Open this photo in gallery A body is removed on a stretcher from the Pinecrest Nursing Home in Bobcaygeon, Ont., on March 29. Photography by Christopher Katsarov/The Globe and Mail

On the day after three residents of the Pinecrest Nursing Home in Bobcaygeon, Ont., tested positive for COVID-19, the facility’s medical director e-mailed family members to brace them for the worst.

“It’s possible that you may face the decision to send your loved one to the hospital, especially if they develop pneumonia and have trouble breathing,” Michelle Snarr wrote on March 21. “This would raise the question of going on a ventilator. A frail nursing-home patient who is put on a ventilator is quite likely to suffer a great deal, and may not survive … I am asking all of you to think hard about what would be in the best interest of your loved ones.”

In the little more than a week since Dr. Snarr sent her e-mail, the worst has come to pass at the small cottage-country nursing home about 150 kilometres northeast of Toronto.

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Nine Pinecrest residents had died as of Sunday evening, seven of them over the weekend. All are presumed to have died of COVID-19 in what is believed to be the worst outbreak of the novel coronavirus in Ontario.

Jean Pollock, an 82-year-old artist who visited her husband, Ted, at Pinecrest every day, and volunteered at the facility, died of COVID-19 at a hospital in nearby Lindsay on Saturday.

Thirty-four workers – more than half of Pinecrest’s staff – had symptoms of the coronavirus as of Friday night, according to the local medical officer of health. Seventeen had tested positive, four had tested negative and the others were awaiting results. “It’s a war zone. I’ve never seen anything like it in all my years of nursing,” Sarah Gardiner, a nurse at Pinecrest, said through tears. “Here’s my fear: It’s going to wipe out the senior population in nursing homes across the country. If Pinecrest is any indication, this is just going to change things forever.”

Ms. Gardiner, an RN with 35 years of experience, returned to Pinecrest on Saturday for her first shift since the outbreak began. She fell ill while visiting family in British Columbia and was swabbed for a coronavirus test on March 19, after she returned. The results still haven’t come back, despite the Ontario government’s promises that health-care workers would be given priority for testing.

Feeling better, Ms. Gardiner returned on Saturday out of a sense of duty, well aware that Pinecrest was perilously short of staff, including the personal support workers who bathe and dress the residents. “I owe it to those people to try to take care of them,” Ms. Gardiner said. She felt she had an impossible choice to make but believed she needed to go back to help the residents.

What she found upon her return was a nursing home that was, “just torn apart.” Equipment everywhere. An eerie silence broken only by the sound of TVs, the coughing of residents and the shuffling of workers in protective masks, gowns and gloves. Patients with dementia had slipped into a kind of “fugue state,” Ms. Gardiner said, while those who knew what was happening had become extremely anxious. “They’re so frightened," she said. “And I don’t have anything to relieve that fear for them.”

In shared rooms, the sick have not been separated from the well, Ms. Gardiner said, because there is no place to move the residents. “It’s too late now. It’s all through both wings. Everywhere.”

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Open this photo in gallery Pinecrest is a 65-bed home in Bobcaygeon, a town of about 3,500 residents in the Kawartha Lakes region north of Peterborough.

Nobody knows how the coronavirus found its way into Pinecrest, a single-storey, 65-bed home owned by Medlaw Corporation Ltd., which is registered to a Paul Burch, according to documents on the provincial government’s long-term care homes website. Mr. Burch could not be reached for comment. Phone calls and e-mails to the home’s administrator, Mary Carr, were not returned.

Lynn Noseworthy, the medical officer of health for the Haliburton, Kawartha, Pine Ridge District Health Unit, said the first two cases of COVID-19 reported to her health unit on March 13 and 14 were in people who had travelled outside Canada. “The third, fourth and fifth cases," Dr. Noseworthy said, "were in this home.”

Those cases were discovered because of what began as a small outbreak of mild respiratory illness at Pinecrest in mid-March, said Dr. Snarr, a Bobcaygeon family doctor who usually visits her Pinecrest patients once a week.

When Dr. Snarr called before her regularly scheduled rounds on Tuesday, March 17, she was told that four patients had mild respiratory symptoms. By Wednesday, eight residents were ill. By Thursday, it was 12, Dr. Snarr said, reading from the journal she’s been keeping since the outbreak began.

On Friday, March 20, with 23 residents sick, Dr. Snarr learned that tests done on three of the residents had come back positive for COVID-19. The next day, Dr. Snarr sent her letter to the Pinecrest families. The letter mentioned that Dr. Snarr had spoken to doctors at the local hospital. “They have limited resources to look after a surge of patients with COVID. They are also concerned about having COVID brought into the hospital by infected patients.”

Dr. Snarr explained in an interview that the Ross Memorial Hospital in Lindsay was absolutely willing to accept Pinecrest patients if next of kin asked for all measures to be taken, but Dr. Snarr wanted families to understand the ramifications of putting frail, sick residents on ventilators. “Even if they survived,” she said, “their quality of life would be abysmal.”

Open this photo in gallery Marguerite Adams Miller, shown in a family handout photo, is a resident at the Bobcaygeon home.

Receiving Dr. Snarr’s letter was difficult, said Jessica Echeverri, whose 98-year-old grandmother, Marguerite Adams Miller, is among the dozens of Pinecrest residents suspected of having COVID-19. Ms. Adams Miller is a retired nurse who spent 30 years working at Pinecrest.

Her son, David Adams, got a call from staff on Sunday afternoon saying that his mother has symptoms and is not doing well, said his daughter, Ms. Echeverri. “They don’t think that she’s going to make it,” Ms. Echeverri said.

Mr. Adams persuaded staff to allow him to visit his mother, who has dementia and whose biggest fear is dying alone, she said.

Ms. Echeverri has been trying to help draw attention to the nursing home’s desperate need for staff, writing a Facebook post urging nursing students or personal support workers to send in their résumés.

“Urgent need for staffing at an Elderly Care Facility / Nursing Home with a COVID-19 outbreak,” she wrote. “Residents need help urgently. The small staff were already infected before anyone was diagnosed and now they are working with a skeleton staff. They are in desperate need of help immediately.”

As word of the outbreak spread and more staff members got sick, nobody showed up for the 3 p.m. to 11 p.m. shift on Monday, March 23. The remaining day-shift staff stayed to work a double, Ms. Gardiner said.

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The first death attributed to the coronavirus happened on Tuesday, March 24, the second on Wednesday, March 25, according to a news release from the local health unit.

No other Pinecrest residents were tested after the first three because of a provincial policy – usually applied in flu outbreaks – that says once the virus at the root of an outbreak has been identified, everyone who is symptomatic is presumed to be infected with it.

Although they were not tested, the first two Pinecrest residents to die were included in Ontario’s official COVID-19 death toll, which stood at 23 as of Sunday night.

Dr. Snarr and Steve Oldridge, the other local doctor who takes care of Pinecrest residents, told The Globe and Mail about the seven deaths on the weekend. Both are helping as best they can from outside the home, wary of catching a virus that would force them into isolation and leave them unable to care for other patients.

“It’s an emotional time. I know all these people," Dr. Oldridge said in an interview from his car on Saturday afternoon. He was driving to Pinecrest to sign the death certificate for the sixth patient presumed to have died of COVID-19.

“I’ve never had four deaths in a day at any nursing home I’ve worked at,” he said. "You feel helpless. Because there’s nothing you can do other than support them, give them morphine and make them comfortable.”

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The Haliburton, Kawartha, Pine Ridge District Health Unit has not publicly confirmed the additional deaths.

When The Globe spoke to Dr. Noseworthy, the medical officer of health, on Saturday night, she said she was not yet aware of them.

“We’re always the last to find out. I’m serious. We’re the last to find out.”

All 123 staff members of the public health unit are working as hard as they can to trace cases in the region, she said. "But we don’t have enough staff to do epidemiological analysis over the weekend. So the data that I have are as of [Friday.]”

Laurie Scott, the local MPP, said that Extendicare, a company that provides staffing for the long-term care sector, is on the ground working with the home and local public health unit.

“Since the onset of COVID-19, I’ve been working in collaboration with my cabinet colleagues, long-term care operators, including but not limited to Pinecrest, to do everything possible to ensure that they have every tool available to prevent new infections and to respond to staffing challenges,” Ms. Scott said in a statement.

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“This is a tragic situation unfolding in this small community and it’s heartwarming to see everyone doing everything they can to help the residents, staff and families of Pinecrest.”

Open this photo in gallery Bobcaygeon residents rallied to help Pinecrest with its coronavirus outbreak.

People in Bobcaygeon, a close-knit town of about 3,500 people in the Kawartha Lakes region north of Peterborough, pulled together to try to help Pinecrest, Dr. Snarr said.

The husbands of two of Pinecrest’s workers are volunteering on the cleaning staff at the home. When Pinecrest ran low on disposable covers for the tips of thermometers, oxygen and an injectable medication, the Ross Memorial Hospital sent backup supplies, said Rob Drury, the medical chair of the hospital’s infection prevention and control committee.

“We reassured them that if at any point in time they hit a wall for anything, we’d help them out,” Dr. Drury said.

Dr. Drury and the staff at Ross Memorial also had at least one COVID-19 patient to care for, Ms. Pollock, the artist who died Saturday.

Ms. Pollock began helping out at Pinecrest shortly after her husband, Ted, moved there almost a year ago after suffering a bad fall. “She said, ‘Well, I’m here every day so I’ll visit with Ted and give them a hand,’ ” said Pam Smith, Ms. Pollock’s daughter.

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Ms. Pollock, a former antique-store owner, began feeling unwell on March 17, which was her birthday and a few days after the nursing home stopped allowing family members to visit.

By March 20, Ms. Pollock, who had asthma and chronic obstructive pulmonary disease, was experiencing shortness of breath and fatigue. She went to the hospital, was tested for COVID-19 and sent home with a prescription.

On Tuesday, the day after Ms. Pollock was taken to the hospital by ambulance, a doctor told Ms. Smith that her mother had tested positive for COVID-19 and because of her COPD, they would not be able to put her on a ventilator.

Ms. Pollock, who was receiving oxygen, was able to have a brief conversation with her daughter on the phone. “She just said, ‘I’m going downhill fast,’ ” she said.

“I told her I loved her and that she was a great mom,” Ms. Smith recalled through tears. “She was really upset.”

Open this photo in gallery Artist Jean Pollock, shown in a family handout photo, often visited and volunteered at Pinecrest. She died on Saturday. Handout

Ms. Pollock briefly rallied late Wednesday and early Thursday, eating some Jell-O and surprising one of the nurses by noticing the date was wrong on a white board. “Even the doctor said, ‘Your mom’s still fighting to live,’ ” Ms. Smith said.

Ms. Smith, who was driving to Bobcaygeon from Vancouver, called the hospital for updates every couple of hours and worried because the nurses told her that her mother seemed anxious at times.

After Ms. Smith woke up on Saturday, she called for an update. The person who answered the phone asked her to wait on the line. After a while, her mother’s nurse came on and apologized for the delay, saying that her mother had just died. She hadn’t wanted to leave her side.

Mr. Pollock, 91, found out that his wife had died when his son phoned him on Saturday and is struggling to come to terms with the news, Ms. Smith said.

At the same time, all around him, fellow residents were dying.

“For now, we are all doing what we have to,” Dr. Snarr said in a text message on Sunday. “We will be scarred forever by this.”