LANGLEY, B.C. -- Troubling new details have come to light about a COVID-19 outbreak that resulted in more than two dozen deaths at the Metro Vancouver care home Langley Lodge.

The information obtained by CTV News Vancouver was outlined in an internal report from the Langley Care Society.

The care home faced two outbreaks, but it was the second one that would leave 51 residents and 15 staff infected. Twenty-six residents would die.

According to the report, the outbreak began with a sick staff member.

The report says that, “The worker avoided the pre-shift screening protocol on several shifts and worked one full shift (the last shift) while symptomatic.”

“I felt sick. I felt absolutely sick to my stomach when I heard that,” says Jo-Anne Morris whose mom lives at the care home. She says she was shocked by some of the findings and says there needs to be protocols to ensure sick workers stay home.

Meanwhile, Fraser Health says workers are expected to follow the rules.

“I’m not aware of the specific details of how this staff person bypassed the screening process…I just know they are no longer employed at Langley Lodge,” says Norm Peters, Fraser Health’s vice-president of regional care integration.

The report lays out the tragic spread of the virus on a unit with residents who have advanced dementia.

“This population was not easily isolated due to cognitive impairment and wandering and all of the residents in the unit became infected,” the report reads.

The report also says the care home faced “critical staffing shortages."

The report indicates that nurses “walked away” out of anxiety and fear for themselves and their families, but that other issues also contributed to the shortage.

“BCNU declared its position on N95 masks as the proper PPE for COVID-19 care, and supported the position of nurses who refused to work, as the “nurse’s right to exercise professional judgment” re safe work,” the report says.

Langley Lodge also faced a “huge drop-out rate among housekeepers, due to burnout.”

Audits found problems such as the risk of cross contamination when linen carts and garbage receptacles were in the same room.

“Is it acceptable that those items were in the same room? It is not. We do not want to see that,” Peters said.

The problem has since been corrected.

Langley Lodge did not return phone calls, but in an email from the CEO and author of the report, CTV News was directed to a statement on the lodge’s website.

It says in part that the intent of the report was “not to shift blame or responsibility to other partners” and that it is “appreciative of the support from Fraser Health.”

However, the report is also critical of the health authority.

It says there were changing directives about the use of masks from Fraser Health and that long-term care homes were left on their own to find supplies.

“It was challenging to source supplies of gowns, and there was no guidance from the province or regional health authorities on the proper gown requirement for COVID-19 care,” the document reads.

Fraser Health says it’s been responding to concerns including a change to help identify asymptomatic carriers of the virus.

“In an outbreak such as Langley Lodge… we have started to implement point prevalence testing where, on a routine basis such as every week, we test those affected units,” explained Peters.

Health Minister Adrian Dix says they will learn from the findings of the report, which makes a series of recommendations.

“We’re going to do better. We’re going to work in partnership. We’re not going to work in a context of blame,” Dix said.

Meanwhile, Morris hopes the report will help better protect seniors in the future.

“We’ve lost too many seniors. We need to make seniors a priority,” she said.

Langley Lodge saw the largest death toll from COVID-19 of any care home in the province.