Some Maine nursing homes still weren’t following rules meant to limit the coronavirus’ spread this summer, even after more than a dozen such facilities saw COVID-19 outbreaks in April and May — including some of the state’s largest and deadliest.

Now, the continuing spike in COVID-19 cases across Maine highlights a distinct risk — that the virus could again slip into nursing homes and assisted living facilities and cause a new round of outbreaks, in which the virus spreads quickly among residents who are especially vulnerable because of old age and poor health.

In just the past week, state health authorities have announced new outbreaks at long-term care facilities in Rockland and Kittery as virus cases have grown in the surrounding areas. The Kittery nursing home, Durgin Pines, had already seen a virus outbreak in May.

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Since the start of the pandemic, the Maine Department of Health and Human Services has found violations of COVID-19 rules at 16 of the state’s 93 nursing homes — nearly a fifth of them. It found almost all of them in June and throughout the summer, after the coronavirus’ acute toll on nursing homes had become clear, according to a review of DHHS records. Residents of long-term care facilities have accounted for 89 of the state’s 146 coronavirus-related deaths to date, or about 60 percent.

State inspectors found nursing home workers not covering their mouths and noses with masks, incomplete screening of visitors and staff for COVID-19 symptoms that resulted at least twice in nursing home employees working while sick, and improper handwashing and hygiene that risked contaminating the protective gear employees have worn to stem the virus’ spread, according to more than 150 pages of records reviewed by the Bangor Daily News.

Maine has seen some of the nation’s lowest rates of coronavirus infections and deaths in nursing homes. Almost eight months into the pandemic, elder care centers are accounting for a smaller portion of outbreaks in Maine, and their more recent flare-ups have been smaller.

But even if the state’s new spike of infections is trending younger, a nursing home outbreak becomes more likely when the coronavirus starts spreading in the community where the facility is located, heightening the chances that an employee, building contractor or EMT responding to a call can contract the virus and bring it with them inside.

From there, the inspections suggest that lapses in mask-wearing, symptom screening and handwashing are still happening at Maine nursing homes, increasing the likelihood the virus can spread once it’s found its way in.

Plus, in a low-paying industry that chronically struggles to attract enough workers, research and Maine’s experience early in the pandemic suggest that outbreaks can become more deadly at nursing homes with below-average staffing.

View of Penobscot Avenue in Millinocket. The three neighboring towns of Millinocket, East Millinocket and Medway had a COVID-19 outbreak after a wedding reception took place in the area on Aug. 7.

Violations, not predictions

On Aug. 1, a certified nursing assistant showed up to work at Katahdin Nursing Home in Millinocket and was allowed to work despite having a cough, headache and sore throat — common COVID-19 symptoms that the employee attributed to allergies but should have disqualified them from working.

That worker later tested negative for the virus and was diagnosed with bronchitis, according to state inspection records, but the case highlighted a close call. It happened just days before the state’s largest outbreak of COVID-19 to date was sparked by an Aug. 7 wedding in the Katahdin region.

Dozens of people in the area tested positive for COVID-19 in the weeks after the wedding, increasing the chances that nursing home employees could have contracted the virus from family members or friends, then brought it to work with them, particularly without rigorous screening to keep sick employees home from work.

State inspectors who went to the Millinocket home in mid-September also found kitchen workers and a nursing assistant not covering their noses with face coverings, and that two visitors had been let in without staff reviewing their answers to symptom and travel screening questions.

As the pandemic took hold in March, the federal government put the regular inspections it requires at nursing homes on hold, and instead asked states — whose employees conduct the inspections — to focus them on homes’ practices to control COVID-19’s spread. Those inspections turned up the violations at 16 of the state’s 93 nursing homes.

The inspectors’ visits provided some of the only outside eyes on nursing facilities at a time when they had barred most outside visitors, Maine’s long-term care ombudsman, Brenda Gallant, told the BDN in September.

And they’re one part of a larger strategy to ensure nursing facilities’ safety, Maine Health and Human Services Commissioner Jeanne Lambrew said. The other efforts include regular webinars for nursing home managers and more expansive testing.

“Part of it is inspections and having that kind of on-the-ground response to practices,” she said. “Some of it is education.”

But the violations don’t appear to predict whether a nursing home will later succumb to an outbreak. In Maine, some facilities have passed their initial inspections only to later have an outbreak, while more than a dozen — including Katahdin Nursing Home — have so far avoided flare-ups despite being cited for violations.

Katahdin Nursing Home appreciates “the importance of keeping the safest environment for our residents in this unprecedented, rapidly evolving pandemic” and is working to improve “when that isn’t the case,” Andrea Otis-Higgins, chief operating officer of First Atlantic Health Care, the facility’s parent company, said in response to questions about the COVID-19 violations.

All 19 nursing homes that have had confirmed outbreaks have been inspected at least once since the pandemic arrived in Maine, but state inspectors found violations at just four.

One of those homes recorded a lapse similar to the one in Millinocket, but which resulted in a far worse outcome.

Visitors wave at a family member during their visit through the window at Tall Pines in Belfast in April 2020. Credit: Linda Coan O'Kresik / BDN

In Madison, Maplecrest Rehabilitation and Living Center initially passed a July 7 inspection without any violations. But it became the site of a COVID-19 outbreak in mid-August as part of the fallout from the Aug. 7 Millinocket-area wedding. An inspector revisited the facility multiple times in late August and early September after the start of that outbreak, which eventually infected 15 staff and 25 residents, seven of whom died.

During those follow-up visits, the inspector found that a certified nursing assistant was allowed to work a 10-hour shift on Aug. 11 despite reporting on a visitor screening log that she had a sore throat, a cough, chills and muscle aches.

That same worker later tested positive for COVID-19 in what state inspectors identified as the first case in the outbreak.

Maplecrest belongs to a Lewiston-based parent company, North Country Associates, that operates 26 long-term care centers in Maine and Massachusetts. They include three Maine nursing homes that have been cited for violations during the pandemic but haven’t had outbreaks, and three others that have had outbreaks.

The first of those to see an outbreak was the Commons at Tall Pines, the Belfast facility that saw 11 staff and 32 residents infected in April, and 13 residents die.

State inspectors found no deficiencies there, but they did at North Country’s Edgewood Rehab and Living Center in Farmington, where four staff and 17 residents eventually tested positive, including one resident who died.

As the outbreak flared up in mid-April, an inspector noticed that a certified nursing assistant at Edgewood who had just left the room of an infected resident did not properly change her protective clothing before entering the room of another resident who had been exposed to the virus but not tested positive.

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The worker used “dirty” gloves to put on a clean new gown, then did not wash her hands before putting on a clean pair of gloves, and she rested a clean gown and face mask on surfaces where there had recently been contaminated gear, the inspector wrote. In doing so, she could have tracked droplets of the virus into the second resident’s room. During an interview with the inspector, she also couldn’t identify which resident was confirmed to have COVID-19.

Mary Jane Richards, chief operating officer of North Country, said its facilities “continue to work on improving policies and procedures” to follow “rapidly evolving public health” guidelines.

She also said the company has implemented a number of measures to prevent COVID-19 outbreaks in its facilities, including distributing protective gear, universal testing of residents and staff, isolating infected residents in private rooms and minimizing interactions between staff and residents.

The two other Maine nursing homes that were found to be violating federal rules after an outbreak had started were Marshwood Center in Lewiston and Pine Point Center in Scarborough, which belong to one of the nation’s largest nursing home chains: Genesis HealthCare of Pennsylvania.

After Marshwood’s outbreak was discovered in late July, an inspector who visited on Aug. 18 and 19 found that a dining services worker did not wear eye protection when sanitizing a cart that had been in a unit for infected residents, and that the facility had shred its recent visitor and employee screening logs.

State disease investigators rely on those logs — which record a person’s temperature and other symptoms that could suggest whether they have COVID-19 — to trace contacts who may be connected to an outbreak.

Although the outbreak was still underway at the time, the facility’s administrator didn’t realize the logs would be needed for contact tracing, according to Genesis HealthCare spokesperson Lori Mayer.

Seventeen workers and 31 residents eventually tested positive for COVID-19 at Marshwood, including four residents who died.

An inspector who visited Pine Point Center after a smaller outbreak in early August — which resulted in no deaths — found that at least one worker rotated between a unit with infected residents and other units, even though that practice could spread the virus to people who weren’t previously exposed to it.

Genesis’ facilities have “diligently followed” state and federal coronavirus prevention guidelines and “in many cases” adopted more stringent protocols, according to Mayer. She pointed out that four of its six Maine facilities with outbreaks are close to Portland, where the coronavirus has hit hardest in Maine.

The Maplecrest Rehabilitation and Living Center in Madison is shown in this Aug. 19 photo. The nursing home suffered a deadly outbreak of COVID-19 following an Aug. 7 wedding in the Millinocket area. It’s one of 16 nursing homes in Maine where state inspectors have found violations of rules meant to contain the spread of COVID-19.

Value of inspections

Experts on long-term care agree on the need for nursing home inspections, but national advocates have questioned their effectiveness.

Nursing homes cited for deficiencies must develop plans to correct the errors, and the state must approve them. For serious errors, they can be fined or risk losing their Medicare certification.

But the agencies that oversee the process have only a narrow ability to issue financial penalties for violations, which limits their enforcement power, according to Toby Edelman, a senior policy attorney for the Center for Medicare Advocacy.

The federal government also does not specifically require oversight of assisted living facilities, though states can inspect them as part of their general licensing process. Of the 26 long-term care facilities in Maine that have seen outbreaks, seven are assisted living facilities, whose residents don’t require as much help as nursing home residents.

Plus, across the country, inspectors appear to be citing nursing homes less often during the pandemic. While about 40 percent of U.S. nursing homes have annually been cited for poor infection control in recent years, fewer than 3 percent of inspections focused on COVID-19 have turned up deficiencies, Edelman’s group has found.

“How can there be no deficiencies when there are all these people dying?” Edelman said. “It’s possible they can be doing it right, but it seems unlikely.”

Maine, however, hasn’t seen the same disparity. The state cited 18 of its 93 nursing homes for infection control violations in 2019 — about 20 percent — including five that later had a COVID-19 outbreak this year, according to data compiled by the Long Term Care Community Coalition. That compares with the 16 that have been cited so far this year for coronavirus-specific violations.

Inspectors may spend limited time in each facility as they race to safely visit all of them, Edelman said. She did approve of a recently added requirement that inspectors specifically observe at least three staff and three residents during each facility visit.

Maine was relatively slow to ramp up its federally required inspections to make sure that nursing homes were following rules to keep out COVID-19, due to delays in securing enough protective equipment for inspectors. The state issued nearly all of its citations for infection control violations after June 1, by which point half of the state’s long-term care outbreaks had already started.

A family member speaks with a resident of The Commons at Tall Pines on April 22 during the height of Tall Pines’ coronavirus outbreak.

Common threads

The greatest predictor of whether an elder care facility may have an outbreak is how actively the virus is circulating through its surrounding community, according to research that Nirav Shah, director of the Maine Center for Disease Control and Prevention, recently pointed to during a press conference.

That could help explain why some of the largest outbreaks in Maine facilities have occurred in Cumberland County, Maine’s most populous county that has also seen the greatest prevalence of the virus.

By sheer case count, five of the state’s six largest outbreaks were in the Portland suburbs, with the top two at Cape Memory Care in Cape Elizabeth and Springbrook Center in Westbrook. Two of the deadliest outbreaks — by total number of deaths — have also been in communities with more transmission of the virus: Maine Veterans’ Home in Scarborough and Sedgewood Commons in Falmouth.

Some research has also suggested that lower staffing levels could leave facilities somewhat more vulnerable to larger and deadlier COVID-19 outbreaks, potentially explaining why three of Maine’s other deadliest outbreaks have been in more rural areas with little known prevalence of the virus.

The most lethal outbreak in a Maine nursing home was in The Commons at Tall Pines, which had the same total number of deaths as Maine Veterans’ Home-Scarborough — 13 — but is less than half the size. The Belfast home had 2.45 deaths for every 10 beds, compared with 1.08 in Scarborough.

By that standard, the second most deadly outbreak was at Maplecrest in Madison, which had seven total deaths but 1.21 deaths per 10 beds. The third deadliest was at the Augusta Center for Health and Rehabilitation, with 1.11 deaths for every 10 beds.

The Augusta Center for Health and Rehabilitation. Credit: Linda Coan O'Kresik / BDN

What all three of those facilities have in common is nurse staffing rates that are below the state and national averages of around 90 minutes of licensed nurse staffing per resident per day, according to federal Medicare data.

Maplecrest and Tall Pines each offered roughly 65 minutes of licensed nurse staffing per resident per day, putting them in the bottom fifth of the state.

The Augusta Center for Health and Rehabilitation performed better, offering 78 minutes. National Health Care Associates, its parent company, didn’t respond to a request for comment.

Richards, the chief operating officer for North Country Associates, which runs Maplecrest and Tall Pines, said the company has “been supporting our heroic staff through increased wages, incentives and education throughout this pandemic” and has “maximized” its staff by moving workers with nursing or nursing assistant backgrounds into different roles, using a new state directory to identify potential direct care workers and recruiting nursing students.