Editor's Note: The following story has been updated to reflect the correction that appears below.

BOSTON – Nearly two-thirds of Massachusetts nursing homes that receive federal Medicaid and Medicare funding are lagging in required annual inspections — a number exceeded by only seven states.

Data from the U.S. Centers for Medicaid and Medicare Services shows at least 237 nursing homes and long-term care facilities in the state, or 63.7% of the total, are behind on their federal health and safety inspections by at least 18 months. The national average is 51.3%, according to the agency.

Those inspections lagged even before the pandemic, the data shows, but ground to a halt last year when the federal agency discontinued in-person visits to nursing homes as they were closed off to the public to help prevent spread of the coronavirus.

That meant that at a time when nursing homes were battling virus outbreaks, rigorous in-person federal inspections were slowed or halted, and families and elder advocates were cut off from visiting their loved ones to check on them.

In Massachusetts, about 30% of COVID-19 related deaths — more than 5,500 people — were among nursing homes residents, accounting for 1 in 6 people living in these long-term care facilities, according to the state Department of Public Health.

One of the state's most devastating outbreaks was at the 200-bed Holyoke Soldiers’ Home, which has been blamed for the deaths of 77 elderly veterans.

Advocates say the lack of federal and state scrutiny likely contributed to the high death toll in the state's nursing homes.

"There’s no question about it that the two are related," said Alison Weingartner, executive director of the group Massachusetts Advocates for Nursing Home Reform. "Nursing homes have been behind on inspections for years and the pandemic only made the situation worse."

Weingartner said about two-thirds of the state's nursing homes were cited for infection-control failures in the federal Medicare/Medicaid inspections over the past three years, which rank facilities based on a one- to five- star rating.

"In some cases we're talking about basic sanitary practices like a lack of handwashing," she said. "And this was prior to the pandemic."

Still, a group that represents long-term care facilities said there has been heightened scrutiny during the pandemic, and points out that the federal ranking system is only one metric by which nursing homes are assessed.

Tara Gregorio, president of the Massachusetts Senior Care Association, said since May the state has conducted more than 2,700 inspections of nursing homes and long-term care facilities in Massachusetts.

"That means that human beings representing the state have gone into our nursing facilities to inspect them for infection control protocols and standards," she said.

Gregorio said the root of the problem is that long-term care facilities have been "woefully underfunded" for years. She said the state and federal governments need to do more to ensure adequate staffing.

"Nursing homes are the ultimate safety net and we need to do all that we can to ensure that they are stable, safe facilities," she said. "We need to do that through transparency and accountability, but also investment."

To be sure, the Department of Public Health said it regularly sends inspectors to the facilities to ensure that they meet COVID-19 infection control standards. The agency says that despite the COVID-19 restrictions it conducted more than 3,000 infection control audits and surveys of nursing homes last year.

"DPH has since resumed routine surveys and is continuing to visit nursing homes on behalf of CMS, working through the delay caused by the required suspension of recertification surveys," the agency said in a statement.

The agency publishes the data in a weekly report, listing the numbers of deaths and infections by facility, as well as deficiencies at about 420 nursing homes.

But the federal federal inspections — which are also conducted by the state health department — are a more extensive review of nursing homes. Medical experts often spend several days at nursing homes observing, interviewing staff and patients, and reviewing records before ranking a facility.

Besides family members and federal inspectors, COVID-19 restrictions also kept about 300 ombudsmen under contract with the state Office of Elder Affairs from entering nursing homes to conduct spot checks or follow up on complaints.

Weingartner said that meant "one less set of eyes" keeping watch on vulnerable residents during the pandemic.

"If you don’t have the family members or the ombudsman coming in to visit them, there’s a potential for neglect that won’t be witnessed," she said.

Meanwhile, nursing homes and hospitals are shielded from legal liability for COVID-19-related deaths under an executive order signed by Gov. Charlie Baker last year.

Baker said the emergency law was "necessary for the immediate preservation of the public health and convenience," but Weingartner said it means families who lost a loved one as a result of COVID-19 infection, or any other type of claim, must prove a higher level of negligence by the facility if they hope to prevail in court.

"This basically holds workers and facilities harmless no matter what happens, even if it wasn't related to COVID," she said. "It means nursing homes can get away with whatever they want."

Christian M. Wade covers the Massachusetts Statehouse for North of Boston Media Group’s newspapers and websites. Email him at cwade@cnhinews.com

CORRECTION -- A story published in the Sunday Eagle-Tribune misstated the percentage of Massachusetts residents who’ve died from COVID-19 who were nursing home residents. About 30% of the state’s COVID-19 related deaths — more than 5,500 people — were among nursing home residents, accounting for 1 in 6 people living in those facilities, according to the state Department of Public Health.

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