An Ontario nursing home besieged by COVID-19 didn't separate healthy from sick residents or staff until after 16 people had died, and two weeks after the home declared a respiratory outbreak, CBC News has learned.

The disease has claimed the lives of more than a third of the residents at Pinecrest, located in Bobcaygeon, Ont., about 150 kilometres northeast of Toronto. A note last month from the home's administrator said residents had been "isolated into separate areas," but that didn't happen until last week.

Efforts to move people to isolated parts of the nursing home were hampered by space constraints, and private rooms only became available after some of the residents with COVID-19 died, a nurse at the home said.

"That's the reason why we actually have the space now. Because we've lost ... residents," said Sarah Gardiner, who has worked at the Pinecrest Nursing Home for 12 years.

"But before, there really was not the space to do that. It would have been an impossibility, I think."

Changes implemented

The facility houses 65 residents.

CBC News has learned that Pinecrest Nursing Home administrator Mary Carr sent an email on April 3 to staff and to members of residents' families stating the facility had implemented changes in the previous three days.

Those changes included moving all the residents who were ill to one section of the home to distance them from healthy residents and mitigate any potential spread of the virus.

By April 3, the death toll at the nursing home had risen to 16. As of Tuesday, 27 residents had died and so had a spouse of a resident who volunteered at the home.

Pinecrest officials did not respond to questions from CBC News.

Nurses from Pinecrest wave to hundreds of residents driving by the nursing home honking their horns in support last week. (Fred Thornhill/Canadian Press)

Gardiner said she doesn't believe implementing stronger infection control measures earlier would have made much difference because of the logistical issues of trying to move healthy residents, their beds and their belongings.

"Because of the layout of our home and the way it's set up, that would have been really difficult to facilitate that many changes when we had that many people living there, because we were full when this started," Gardiner said.

The deaths of some residents has opened up some private rooms where residents who have no symptoms can now reside.

"Now, unfortunately ... there is more space. We have more spaces and more ability to move people around."

WATCH | Nurse Sarah Gardnier explains why it was hard to separate residents at Pinecrest Nursing Home during the initial outbreak of coronavirus:

Sarah Gardiner, a nurse at the Pinecrest Nursing home in Bobcaygeon, Ont., explains what other nursing homes can learn from Pinecrest's inability to contain the initial spread of the novel coronavirus. 4:12

'Only curtains in between'

Pinecrest has a mix of private, semi-private and ward rooms — four people to a room. Before the new infection control measures were implemented, patients who were healthy could have been sharing a room with patients who were sick "with only curtains in between to provide isolation," Gardiner said.

"That was an untenable situation."

By last Thursday, new isolation measures were being put into place at Pinecrest, with the goal of moving all healthy residents to one end and all sick residents to the other, Gardiner said.

The disease has claimed the lives of more than a third of the residents at Pinecrest, located in Bobcaygeon, Ont., about 150 kilometres northeast of Toronto (Evan Mitsui/CBC)

Staff who had been ill and recovered and returned to work were all moved to the end with the sick residents. Staff who were healthy and had not been ill were to take care of the healthy residents. And they weren't to mix, Gardiner said.

A Mar. 20 news release from the Haliburton, Kawartha, Pine Ridge District Health Unit stated that three residents at Pinecrest had tested positive for COVID-19, and that a respiratory outbreak had been declared at the home two days earlier.

Carr, the home's administrator, was quoted in the release saying that residents "have all been isolated into separate areas."

But in another news release sent almost a week later, the HKPR health unit said that residents "were isolated as best they could in the smaller facility."

"Pinecrest Nursing Home faces some unique challenges in an outbreak situation. The residents share rooms and there is not a lot of extra room within the facility to isolate or separate residents and staff work assignments," it said in the news release.

"Larger facilities have more ability to isolate to a wing or separate building; unlike Pinecrest."

Virus 'a different beast'

Stephen Oldridge, one of two attending physicians at Pinecrest and the former medical director at the home, said with what is now known about COVID-19, there should have been a greater attempt to separate residents who were asymptomatic with those who were sick.

But, he says, Pinecrest may not have acted sooner because the process of isolating patients in safe wings and safe rooms is not the usual practice and hasn't been necessary for most diseases.

"As I say, in hindsight, it's not the way we've had to treat other viruses — that may be part of the problem. This is a different beast we're dealing with."

WATCH | Pinecrest Nursing Home doctor Stephen Oldridge spoke with CBC's Rosemary Barton last week about why COVID-19 has hit the facility so hard:

'It's a home — we're not set up as a hospital,' says Pinecrest Nursing Home doctor Stephen Oldridge about why COVID-19 has hit so hard and killed so many residents at the seniors facility in southeastern Ontario. 9:27

Ian Hanscomb, whose father Bill is a resident of Pinecrest, said with a staff so small, it would have been a huge undertaking to move patients around and would have disrupted them.

"I can see this staff not wanting to all of a sudden pick everything up and move them around when they're really trying to deal with the care of the patients within the facility," Hanscomb said.

Hanscomb suggested that second-guessing actions taken to combat the pandemic is now a regular part of life.

"This is the whole disease or the virus: Could we? Should we? It's so new to us all. And I really think the staff was in a very hard position."

Gardiner said containment would certainly have been easier if all the residents had their own space.

But she doesn't believe there was any glaring oversight at Pinecrest.

"I think this just caught us all off-guard," she said.

There have been confirmed cases at more than 600 nursing homes across Canada. And with shared accommodation common in older facilities, along with space constraints, Gardiner said she fears a repeat of what has happened at Pinecrest.

She said these nursing homes need to have their outbreak plans in place.

"Pinecrest is the canary in the coal mine for this. This is going to happen in other homes," she said.

"Unfortunately, we're the first. So, if people can learn from what has happened to us and take away something that saves other people, I would be happy with that."