Less than 0.5% of the US population reside in nursing homes but accounted for about 40% of COVID-19 deaths before vaccinations became available. Pennsylvania's large elderly population and 700 nursing homes are studied to examine the causes of problems and changes needed to improve nursing home outcomes. Community disease spread by low paid staff unknowingly asymptomatic with COVID-19 and working in multiple communities and facilities best explains disease outbreaks. Staffing, training, and working conditions need regulatory reform, but victims are dependent on society's overall response to the pandemic.