020 according to its financial statements.
When Global News visited the home of Extendicare CEO Michael Guerriere, he wouldn’t come to the door to answer questions.
Extendicare Canada is named in a massive proposed class action lawsuit, which hasn’t yet been certified, over claims that dozens of nursing homes failed to respond properly to the pandemic and that it was negligent in the care of residents. Extendicare Assist, which runs day-to-day operations, has been the operator of two homes in Ontario that have seen the most deaths from COVID-19 — Tendercare, with 81 deaths, and Orchard Villa, with 70.
In response to the litigation, Extendicare said it would “respond in the appropriate venue, in due course.”
Minister of Long-Term Care Merrilee Fullerton declined several requests for an interview.
The ministry also did not answer several questions from Global News about what happened at Tendercare and whether long-term homes’ “preparedness assessments” were tested to ensure the plans would protect residents.
“Homes were encouraged to work with their partners and Ontario Health to conduct preparedness assessment exercises to help identify any gaps in preparedness planning,” spokesperson Rob McMahon said in an email.
In early January, now over a month into the outbreak at Tendercare, James Ha’s family received the call he had been dreading.
His father was now infected with COVID-19 and was transferred to hospital. Three weeks later he was moved back to Tendercare, his body ravaged by COVID-19 and dementia. He died on Feb. 25.
“He had some food particles that came into his lungs and the doctor believes that caused pneumonia,” Ha said. “He died basically of suffocation.”
Ha’s father was not included in the death toll attributed to the coronavirus, which had now reached a staggering 81 at Tendercare, the highest in Ontario.
“He would absolutely be here if he did not contract COVID,” Ha said. “He would absolutely still be with us today.”