When 97-year-old Tannis Snukal died in hospital, it was four weeks to the day since she'd suffered a broken leg after being dropped by nursing home staff during a bath.

An investigation concluded that what happened at AgeCare Glenmore was abuse, due to having only one staff member present during the senior's bath and using an improper transfer method between the tub and her wheelchair.

Now, Tannis's son Jerry Snukal wants others with loved ones in nursing homes to be vigilant and ask more questions.

"Something as important as bathing, I just assumed was being done in the safest manner," said Jerry.

A report on the incident was done by Burness and Associates Consulting Inc., for the Protection for Persons in Care office. It was released by the Alberta government.

2 staff required

On Aug. 25, 2016, Tannis was being bathed by a single staff member at the nursing home despite a requirement that two people be on hand for transfers between wheelchair and bath.

The lone staff member was unable to handle Tannis on her own and the elderly woman slipped from the tub chair to the floor, breaking her leg, according to the report.

"These circumstances do constitute abuse," reads the report.

Abuse is defined in the Protections for Persons in Care Act as "failing to provide adequate nutrition, medical attention or another necessity of life without a valid consent causing serious bodily harm."

Jerry says he had no idea his mother was being improperly bathed and wonders how long it had been going on.

That thought torments him.

"When you think about it, the place you can get hurt the most, really, is in the shower or bath area."

'She was screaming her head off'

One of the nurses on the night shift after Tannis was injured told investigator that the elderly woman had screamed and cried through the night.

Staff at the facility did not take Tannis to a hospital until the next day. That's when doctors determine she'd broken her right leg in two places.

But because of her arthritis and the shape of her leg, a cast or boot weren't options.

Jerry says his mother was in agony as they wrapped her leg. He remembers the pain she was in: "I was standing there as she was screaming her head off."

Tannis's health quickly deteriorated. She contracted pneumonia within days, began aspirating her food, developed a hernia related to the aspiration and died hours before her 98th birthday.

'Ask as many questions as you want'

For 12 years, Jerry advocated and helped care for his mother. He was diligent about getting her to the dentist, the podiatrist and watching her weight.

"I was really diligent with my mother. I was semi-retired, I had time. But what about all the other people who are busy, don't have a lot of time and probably ask a lot less questions than I do?

"Whatever is being done to your loved one in these places, you have to know that it's the safest way," Jerry says.

He felt he was taking care of the big stuff and leaving simple tasks like bathing to the professionals.

"Sometimes we think we're bothering the nurses, or if we ask too many questions, that my mother won't get good service. It's all malarkey," says Jerry.

"You're entitled to ask as many questions as you want, and that's really the issue here."

Lawsuit filed against nursing home

Jerry has filed a $50,000 lawsuit against the centre, alleging staff at the facility failed his mother in a number of ways.

He says if he receives any money, it will be donated to the Alberta Children's Hospital.

A statement of defence filed by the AgeCare Glenmore (formerly the Beverly Centre Glenmore) denies any connection between Tannis' broken leg and her death.

A lawyer for the facility declined to comment further.

"As the matter is before the court, Age Care Health Services will not comment at this time," wrote Michael Thorne in a written statement to CBC News.

None of the allegations contained in the statement of claim has been proven in court.

'Strong, not weak'

Tannis Snukal should be remembered for more than her final weeks of suffering.

She struggled her whole life with anxiety at a time when mental illness was not well understood and rarely talked about.

Widowed young, Tannis got a job and made a life for herself, finding comfort and pleasure in music.

The Snukal family believed Tannis would live to 100. Jerry credits two factors for her longevity: she ate soup every day for supper and she never drove, walking everywhere instead.

Jerry admits he didn't always see his mother in the same light.

"To have a mental condition and not have a husband and have to go to work and not have confidence in yourself; to be able to actually pick up and do that one day, then she must have been strong, not weak."