VANCOUVER -- An inspection of a long-term care home that was the site of British Columbia's deadliest COVID-19 outbreak found staffing levels were low and cleaning was inadequate as the virus spread throughout the facility.

The Vancouver Coastal Health inspection report obtained by The Canadian Press through a freedom of information request says these two issues were rectified while the outbreak was underway in Little Mountain Place.

Bernadette Cheung, whose grandmother died of COVID-19 at the facility along with 40 other residents, wants more answers, including details on how the staffing shortage and poor infection control potentially worsened the outbreak.

She filed a complaint that prompted the inspection on behalf of several family members who lost loved ones at the Vancouver care home. Cheung said she feels equally in the dark after receiving the report as she did before.

“I feel like the investigation was very much done just to check off a box, as opposed to properly finding out where the failures were and really digging into finding solutions and ensuring that families have some sort of peace that this is taken seriously,” she said.

Little Mountain Place referred questions to Vancouver Coastal Health, which did not immediately respond to a request for comment.

In a written statement released in January, the health authority said it worked closely with the care home to bring the outbreak under control, including by screening and testing staff and residents, promptly isolating cases and employing infection prevention and control practices.

The inspection report says a complaint was received on Jan. 6 and a site visit was conducted Jan. 11.

The inspector found when the COVID-19 outbreak was declared on Nov. 22, staffing coverage was sufficient. However, as more employees contracted COVID-19, staffing levels “fell below facility baseline,” which temporarily affected daily operations and staff ability to respond to families' questions.

In response, Vancouver Coastal Health redeployed a significant number of staff to exceed the baseline requirements by 20 per cent, the report says, adding that most of the original staff returned to work and one-third of the redeployed health authority staff remained on site as of the inspection date.

The report does not say how many staff members the facility was missing, how long the understaffing persisted and how it affected the home's ability to limit the spread of the virus. B.C. Centre for Disease Control figures show that 72 staff members contracted the virus over the course of the months-long outbreak. None died.

Cheung questioned what the point was of the “vague summary” of understaffing.

“I would imagine that these processes are in place to learn and understand where problems can occur and find maybe where the breakage point is in terms of understaffing,” she said.

The report also says that when the outbreak was declared, Vancouver Coastal Health monitored the facility closely for the rate of transmission and any areas of concern.

“Following this audit period, it was identified that the facility household team did not fully comprehend or implement the intended infection control/enhanced cleaning measures appropriately,” it says.

On Dec. 13, three weeks after the start of the outbreak, Vancouver Coastal Health deployed a specialized infection control cleaning team to the facility. Education was provided to the staff and regular audits of enhanced cleaning measures continue to be conducted on a regular basis, the report says.

Cheung said she's frustrated that the focus appears to be on the cleaning team not knowing what to do, as opposed to management's responsibility to train them.

She also took issue with the inspector's finding about the care home's communication. The inspector said families were sent letters regularly with updates on the status of the outbreak and weekly Zoom calls were held to answer their questions.

However, Cheung said two weeks passed before the first Zoom call, when families were shocked to hear there were already dozens of positive cases. During the calls, Cheung felt managers were evading questions.

“We felt like we were being kept in the dark,” she said.

In its previous statement, Vancouver Coastal Health said it takes all concerns raised by residents and families seriously and any allegations of insufficient care are fully investigated. It also said it shared written communications regularly, in addition to the Zoom calls, and doctors and staff followed up with families directly.

Cheung is still calling for a broader investigation of what went wrong at the care home, where ultimately 99 out of 114 residents tested positive. Cheung also wants to see an oversight board for care homes that exists outside of health authorities.

“I don't feel like anyone has truly taken accountability for what has happened,” she said. “I get it. It's a really challenging situation. But at the same time, as family members we would have appreciated forthcoming responses.”

B.C.'s seniors advocate, Isobel Mackenzie, is working on a larger review of COVID-19 outbreaks in care homes, which she hopes to publish in July. She said of about 500 sites in B.C., 212 had outbreaks.

Of the sites that had outbreaks, most were contained to staff or a couple of residents. Therefore, her office plans to look at 25 or so of the worst outbreaks, including Little Mountain Place, to understand what went wrong.

The age and size of the buildings, whether residents had shared rooms or shared baths, staffing levels, sick-leave policies, infection control practices and the age and conditions of residents could all be factors, Mackenzie said.

Her office will also undertake a survey of care home staff in B.C. that will hopefully give insight into the training they received, she said.

Mackenzie said she expects the provincial government will face pressure from the public to implement her upcoming recommendations.

“One of the things that's been very heartening has been that the public is very much getting behind the issue of improvements to long-term care,” she said.

“They now see what can happen, what does happen and they've said, 'We need to do better. We need to make improvements.' So, I think people will be listening and they will expect their governments to act.”

This report by The Canadian Press was first published April 1, 2021.