The Pennsylvania nursing home where all 750 residents and staffers may be infected with the coronavirus was hit last year with a "below average grade" by state inspectors who warned that lax sanitary conditions could lead to the "spread of infection and diseases," Medicare records revealed.
The revelation came as five deaths were reported at the Brighton Rehabilitation and Wellness Center, about 30 miles north of Pittsburgh. Operators of the facility, where more than 40 infections had already been tallied, said Monday they were no longer counting cases "and presuming all staff and residents may be positive."
The "deficient" conditions that may have hastened the spread of the coronavirus were laid bare in a Medicare report dated Sept. 13, 2019, in which Medicare inspectors said the facility did not have enough trained nurses and some patients were living in filthy conditions.
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The report "identified repeated deficiencies related to proper infection control procedures not maintained during dressage change, improper storage of soiled linens and failure to provide appropriate facilities for hand washing which created the potential for cross contamination and the potential spread of infections and diseases."
In the kitchen, inspectors reported that most workers were washing hands and donning gloves when handling food -- steps health experts agree are vital to stop the spread of the coronavirus or any other communicable disease. But the "facility failed to make certain that pots and large pans were thoroughly sanitized," the report states.
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Among other things, inspectors found a patient in a urine-soaked bed whose catheter was leaking and nobody had changed "the wet sheets and pad."
Another patient reported that "his leg hurt and the dressing had not been changed in three days," the report states.
State inspectors also found several instances where nursing home workers "failed to maintain resident privacy and dignity" while changing their dressings and often "failed to maintain a safe and homelike environment."
There were multiple examples of filthy conditions noted in the report like stained ceiling tiles, splintered wood and chipped vinyl on door frames, chunks of plaster missing, and "visible dirt, dust, debris and black spots" on the front grills of air conditioner units.
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In total, state inspectors hit the facility with 19 health citations, more than twice the average for retirement facilities in the state, according to the report. Some of the same conditions are noted in a subsequent Medicare report dated Dec. 13, 2019. It was not clear if these deficiencies have been corrected.
NBC News reached out via email to the spokesperson for Brighton to see whether the facility had corrected the deficiencies noted in the report. There was no immediate response.
But Brighton was already on the radar of Pennsylvania's Health Department. Records reveal that the facility was hit with $21,000 in sanctions from March 23, 2017, to July 3, 2018, making Brighton among the most heavily fined retirement homes in the state during that time period.
Pennsylvania Health Department spokesman Nate Wardle declined to comment specifically about conditions at Brighton and the troubling findings in the Sept. 13 inspections report about this facility being highly susceptible to the spread of communicable diseases.
But, Wardle said by email, "whenever we find deficiencies at a facility, they are required to submit a plan of correction that must be approved by the department as to how they will address the issues identified," Wardle said, adding that the facility did submit a plan of action which was approved but it's not clear if the problems have been corrected.
As for the fines, Wardle said, "our fines are meant to be meaningful, but not punitive."
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"It is essential that we do not put nursing homes out of business, as that would leave many people, and in reference to Brighton hundreds of people (the bed count is 589) without a place to go," Wardle said.
In Beaver, Pennsylvania, Brighton was owned by the county and called Friendship Ridge until 2014, when it was bought for $37.5 million by an investment group called Comprehensive Healthcare Management that records show is based in Teaneck, New Jersey. Comprehensive Healthcare Management did not immediately return an emailed request for comment.
The Pittsburgh Post-Gazette reported that the first figures on how many people were infected at Brighton came from the union representing workers there.
In a ProPublica survey of nursing homes, Brighton was deemed a facility with "a history of serious quality issues but has not been formally flagged by the government." It noted that as February 2019, it had been hit with 61 deficiencies and fined $68,000 since July 2016.