“It was so still and quiet,” says Walters, whose description of desolation at the home aligns with records showing its staffing level has fallen over the course of the pandemic. “How alone must he have been.”

Even before COVID-19 bared the truth of a profit-driven industry with too few caring for society’s most vulnerable, thin staffing was a hallmark of nursing homes around the country. Now, staffing is even thinner, with about one-third of U.S. nursing homes reporting lower levels of nurses and aides than before the pandemic began ravaging their facilities, an Associated Press analysis of federal data finds.

“It’s already so low. To drop further is appalling,” says Charlene Harrington, a professor at the University of California, San Francisco, whose research on nursing homes has frequently focused on staffing.

As COVID-19 engulfed homes, some workers fled over fears of exposure. Others were lured to easier work at similar or higher pay in restaurants and stores. And some were laid off by homes as occupancy fell.

Nursing aides are the backbone of homes’ staffing. They are overwhelmingly female and disproportionately members of minority groups and, working jobs with high injury rates and low pay, the industry has long struggled to hire and retain them. Critics say if they simply boosted wages, the applicants would come.

Whatever the reason for skeletal staffs, the result is clear: Residents have fewer to answer their calls to keep them safe, clean and fed, while facilities have helped their bottom lines.

Some 32% of nursing homes reported staff-to-resident ratios in June that were lower than those in February 2020, AP’s analysis shows. In homes posting lower ratios, the average resident had 21 fewer minutes of contact with staff each day, or about 11 hours a month, translating to scarcer help at mealtime, fewer showers and less repositioning to prevent painful bedsores. In the worst cases, when someone falls, chokes or is otherwise endangered, it means there are fewer people to discover the problem or hear their calls for help.

Tamika Dalton saw it first-hand with her 74-year-old mother, who moved to Blumenthal Nursing and Rehabilitation Center in Greensboro, North Carolina, in January 2019 as her multiple sclerosis worsened. At the time, the facility had a staffing level above the benchmark recommended by many experts.

But once COVID-19 kept visitors from going inside, Dalton peered through her mother’s window, seeing fewer and fewer aides pass by and her mother sometimes sitting for hours in a soiled diaper. Her hair was often matted and her toenails grew long. A bedsore the size of a fist festered on her backside. Sometimes, unable to dial a phone herself and with no aides in sight, she would holler to a passing custodian for help.

“She would call out for help and no one would come,” she said.

As conditions continued to deteriorate, Theresa Dalton, a retired minister, contracted COVID-19 and died Feb. 12. By June, the facility’s staffing was down 15% from the start of 2020, and 25% from the start of 2019.

“They did that for their own pockets,” Tamika Dalton says of the lower staffing.

Requests for comment to Blumenthal and its operator, Choice Health Management Services, were not returned. In a letter to state regulators, an attorney for the facility said complaints were taken seriously and that some problems, like the bedsore, were exacerbated by the patient’s failure to follow orders.

“The facility never fell below staffing expectations,” the letter said.

The American Health Care Association, which lobbies for care facilities, said 99% of nursing homes and 96% of assisted living facilities said they had staffing shortages in a September survey. In a June survey, AHCA found 84% of nursing homes were losing revenue due to fewer patients coming from hospitals, and that nearly half of nursing homes and assisted living facilities had made cuts.

AHCA officials declined an interview request but, in a statement, called for additional federal funding, changes to Medicaid and government programs to bolster caregiver hiring and development.

“The labor shortage in long-term care is the worst it has been in decades. Many facilities are now in danger of closing because of workforce challenges,” the organization said.

Medicaid, whose benefits are reserved for the poor, is the largest payer of long-term care in the U.S. Older adults’ shorter nursing home stays — a monthlong rehabilitation after a hip replacement, for example — are typically covered by Medicare, which often pays providers a rate several times higher than Medicaid. For that reason, short-term Medicare patients are nursing homes’ golden geese.

But the pandemic shrank new Medicare admissions just as outlays for things like protective gear soared.

With profits imperiled, some homes went on a search to cut costs.

All told, across all job types, nursing home employment, which had grown steadily in the decade prior to the pandemic, has plunged by more than 380,000 jobs in the past year and a half, according to Bureau of Labor Statistics data. Staffing ratios would almost certainly be worse if not for lower occupancy due to more than 135,000 COVID-19 fatalities in nursing homes and higher-than-normal deaths of other causes.

Many families of those who have died in nursing homes since COVID-19’s start are convinced their loved ones’ deaths were precipitated or hastened by poor staffing. Linking an individual death to staffing is difficult, but studies have repeatedly linked higher nursing home staffing with better outcomes.

Harrington has little doubt that low staffing, combined with poor testing practices and lack of protective equipment, played a role in COVID-19’s proliferation.

“This is why the infections spread,” she said. “If the nursing homes had beefed up their staffing, done the testing twice a week and had adequate PPE … they would have saved thousands of lives.”

For those who remain in nursing homes, the impacts of lower staffing are dovetailing with the pandemic’s toll.

Dave Bartok, a 74-year-old retired steelworker with vascular dementia, has lost weight since COVID-19’s start and has often been so weak he could barely hold his head up. His family blames much of that on isolation.

But they see other problems as products of lower staffing: Unchanged diapers. Ants crawling on the mattress. Being left in bed instead of taken on a walk.

Bartok’s son-in-law, Eric Paulikonis, said staff would drop off food for his father-in-law but left without helping him eat, leaving him unable to open milk cartons and attempting to eat cellophane-wrapped sandwiches through the plastic. The staff ratio at the facility, The Laurels of Huber Heights, just outside Dayton, Ohio, fell 8 percent from the pandemic’s start through June, according to its filings.

In a statement, The Laurels of Huber Heights acknowledged “a staffing situation that looks much different than when Bartok was initially admitted to the facility in 2019.” The facility is committed to hiring and retention, the statement said, “but it is an uphill battle to overcome preconceived notions about the industry” and because it is “unable to match” the wages of competitors.

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