One of the first nursing homes in Pennsylvania to encounter an intense outbreak of the deadly coronavirus had been repeatedly cited by the state for failure to protect patients from infectious and communicable diseases.

Nevertheless, the Brighton Rehab and Wellness Center in Beaver County has had no visits from state inspectors since early March when Gov. Tom Wolf issued guidelines designed to protect patients and residents. In fact, no inspections are occurring at nursing homes across the state unless a report has been made that a patient is in immediate danger from something other than COVID-19.

Among the most vulnerable people in the state's coronavirus outbreak are residents of Pennsylvania nursing homes, and emergency response plans show they largely have no state and federal oversight during the crisis.

By Friday, 903 COVID-related deaths had been reported at nursing homes across Pennsylvania. That accounted for more than half of all coronavirus deaths in the state.

And while patients in such facilities are often at risk of death for many reasons, inspections help ensure these businesses follow protocols designed to protect and comfort residents.

These deaths come at a time when state and federal regulators have stopped routine inspections because of the virus, and about a year after the Trump administration proposed relaxing nursing home guidelines for infection control.

It's a complicated situation. If the state continues on-site inspection visits, it risks carrying the virus into a facility that's home to vulnerable residents. It also risks carrying it out.

But patient advocates say now is not the time to let nursing homes police themselves, especially the facilities with prior infection control violations.

For the family members who have loved ones inside these nursing homes, it's personal.

To Keri Boyer, her dad's death at Brighton was more than a benchmark.

"He wasn’t disposable," she said. "He was a father, a grandfather, a brother. Just because he was in a nursing home doesn’t mean he didn’t have a family that cared about him. It’s not fair that he had to die by himself."

Inspections on hold

On March 7, Earl Denbow Jr. was talking to his grandsons about spring track and baseball.

"Get a home run for pap," he said.

It was the last thing he told 11-year-old Jonathan and 14-year-old Anthony.

Five days later, school sports were put on hold and Boyer got a call from her father's nursing home, Brighton Rehabilitation and Wellness Center, that explained visitors were not allowed at the Beaver County facility.

The coronavirus was spreading across Pennsylvania, and infection control measures were being put into place.

But Denbow, an Army veteran who served during the Vietnam War, still got sick.

On March 28, he became one of the first people at the Beaver County nursing home to test positive for COVID-19.

Five days later, on April 1, the 73-year-old Denbow became one of the first residents to die.

There were so many cases at the nursing home by April 6 — at least 50 — that the nursing home said it was assuming all 450 residents and more than 300 staff may have been positive for the disease. Brighton Rehab and Wellness Center in a press release said, upon consultation with the Department of Health, it would stop counting test results and start treating all staff and residents as though they were symptomatic.

In accordance with Gov. Tom Wolf's disaster emergency declaration on March 6, the Department of Health issued a new set of inspection guidelines. It explained that the state would stop regular inspections and investigate a facility only if a complaint indicated a patient was in immediate jeopardy.

And 849 patients dying in 408 nursing homes from an incurable disease does not count as immediate jeopardy.

Immediate jeopardy occurs when a nursing home's lack of compliance with one or more state health requirements causes, or is likely to cause, serious harm, injury or death to a resident.

Infection control surveys will be conducted for facilities and agencies identified by the Centers for Disease Control and the U.S. Department of Health and Human Services.

And the state health department is still working to ensure proper infection control efforts are being carried out, even without regular routine inspections, according to spokesman Nate Wardle.

But the department is not doing on-site visits at facilities, even if they've had infection control violations in the past.

A history of violations

Brighton Rehab and Wellness Center has been cited for infection control violations several times in the last five years, including three times in the last year, state inspection data shows.

In October, state regulators ordered the facility to establish an infection prevention and control program to prevent, identify, report, investigate and control infections and communicable diseases for all residents, staff and visitors.

State inspectors had ordered that plan so many times the facility received a "below average grade" last year for a pervasive pattern of conditions that could lead to the "spread of infection and diseases," according to Medicare records.

In the two years that Denbow was at Brighton, the facility was hit with more than $20,000 in state fines.

The state health department took no extra COVID-19 prevention measures with nursing homes that had a long history of infection control lapses like Brighton Rehab and Wellness, Wardle said. All Pennsylvania nursing homes were given the same guidance.

Boyer knew about the facility's track record of violations when she took her dad there a little over two years ago. He had Parkinson's disease that was accelerating quickly, and he was becoming a danger to himself, she said.

"Brighton was the only nursing home here that had an open bed," Boyer said. "It had failed so many inspections, but I just didn't have a choice to go anywhere else."

But she said she had "no complaints" about the care her dad received there.

He loved all of his nurses, Boyer said.

She also found them to be nice and caring. They worked hard, but there were so many patients that they were stretched thin, she said. And Boyer said she wasn't always informed of major things. For example, she didn't learn of her father's colon cancer until she read his health records.

"I'm still trying to get answers about when he received that diagnosis," Boyer said.

Comprehensive Healthcare Management, a New Jersey-based investment group, bought the 589-bed nursing home in 2014 for more than $37 million. Until then, Brighton was a county-owned facility known as Friendship Ridge.

The ownership company did not respond to requests for comment.

Boyer has mixed emotions the more that she learns about all the deaths in nursing homes in Pennsylvania.

"It's astonishing," she said. "More oversight is needed for sure. Brighton had failed so many inspections. Why were they allowed to continue to run a nursing home during COVID-19?"

State health officials said that when they issue fines, their goal is not to put nursing homes out of business because that would leave many people without a place to go.

Boyer now wonders if it would have made a difference in her father's outcome if earlier actions had been taken by the state or nursing home. Would that have prevented her from having to say goodbye to her dying father through FaceTime.

For anyone who thinks COVID-19 is not that serious if it's "just killing old, nursing home patients who would probably die anyway," she has a message: "I hope they never have to say goodbye to a loved one through a stranger’s phone."

Tough choices

Death is never easy to watch, Boyer said.

Her mom died "quite peacefully" of ovarian cancer when Boyer was 20, but it was still hard.

It was harder with her father.

"Dad didn't die peacefully, even though he was on comfort meds," she said. "He struggled for every breath until the end."

Denbow wasn't on a ventilator, a life-saving machine that helps patients breathe or breathes for them. It was one of many choices facing Boyer.

"I had to make a lot of tough decisions and quickly," she said.

On Friday, March 27, Boyer received a call from Brighton Rehab and Wellness Center, telling her that her dad had tested positive for COVID-19.

On Sunday, March 29, she got a call to say her dad was declining and they were calling in hospice care.

On Wednesday, April 1, she got a call that her father was dying.

Boyer, an only child whose mom died of ovarian cancer when she was 20, said goodbye to her dad through a nurse's phone.

"I told him that I loved him, that it was OK, that he had people waiting to see him," she said.

Dying of COVID-19 in a nursing home took away something from both of them, she said.

"The guilt that he died with a stranger is unbearable for me," Boyer said. "It also took away part of my grieving process."

Why Brighton matters across Pa.

We know about Denbow, a lifelong Steelers fan and retired laborer, only because Boyer is telling her dad's story.

And we know about the hotspot at Brighton Rehab and Wellness only because union workers there were getting sick with the patients and started to speak out.

Eventually, the facility issued a press release, but no state rule requires nursing homes to inform the public about infectious outbreaks.

Facilities in Lancaster, Lackawanna and Montgomery counties have also shared public information about their COVID-19 outbreaks.

The state Department of Health is now releasing county-by-county data on nursing homes, but it is not releasing data for each of the 1,900 long-term care facilities in Pennsylvania.

There is no way to track how each facility is handling the COVID-19 crisis and controlling the spread of infection.

Fewer state and federal inspections, a lack of data and a ban on visitors have left more than 134,000 long-term care patients vulnerable in Pennsylvania.

When asked why the state isn't releasing data for each facility, Wardle said:

"We are receiving data from a number of different sources and through a number of different methods. We are working to reconcile all of that to try to have more comprehensive information on what is occurring at long-term care facilities."

This information isn't just vital to protecting nursing home patients and workers. It is a matter of public health that shows in what local areas the deadly infection is spreading.

More:Coronavirus and deaths in Pa. nursing homes: What we know and don't know

Pennsylvania Sens. Bob Casey and Pat Toomey on April 6 sent a letter to the Centers for Medicare and Medicaid Services, which handles federal inspections of nursing homes, asking the agency to provide answers within a month about how it is monitoring the nation's worst nursing homes.

The senators specifically wanted to know about nursing homes in the Special Focus Facilities programs, which targets places that "substantially fail" to meet Medicare and Medicaid standards.

Brighton Rehabilitation and Wellness has been on the list of the nation's worst facilities.

"As many families rely on nursing homes to provide quality care for their loved ones, Senator Toomey and I asked the (Trump) administration what actions are being taken to ensure nursing homes are doing everything possible to save lives and limit further spread of this virus," Casey said.

The senators also want the federal government to provide data about COVID-19 cases in individual nursing homes. They say residents and their loved ones, employees and first responders don't have access to information about infections and deaths in nursing homes.

"This is information that could help slow the spread of COVID-19," Casey said.

The last weekend

Boyer used to visit her dad every weekend. She always took her sons and dinner.

Denbow had simple tastes. He preferred hot dogs, hamburgers, french fries, hot sausage or pizza, she said.

"Never anything fancy," she said.

Her dad was a big kid at heart who always joked around with her sons. He loved to watch the History channel series "Swamp People" and "Tanked" on Animal Planet. Denbow was also a fan of the WWE. And it seemed like he never met a local restaurant that he didn't like.

When she left the Brighton Rehab and Wellness Center on March 7, Boyer had no idea that would be their last dinner together or their last weekend visit.

She was able to have a small funeral, with only her husband, Joe Boyer, their sons, an aunt and two uncles. But there were no military honors because of the restrictions in place.

The funeral director was kind enough to offer another memorial when restrictions are lifted, "but I don't know if I could do that again," she said.

And everyone has already offered their sympathies and respects, Boyer said, even if virtually.

But she is still grieving.

"It's hard because COVID-19 didn't just kill him. It also kept me from him," Boyer said.

She is getting a lot of support through phone calls from family and friends. "And my husband has been really wonderful," she said.

It's not just that she lost her dad in a pandemic when she was separated from him, but how fast it all happened.

One weekend she was there. The next she wasn't allowed back. One day he received a positive test, and five days later he was dead.

A thought that sometimes offers comfort is bittersweet: While her dad's body was dying in the nursing home, dementia had started to take his mind before Denbow moved into Brighton Rehab and Wellness.

"In some way, I started to lose my dad a couple years ago, but I didn't want to lose the rest of him like this," Boyer said.

"During the FaceTime when I was saying goodbye, his eyes were open, but he couldn't tell me anything," she said. "I don't know if he knew anyone was talking to him. I hope 'I love you' was the last thing he heard."

Candy Woodall is a reporter for the USA Today Network. She can be reached at 717-480-1783 or on Twitter at @candynotcandace.

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