Margaret Warholm, who was 74, lived at the Santa Maria Senior Citizens Home in Regina when she was admitted to hospital in October 2013. She died several days later.
Health Minister Dustin Duncan has written a letter to ombudsman Mary McFadyen asking her to look into the death and to examine whether provincial guidelines were followed.
"This is clearly a case where care wasn't provided in a manner that I think people should have an expectation (for) in our long-term care facilities," he said.
Medical records show that Warholm reported losing 30 pounds in a year and had compression fractures in her vertebrae. Her family attributes those to a fall she took while aides at the centre were moving her. She also had a large bedsore on her back that her family believes could have been prevented.
The Opposition raised the case in the legislature as an argument for minimum care standards in the province.
On Thursday, the NDP reintroduced a bill that was voted down last spring. It would require every care home to have a bill of rights for residents.
Duncan said Saskatchewan has comprehensive care standards.
"When we don't reach or exceed that bar, then we have to take additional steps like reaching out to the ombudsman," he said.
NDP Leader Cam Broten said the government is portraying Warholm's case as an anomaly.
"Yes, the details of Margaret's case are extreme, are graphic," said Broten, who added that he hears similar stories frequently and doesn't believe Warholm's case is unique. "This is something that is widespread.
"I think minimum care standards are a very important step to start improving the quality of care."
The Santa Maria facility is affiliated with the Regina Qu'Appelle Health Region. Executives from the region conducted a quality assessment on June 4, 2013. The report stated that there was "general concern about having enough staff."
"Management advised that they are trying to maximize the use of resources they have, but are still lobbying for more care resources," the report said.
The centre's executive director, John Kelly, said he can't talk specifically about Warholm's case, but he pointed out that the province has 193 pages of standards for long-term care facilities.
"We're still working at attaining those standards," he said.
Kelly said in an interview that the standard of care at Santa Maria is "as good as anywhere in the region," but he wouldn't say whether he thought the centre was understaffed.
"We can always look for an enhancement in staffing," he said. "Our staff work daily very hard, and work for the residents, to provide the best care they possibly can."
In a letter to Warholm's family dated Nov. 6, Kelly wrote that "a number of matters related to the care of Mrs. Warholm should have been better managed."
Kelly listed plans for changes that include "enhanced dining for residents" and a better charting system to "allow for better care planning, communication and followup."
He said staff involved in Warholm's care were advised that they did not provide the expected standard of care.
"They have been/will be provided with remedial training," the letter said.