The 43-page document paints a disturbing picture of failures at the Menlo Park and Paramus homes, where dozens of deaths occurred early in the outbreak. According to the report, poor communication, lack of staff competency, and other issues allowed the Coronavirus to spread "virtually unchecked throughout the facilities."
Among the findings, the report highlights that the homes failed to group residents into cohorts based on their exposure to COVID-19, resulting in the commingling of infected and uninfected individuals. Additionally, the homes did not properly use personal protective gear, failed to communicate effectively internally, and did not maintain improvements achieved after the U.S. Veterans Affairs Department provided assistance.
"Even by the standards of the pandemic's difficult early days, the facilities were unprepared to keep their residents safe," the report states.
The report goes on to reveal that infection control problems have persisted, including during the Omicron outbreaks in 2021 and 2022. The homes have not adequately trained their staff or monitored compliance with infection control protocols, among other failures.
"These failures are substantial departures from generally accepted standards of care in long-term care facilities and inhibit the Veterans Homes' ability to stop the virus from spreading inside the facilities, creating a serious risk of harm," the report warns.
The Menlo Park and Paramus homes, each with just over 300 beds, are operated by the state's Department of Military and Veterans Affairs. In 2021, the state reached a $53 million settlement agreement to resolve claims of negligence and contribution to over 100 deaths at the two VA homes.
Democratic Governor Phil Murphy responded to the report, calling it a "deeply disturbing reminder" that the treatment veterans received was unacceptable. He acknowledged that his administration had made policy changes to improve conditions, including hiring private management for the two homes, but acknowledged that more work needs to be done.
Governor Murphy faced criticism for his handling of the pandemic in veterans homes, with Republicans calling for investigations into his management of the outbreak.
The report also criticized the state for the lack of independent oversight in its attempts to address the situation. It stated that the Veterans Homes, even with the assistance of paid outside consultants, have been unable to implement systematic changes without external accountability.
Paul da Costa, an attorney representing many of the families in the settlement with the state, expressed disappointment despite feeling vindicated by the report. He also highlighted the facilities' inadequate cooperation with the Justice Department's investigation.
The report noted that state staff attorneys and facilities managers followed investigators while they were talking to witnesses, and officials discouraged staff from speaking to the Justice Department. The CEO of the Paramus site even warned department heads that the DOJ could shut them down, urging caution in their statements.
Governor Murphy had previously pledged a comprehensive study into his administration's handling of the virus, launching a review in 2022. The report was expected to be released by the end of this year.
The report includes a tragic account of a former Marine, identified as Resident C, whose condition declined without proper monitoring for COVID-19. Facility staff took away his scooter and shut the door to his room, leaving him unable to call for help. He later developed a fever and died without any mention of COVID-19 in his chart.
The report also reveals that the number of deaths during the early months of the outbreak was much higher than publicly disclosed. In April 2020 alone, 98 residents of Menlo Park and 92 residents of Paramus died of all causes, roughly equal to the number of deaths in a year at the homes.
The state's published data showed 81 deaths at Paramus and 65 at Menlo Park as of July 2020. However, the actual number of residents who died from COVID-19 was much higher, as COVID-19 tests were not readily available early in the pandemic. Universal testing did not begin until April 20, 2020.
"It is clear that the number of deaths during COVID's early months was substantially higher than the numbers publicly disclosed, and substantially higher than at other facilities," the report concludes.
The report is based on interviews with witnesses, current and former staff, family members of residents, visits to the facilities, and the review of thousands of documents.