A shortage of nurses, aides and other staff at nursing homes across Maine is worsening amid a deadly COVID-19 pandemic that has exacerbated the industry’s long-standing workforce challenges in the nation’s oldest state.

“The situation is dire,” said John Orestis, president and CEO of North Country Associates, the state’s largest Maine-based long-term care provider. “North Country, between the homes that it owns and manages, has 26 buildings and I would say a large majority … of them have extremely difficult situations.”

More than one third of nursing homes in Maine reported shortages of both nurses and aides at the beginning of this month, while more than 20 percent were short on other staff, according to reports filed with federal regulators.

Facilities are not required to specify how many staff members they are down as part of the weekly reports, which also cover COVID-19 cases and deaths, testing and availability of protective gear. But the reports filed with the federal Centers for Medicare & Medicaid Services show the number of homes in Maine reporting staffing shortages has increased steadily since the summer.

Between the ends of May and August, the number of Maine nursing homes reporting unfilled nursing positions increased from 15 to 24, while the number of homes reporting shortages of aides inched up from 22 to 26. Those numbers have continued to rise since then, however, to the point where 35 of the state’s 93 nursing homes had too few nurses and 35 were reporting a shortage of aides.

“I think everyone understood staffing to be a challenge before COVID, so it’s not difficult to see how it can go from being a challenge to a crisis very quickly,” said Rick Erb, president and CEO of the Maine Health Care Association, a professional organization representing more than 200 nursing homes, assisted-living and other residential care facilities in the state.

Erb said the majority of the state’s residential facilities were managing through the spring and summer even as COVID-19 hit some nursing homes hard. But then the fall surge of the virus hit, with total cases in Maine jumping sixfold – from 5,431 to 32,781 cases between Oct. 1 and Jan. 15 – and deaths tripling during that period.

“When facilities are looking for staff, it makes it that much more difficult if all of the facilities around them are experiencing the same problem,” Erb said.

Staffing shortages are by no means unique to Maine’s long-term care facilities.

An August study of Centers for Medicare & Medicaid Services data from more than 15,000 nursing homes across the country found that 22 percent reported staffing shortages as of late July. Maine’s percentages were even higher, with more than 50 percent of homes in five rural counties (Franklin, Lincoln, Knox, Waldo and Hancock) reporting shortages and between 35 and 50 percent of homes in Oxford, Kennebec and Aroostook counties.

The authors of the study, which was published in the journal Health Affairs, noted that homes across the country that were the most heavily reliant on historically low Medicaid reimbursement rates and with lower federal ratings were more likely to report insufficient staff, personal protective equipment (PPE) or both.

“This disparity illustrates that policies to address shortages will need to account for the heavier burden among nursing homes serving more disadvantaged populations,” the authors wrote. “Without more policy attention and additional investment, nursing homes serving disadvantaged populations may struggle to meet even the most basic needs of their residents, regardless of COVID-19 status.”

One of the authors, Dr. Michael Barnett, an assistant professor at Harvard University’s T.H. Chan School of Public Health, speculated that Maine’s higher rates of staff shortages were likely tied to the pool of available workers, particularly in more rural areas.

COVID-19 outbreaks have occurred in long-term care facilities throughout Maine, from Kittery to Madawaska. While long-term care facilities account for a small portion of Maine’s more than 30,000 cases, residents of those homes account for more than half of all deaths.

Maine and federal agencies have required all long-term care facilities to develop and follow strict infection-control plans during the pandemic. But staff members live and circulate in communities where the virus is now well-established and spreading. So when the virus pops up among residents and staff at long-term care facilities, investigations typically show it arrived with a staffer who picked it up in the community or from a family member but was asymptomatic for COVID-19 while working.

In the early months of the pandemic, many of the largest outbreaks were clustered in nursing homes in the Greater Portland area or in York and Androscoggin counties, where the virus was more established in the community. By summer and fall, however, the virus had spread throughout Maine and COVID-19 cases were popping up in rural areas of Washington, Hancock and Somerset counties.

Aroostook County, which had largely evaded the virus before the fall, has had at least three outbreaks in long-term care facilities since December that have sickened more than 130 residents and staff. Fourteen people had died in Aroostook County homes as of last week, according to local news reports.

Dr. Nirav Shah, director of the Maine Center for Disease Control and Prevention, said last week that his staff is checking in with homes “very frequently to make sure they are not running into staffing jeopardy.”

Tessie Dubois, who handles communications for Northern Maine General, which operates the Mercy Home facility in Eagle Lake that has experienced an outbreak, said Aroostook County had staffing challenges before the pandemic but that the nonprofit has been “aggressive” in trying to ensure facilities are properly staffed.

During the recent outbreaks, that includes staff members’ spouses who are trained medical professionals stepping in to pick up shifts and other workers filling in where they can. Dubois volunteered to help with infection control and cleaning in one home and then in the kitchen of another.

“We are all a team here,” Dubois said. “We are just trying to get through this.”

Nationwide, 94 percent of nursing homes have asked or required staff to work overtime or double shifts since the pandemic began, and 86 percent had provided bonuses (sometimes referred to as “hero pay”) to staff members, according to a survey of nearly 1,000 homes.

The American Health Care Association/National Center for Assisted Living, which conducted the survey of member facilities, found that 43 percent of homes said additional staff pay was their top cost during the pandemic, while 15 percent listed hiring additional staff as the largest expense. By comparison, outfitting staff and residents with PPE was the top cost for 26 percent of facilities.

Roughly two-thirds of the homes surveyed said they were losing money and unlikely to last another year if the current financial situation continues. While the roughly $900 billion COVID relief package passed by Congress in December contains some money for long-term care facilities, the American Health Care Association called it “minimal” and urged lawmakers to pass more substantial relief.

Last year, a state commission studying workforce shortages in long-term care in Maine recommended that the state increase starting wages for so-called “direct care workers” to no less than 125 percent of minimum wage. The panel also recommended broader changes to how the state sets reimbursement rates paid to facilities and to significantly expand training, recruitment and retention programs in the industry.

But the Legislature adjourned early as the COVID-19 pandemic hit the U.S., so most of the commission’s recommendations were never acted upon.

“We need to get through the emergency situation that we are in,” said Erb, with the Maine Health Care Association. “But it really brings to mind, in the long term, that for nursing homes, assisted living and other congregate care (facilities) we need to do what everybody has known for a long time, and that is truly address the root problems of staffing.”

Matthew Trombley, senior executive director at Island Nursing Home in Deer Isle, noted that long-term care staffing has been a “delicate” situation nationwide for years. When the coronavirus finally showed up in the small Hancock County nursing home in November, it sickened all 62 residents and nearly one-half of the facility’s staff members.

In response, Island Nursing Home reached out to the Maine CDC for assistance, brought in trained volunteers, hired outside contractors and partnered with the University of New England to have nursing and medical students pick up shifts at the home.

“We were never short before” COVID, Trombley said. “Certainly, were we light on staffing? Yes. The applicant pool is very shallow and sometimes it does take a number of weeks before you can get one individual hired for a position.”

The Maine CDC as well as other agencies with the Maine Department of Health and Human Services work with long-term care homes on staffing. Nearly $1 million in federal coronavirus relief money went to help with infection control and prevention in congregate care settings, including for free consultations with experts in the field.

In the event of an outbreak, Maine CDC provides guidance on disinfection, free test processing and occasionally helps to coordinate temporary staffing for homes struggling with infections or absences within their workforce.

Additionally, hundreds of retired or qualified professionals have stepped up to help fill the temporary voids statewide, many of them connected to facilities through the MaineResponds.org emergency health volunteer system website. Maine National Guard personnel have also been deployed to help with sanitation and disinfection in facilities, while traveling nurses and doctors from other states have helped Maine homes.

But staffing issues persist and are getting worse, in some areas, as the virus spreads across Maine.

Orestis, the president and CEO of Lewiston-based North Country Associates, said the staffing situation has become so dire that some of his facilities have had to restrict new admissions. That has included turning away local hospitals desperately trying to free up space within their own walls amid the pandemic.

“It’s not every facility and it’s not every day, but it is happening,” Orestis said.