The first two sanctions, in 2017, were fines for incidents of “actual harm” — one of four harm categories the state levels for each violation — with one fine levied after a resident broke an arm after falling off an air mattress with insufficient assistance from staff. The other 2017 fine was because six residents were found with bedsores, something that experts say demonstrates residents did not have enough care.

There was another fine after a finding of “actual harm” in 2018, when a resident’s skin was burned off his lower body by a moist compress that was too hot.

In 2019, there were two findings of “serious harm” — the most serious category — for the same incident after residents of The Grove were placed in “immediate jeopardy” because heat in the wing did not work for two days. That resulted in a fine and placement on a provisional one license.

Another fine, and placement on a provisional two license, was assessed later in 2019 after a finding of “actual harm” was given after a resident broke an arm while being moved by an employee.

Since 2014, only 39 nursing homes in the state — just 5% of all facilities — have been placed on a provisional two license or higher (provisional three or provisional four) out of 693 nursing homes in Pennsylvania.

Those incidents and other poor inspections also led the state to nominate Brighton in February 2018 to the Centers for Medicare and Medicaid Services’ nationwide Special Focus Facility list.

The list represents the worst performing nursing homes among 15,000 nationwide. Being placed on the list is a warning to facilities to work harder to achieve clean inspections so they aren’t named to the top 100, which then requires extra inspections until the nursing home shows significant improvement.

Despite beginning to hire more full-time and agency staffers in 2018 and 2019 after it went on the Special Focus Facility candidates’ list, Brighton continued to have poor inspection results and is still on the list. Only 24 other facilities on the current list of more than 400 have been on it as long as Brighton.

State inspectors continue to have a strong interest in Brighton.

In 2019, the state inspected its 693 nursing homes an average of 7.8 times, with an average of 4.7 of those inspections coming as the result of complaints from residents, staff or families — although the reports do not say where the complaints came from or what they concerned. Brighton, on the other hand, was inspected 23 times that year; 13 were as a result of complaints.

Brighton, with 589 beds, is the third-largest nursing home in the state. Size by itself could lead to more complaints and more inspections.

But its 23 inspections in 2019 were more than at any of the nine other nursing homes in the state with 400 or more beds.

Only four of those other large nursing homes had 10 or more inspections in 2019, and only one — Spring Creek in Dauphin County — had more complaint-based inspections — 15 — among its 22 overall inspections.

That trend has continued for Brighton this year.

Asked why staffers were repeatedly found to be violating infection prevention protocols in the midst of a deadly outbreak, Brighton officials said in an email: “In any instance where a staff member or contractor may have gone outside of proper protocols, leadership works to immediately correct the individual to ensure compliance. Because of the hard work and dedication of staff to adhere to protocols, the facility has now gone months without a new case of COVID-19.”

Family members of residents are concerned by Brighton’s recent insistence that it hasn’t had any new cases since early on in the pandemic, when 332 of the 460 residents who lived there then tested positive for COVID-19, with at least 82 of them dying.

As Jodi Gill, daughter of Glenn Gill, 82, a resident of Brighton who tested positive and survived COVID-19, said, “They don’t have any new cases because almost everyone in the building has either died or already tested positive.”

“And that’s the saddest part of all of this.”

  Next: Managing internally