TORONTO -- The last time Carolin Wells saw her father was through one of Orchard Villa’s large black-framed windows. Due to a stroke years ago, he had trouble speaking and was paralyzed on one side of his body, but his daughter says his eyes danced with excitement when seeing her. He looked well.

That was five days before his unexpected death on April 9, the same day the Pickering, Ont. retirement and long-term care home first declared a novel coronavirus outbreak, which has since infected at least 96 staff and 225 residents and has killed at least 65 people at the facility.

Wells is one of the many people who lost a loved one at the home. Together, the families are now calling for an investigation into Orchard Villa’s outbreak, one that is recorded as the deadliest in the province.

The families fear that Orchard Villa, which according to ministry inspection reports has a history of violations, provided them with little to no information about their loved ones' illness and they were simply left to die.

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Southbridge Care Homes and its Orchard Villa home have not responded to CTV News Toronto’s recent requests for comment on the frustrations and concerns of these families.

To get a better picture of what happened inside the 294-bed facility, we spoke to six people who have lost loved ones at the home, many of who were asked to remove their family member's body from the facility within three hours.

Here are their stories.

Shirley Bacchus – Died April 20, 2020

Desiree Jagassar believes it wasn’t COVID-19 that killed her 90-year-old mother, but neglect.

Before the outbreak, she said that her mother, Shirley Bacchus, struggled with eating due to her dementia and so she visited her daily to make sure she had enough food.

“We've been going to the home every single day … helping out because we realized at the home that there were never enough staff to really sit and feed my mom and she needed encouragement,” Jagassar said.

When COVID-19 hit, Bacchus’ family was no longer allowed to visit the home. Jagassar said she knew she had to check in often to make sure her mother was eating and doing well.

Shirley Bacchus

Southbridge Care Homes told CTV News Toronto, over a week ago, that its Orchard Villa home has been struggling with a severe staff shortage and it has asked various levels of government for help. As more people died and the infection spread to almost all of the residents, the military and a local hospital finally stepped in to help provide care.

Jagassar said that while it was nearly impossible to get in touch with the home’s administration, nurses would sometimes pick up the phone even though they were told not to due to the staff shortage.

The families of residents said that every morning all they would get is an automated voicemail reporting the number of COVID-19 cases in the respective ward. Jagassar said her family would have to call 10 to 15 times to get any actual information about her mother’s health.

“We just wanted to know how our mom was doing. They said they were taking her temperature every day and that she was well and so we felt good about it,” she said. “We were always sending notes to management but no one responded.”

Her mother had tested positive for COVID-19, but she was told that she was not showing any symptoms and was doing fine. Then, the night before her mother died, Jagassar said a nurse, who she had a good relationship with, called and said her mother was not moving, eating or drinking.

Jagassar said they tried contacting a supervisor to find out what they could do, or if they could visit, but no one picked up the phone.

The next day, on April 20, someone from the home called to say her mother had died. “[They] said do you have funeral arrangements made, I said ‘No my mom was fine. No one told us our mom was declining.’”

Jagassar said that three days before her mom died, she was able to Facetime with her. She said she saw her mother lying in bed but the home told her she was fine.

“When I asked why she was in bed, they said they don’t have time to put the residents in their wheelchairs and then back in bed so they are left in the bed all day,” she said.

“I’m not blaming the personal support workers or nurses. I knew they were trying their best, but from the beginning they were understaffed.”

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The Ministry of Health and Long-Term Care’s inspection reports of Orchard Villa over the past few years reveal that the home has a long history of violations related to staffing issues, cleanliness and nutrition.

A 2019 report, reviewed by CTV News Toronto, reveals an incident where a personal support worker told an inspector they were unable to provide appropriate care for a resident due to time constraints. In a 2018 report, an inspector found there was no registered nurse at the home on at least four occasions.

Jagassar said her mother suffered from dementia, but was still a fascinating person. She couldn’t remember a lot of stuff, but she still had a spunky personality and made people laugh. She said she and her siblings would visit their mom and sing hymns with her.

“We can’t move on right now because we are feeling anger, we fought a good fight for my mom because we were always up to date with her care. We were there, but the minute we could not be there, we knew that things would break down,” Jagassar said.

“These residents, they are all gone but we need to know why was there a breakdown in their system? Why did the home not reach out to help in the right time?”

Margaret Thomas – Died April 19, 2020

Darlene Thomas saw her grandmother for the last time through a window. She had lost weight, and the skin on her feet was especially dry. She was covered in a blanket and wore a head guard.

But the administration at the home, Thomas said, told her family that her grandmother, Margaret Thomas, was well.

“She was very frustrated, she was always one to touch us and hug us,” Darlene said of her 84-year-old grandmother who suffered from aggressive dementia. “She kept asking for my dad and I to come in.”

Margaret Thomas

Thomas said her grandmother tested positive for COVID-19 on April 18 but had no symptoms. A few hours later, on April 19, Darlene said she got a call from someone reporting her grandmother’s death.

“I was very confused, they had called us just five hours ago saying that she was fine,” Darlene said. “We wished someone could have given us notice that she was not well.”

Thomas said her family has had concerns about her grandmother’s care for months after she was transferred to a new ward at Orchard Villa, where it seemed there was not enough staff.

She said she was also concerned from the start about the COVID-19 lockdown because so many residents relied on family members for care.

“There are fantastic [personal support workers and nurses] there but I know they were very overwhelmed even before all of this happened,” she said.

Seven days a week, Thomas said someone from her family would be at the home to make sure her grandmother was having her meals. The home never told them, she said, it was now dealing with a severe staff shortage due to COVID-19, but the family had heard rumors about it.

Thomas said her family tried repeatedly to call the home to ask about Margaret’s health during the pandemic and if she was eating well, but very often the phone was not answered.

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In 2017, an inspector found that Orchard Villa failed to ensure some residents were provided with personal assistance and encouragement required to eat and drink. The report stated that a number of residents experienced weight loss and were identified as being at high nutritional risk.

Other inspection reports cite a number of other issues related to sanitation and cleanliness, as well as issues with preventing falls. In April 2019, an inspector found, on one date , four beds were stripped to the mattress and there was no bedding available to make them. There were also no towels or facecloths in any of the resident rooms.

Thomas said it’s difficult to think about her grandmother dying alone.

“We were there every day and that’s what she knew,” she said. “That’s what’s bothering us a lot.”

She described her grandmother as sweet and sassy. Toward the end of her life, the dementia took a toll and she would often repeat things, and could be a bit aggressive but she was overall healthy, and loved having her family visiting.

“I want her to have a face and a voice and for her not to be just a number that just died in the home, every day you hear, just talk about the numbers and not the people.”

Over a week ago, Southbridge Care Homes told CTV News Toronto that it was following all public health directives in the home and two temperature checks were being done on all residents per day.

“Our testing capacity continues to increase. All of our residents have now been tested … Our main focus remains on the care and safety of our residents. In the event of positive test results, our first priority is to make sure the resident is receiving adequate care for their symptoms and that their family is informed,” the company said.

Louise Champ – Died April 16, 2020

The last time Carol Marchant saw her mother, Louise Champ, was also from the window of Orchard Villa, back in early April when the home still did window meetings.

Although they could not touch or hold hands, she said her mother, who had trouble talking and suffered from dementia, smiled at her.

Days later, she received a call that her mother was COVID-19 positive. Marchant said she later called every number she had for the home. She wanted to follow up on her mom’s condition, but could not get through.

She said her brother did, finally, get someone on the phone and was told that their mother had not been out of bed for several days, but she had no fever or other symptoms and was doing fine.

Louise Champ died on April 16, four days later.

Louise Champ

Marchant said her mother had difficulty eating before the outbreak even began and she would visit her regularly to help her eat.

Once she and her family were barred from entering the facility, Marchant said she didn’t know how, or if, her mother was eating because her phone calls to the home were not picked up.

“Not knowing what was going on was the hardest part, not knowing what they were doing for her,” she said. “She was a slow eater, and I hope she was getting water, she couldn’t get up to feed herself, I don’t know how much care in the end she was getting.”

But as soon as her mother passed away, Marchant said she had no fewer than four calls from the home urging her to pick up her mother’s belongings. Suddenly, every time she called back, she said, the phone would also be picked up.

“I had four or five people call me to get the stuff from the room, but they never called me once to tell me how she was,” Marchant said. “I don’t know what changed.”

Marchant said that even though her mother has passed away, she is glad the military and local hospital have stepped in to help the other residents.

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“If they can get people up out of bed and into wheelchairs, it would help a lot for people,” she said. “Someone being in bed for that long, like what happened with my mother, others will die too if they can’t get them moving.

“I know there are a lot of families going through the same thing, it’s just very sad. I’m glad they are getting help now. It’s about time they brought in some help.”

Marchant described her mother as a giving and friendly person who would always keep herself busy with painting and woodworking. She remembers her often volunteering and offering to make things for people, and how she always looked forward to holiday bazars. Toward the end of her life, at 96 years old, she was suffering from dementia and stayed at Orchard Villa.

Marchant said her mother had a private room at Orchard Villa. She said she can’t help but think about her mother’s final days lying in bed and alone in that room.

Paul Parkes – Died April 15, 2020

Pickering resident Cathy Parkes said she lost her father, Paul Parkes, to the disease on April 15, despite the home telling her that he was doing okay.

"If it wasn’t for the personal support workers and the nurses on staff, I would have no true information about my father. Not only were they the ones putting their lives on the line, but they were the only ones telling me how he really was doing … when I was talking to the administration it was always holding back information,” she said.

“I was putting my trust in people who are taking care of my dad … I couldn’t get in and I couldn’t see him so I had to take their word for it and I regret it.”

She said the administration kept telling her that he was fine and was eating well, and that his temperature was stable for the most part, but, over the phone, her father was not even able to communicate with her anymore.

Paul Parkes

"I had to demand that he be swabbed," she said. "I said ‘What you are telling me is not matching with the dad I know.’”

Afraid and anxious, she managed to find a frontline staff member and arranged a window meeting with her father the day before he passed away.

“She pushed his bed up, opened the curtain … put the phone to his ear, but he couldn’t hold the phone, he couldn’t open his eyes, he couldn’t respond or speak.”

She said she asked administration to put him on oxygen to help with his breathing but they said he didn’t qualify. “He had no fighting chance,” she said.

On April 15, she said she got the call that her father passed away. They asked her when she would be ready to remove his body and pick up his things.

Parkes said she is speaking out now out of concern for the other residents and staff. She said she’s heard from workers about the staff shortage and lack of personal protective equipment.

“The people dad ate meals with, I saw that one of them is gone, my mom had a friend in there … she also passed away,” Parkes said.

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“I go on the funeral website and I see all these faces that I know and it's heartbreaking because I know that it's just not me. My dad never would have wanted to see something like this left. He always encouraged us to use our voices; to speak up if we see things wrong.”

“It would be easy to lock myself in a bubble of mourning but I can't because dad wouldn’t want that. I felt it was necessary to say something for the people that are still in there ... they need to know what's going on.”

Now that the military and a local hospital have stepped in, a days-long deep-cleaning started last week. The new support staff are helping with feeding, housekeeping and infection control and a new “patient experience team” is supposed to provide families with the latest information about their loved ones.

Parkes said the changes make her hopeful.

"It’s a step in the right direction.”

Mary Walsh – Died April 20, 2020

Marie Tripp’s story is a little different from the others. The Toronto woman said she had a camera in her mom’s room that everyone at Orchard Villa knew about. 

On April 17, she watched through the camera as her mother started vomiting and appeared to have difficulty breathing. Panicking, Tripp phoned the nursing station. 

A nurse picked up, and as she read off her vital signs, she mentioned that Marie’s 89-year-old mother, Mary Walsh, had tested positive for COVID-19. It was the first time someone had told her the news, Tripp said. 

Mary Walsh

“I got the official call that my mother was tested on Thursday, April 16. They said it was going to take five to seven business days to get the result,” she said. “There was no clarity, no transparency, there was no one reaching out to family members to tell them what was happening.”

Tripp said she got a call from the home saying her mother was not well the night before she died on April 20. She said she was one of the lucky few that managed to convince management to let her visit her mother before she died. 

“I got there after midnight … on my way out I captured photos of garbage bins overflowing with PPE spilling onto the grass and near picnic tables,” she said, adding that while she was given gloves and a gown, she was not given a mask when visiting. 

“This is why I am blaming management for the widespread outbreak. There was a lack of staff, a lack of PPE and procedures and protocols were not followed,” she said.

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Before the outbreak and up until testing, Tripp said her mother was doing well. 

“She would wheel her chair to the window, and was in good spirits,” she said. “She had a grasp of what was going on, she had dementia, but she understood why we couldn’t come in. We would be writing notes to her and she would be smiling and nodding.”

Tripp said she thinks the camera may have helped her get better access than other families. 

“Everyone was aware of the camera, and I think she got more gingered care, because they knew I was watching,” she said.

Tripp did say that she never saw through her camera, a doctor visit her mother while she was in her final stages. She said a nurse declared her dead. 

She said she feels the residents at the home were left to die. 

“It seemed like my mother was thought not to be worth a follow up or a phone call and the death did not matter,” she said. 

“I have to speak out. My mother passed away. I can’t do anything more for her but there are still loved ones of other families in there. The light has to be on this home and all homes. These people need help. They need love and care. They are not getting it at Orchard Villa.”

James Shankland Fleming – Died April 9, 2020

Carolin Wells’ father, James Shankland Fleming, was known for his resilience through a number of health problems, but he was one of the first people to die at Orchard Villa when the outbreak began.

The last time Wells saw her father, during that window visit on April 4, he was doing well and looked great. She noticed he had a slight cough.

James Shankland Fleming

Five day later, just past midnight on April 9, the home called Wells’ mother and reported that his health situation had suddenly changed. He was not doing well at all and was put on oxygen, Wells told CTV News Toronto.

Overnight, Wells and her mother were glued to the phone and calling the home repeatedly to ask about Fleming, but no one picked. They simply wanted to know how he was doing and if they could come by to see him, she said.

When they got through at 9 a.m. the next day, the home told them Fleming had died.

At his funeral, Wells said the family was told her father suffered from pneumonia for two days before his death. She said Orchard Villa had never told them that.

Days after his burial, it was determined that her 88-year-old father had the novel coronavirus.

Fleming was once a police officer, a boxer, and an electrician. Despite his trouble speaking, he spoke and laughed with his eyes.

“He was a provider and just strong. He was always fighting for his life, always wanted to be 100 years old, always thought he would,” she said.

She said she begged the home to tell her what was done for him before he died. She wanted to know if he died peacefully. She said she was told he had some Tylenol.

“The main thing for me is that he was left to die alone. I wished they could have told us he had pneumonia or how bad he was doing, we would have come to see him that night,” she said.

“I had always assumed we would be able to be with him when he was dying. I read stories of other people doing that. I heard some people were able to go see and be with their dying loved one and I can’t help it but that makes me angry.”

Orchard Villa

Wells said she believes communication with families and the testing protocols at the home were problematic. She said she wonders how many other residents her father may have infected while the home was unaware of his illness.

She said her hope was that, at the very least, his death would have sparked change, and that more COVID-19 testing would be done.

The provincial government has come under fire for its response to outbreaks at long-term care homes. More than 500 people have died in these facilities.

Provincial health authorities finally ordered testing for all residents on April 22 to better help manage the outbreaks, something Ontario Premier Doug Ford began calling for weeks ago.

The change came almost two weeks after James’ death, and for Carolin, watching dozens of people at Orchard Villa die, it felt too late.

Wells said the people who have died at Orchard Villa, especially those after her father, should not have. Changes should have been made by management earlier, she said. She said knew the home had a staffing shortage even before the COVID-19 outbreak began.

“That’s what’s bothering me. Seeing this all playing out the way it is. I don’t think it should have been this way,” she said.