The Pennsylvania Department of Health's 164-page report on its August inspection of St. Francis Center for Rehabilitation & Healthcare included gruesome details on rampant neglect at the Darby nursing home.

What the inspection report did not say is that four St. Francis residents — including at least two with wounds so severe that they went down to the bone — died around the time of the inspection that led the state to revoke St. Francis' license.

Those deaths, disclosed inadvertently last month by Health Department officials while discussing "extreme" conditions at St. Francis, were not the reason the state took the extraordinary steps of revoking the license and later fining the facility $675,750, said department spokeswoman April Hutcheson.

"The license was revoked because they weren't providing proper wound care. They weren't providing the nursing care that they should have been. The medical director wasn't doing his job," Hutcheson said.

She said the state did not draw a direct line between the deficient care and those specific deaths. That is why they were not mentioned in the inspection report, she said.

Among those who died was Lois Coleman. Her children, who live in distant states, were in the process of moving her from St. Francis when they found out she had a bedsore that exposed bone. She died Sept. 7, two weeks after the inspection that found severe neglect in the facility and led to the license revocation.

Further details on the deaths cited by state officials were not available.

"A lot of people suffered to get to that point," said nursing home expert and former federal prosecutor David R. Hoffman, referring to the license revocation. "That's unconscionable."

St. Francis, one of six nursing homes bought by Charles-Edouard Gros, of Center Management Group, for $145 million from the Archdiocese of Philadelphia in 2014, successfully appealed the license revocation and is now operating under a provisional license.

Gros, who speaks softly and doesn't give his age because he looks young and likes to let nursing home residents guess his age, did not respond to an emailed request for an interview about St. Francis and his other facilities. Federal records identify him as an owner of 19 nursing homes in New Jersey, New York, and Connecticut, in addition to Pennsylvania.

Instead, Paula G. Sanders, principal and cochair of the health care practice group in Post & Schell P.C.'s Harrisburg office, serving as spokeswoman, provided a statement saying that Center Management could not comment on the $675,750 fine because it is under appeal. She also said St. Francis had put the problems cited in the August inspection report behind it.

"St. Francis is a good facility with wonderful residents, strong staff, and sound care. Using rumors, innuendo or non-cited allegations to recolor history is not fair to our residents and those who are dedicated to providing high-quality nursing and restorative services," Sanders said.

Sarah Newman Boateng, executive deputy secretary at the state Health Department, said the facility had indeed improved. "They made significant changes in the facility, created an entire new leadership team, made aggressive investments in terms of resources and expertise, and have really improved the care over the last couple months," she said.

However, St. Francis' path to improvement started off at an extremely low level, judging by the August inspection.

Nursing home surveyors typically base their assessments on a sample of patients and if they find deficiencies, they usually involve a small percentage of the residents. Not so in the case of St. Francis, where surveyors found that the facility had neglected 11 of 28 residents reviewed.

"That's ridiculous," said Toby Edelman, senior policy attorney at the Center for Medicare Advocacy, a tax-exempt public-interest law firm in Washington that works on behalf of the elderly and disabled. "That's a huge number. That's a huge proportion."

It's not clear what happened at St. Francis to cause such high levels of neglect.

An Inquirer analysis of Medicaid cost reports found that Gros reduced by 29 percent the amount of care provided by registered nurses in the year ended June 30, compared with the last full year the archdiocese owned the facility. That calculation is based on the amount of time worked by registered nurses spread over all the residents for every day the residents were at St. Francis.

Academic analyses have found that the presence of registered nurses is key to high-quality care in nursing homes.

The number of registered nurses, measured on a full-time equivalent basis, fell to 15 on June 30 from 28 at the end of fiscal 2014, before the archdiocese sold its nursing homes to Gros. Overall nursing staff fell roughly 20 percent to 163 full-time equivalents, from 202.

Gros reduced the amount spent on nursing care even more dramatically, to an average of $98 per patient day in fiscal 2017 from $165 per patient day. That is a 41 percent decline.

"It's important for us to be competitive with the other for-profit facilities and with the not-for-profit facilities," Gros said in 2014 soon after acquiring the archdiocesan facilities. "Certain things that they had were above the normal and all we're trying to do is bring it back within the range of normalcy."