Exclusive: Exec who blew the whistle on NJ COVID deaths at vets home says key flaws remain
As COVID raced through the state-run veterans home in Paramus at the start of the pandemic in 2020, an administrator watched with growing alarm as residents died, staff members fell sick and the facility ran short of masks, gloves, gowns and tests. Panic spread as quickly as the virus itself.
When the death toll climbed to six or seven a day at an institution that typically saw three or four resident deaths a week, that administrator became the whistleblower who called himself “vetkeeper.”
On April 8, 2020, using his pseudonym and an encrypted email service based in Switzerland, he contacted NorthJersey.com to report what he was seeing.
“Nearly 40 resident deaths since March 25,” he wrote. “Ten more residents positive, 47 waiting test results ... The public needs to know. I am on the inside. I will keep you posted.”
The first story of the deaths at the New Jersey Memorial Veterans Home at Paramus, based on information from “vetkeeper” and other sources, broke that evening. “Vetkeeper” arrived at work the next morning to find two news trucks out front, a helicopter overhead and the National Guard on the way.
But in many respects, it was too late. Nearly a third of the residents at the Paramus veterans home would die of COVID or presumed COVID. In all, more than 200 residents died at New Jersey’s two hardest-hit veterans homes — 86 from confirmed COVID in Paramus and 72 in Menlo Park, with another 47 at the two homes presumed to have died from COVID.
Now “vetkeeper” has decided to reveal his identity and say more about the veterans home. He is Dave Ofshinsky, former business manager and, for a brief period, assistant CEO for non-clinical affairs at the Paramus home, where he worked for 5½ years.
He says he is doing so out of frustration at what has not happened since that initial COVID crisis.
“Nothing has happened from the administration [of Gov. Phil Murphy] on this,” Ofshinsky said in a recent interview at his home. “When it was happening, the governor said there was going to be a ‘post-mortem. We’ll get to the bottom of this.’”
A recent scathing inspection report on the state veterans home at Menlo Park, a sister institution, only strengthened his views. It cited the home for having COVID infection control lapses that jeopardized the health and safety of all its residents and staff, as well as abuse of a resident. This week, the federal Centers for Medicare and Medicaid Services, threatened to effectively shut down the home saying they would stop paying for new admissions beginning Nov. 22, and stop all payments by March 8 unless "substantial compliance is achieved."
“All that’s happened has been the payouts to families,” Ofshinsky said, referring to $69 million in state funds to 190 families of dead or sickened veterans to quietly settle their legal claims.
Payouts to settle legal claims might bring a sense of closure to some, Ofshinsky said, but “I myself never had a sense of closure that the state has done the right thing to prevent something like this ever happening again.”
On Tuesday, a spokeswoman for the governor said the Murphy administration “is currently working on a comprehensive and independent construct to review the state’s response during the height of the pandemic."
“The administration will continue to pursue ways to provide the highest quality of care to the residents in state veterans homes in order to protect the health and well-being of our veterans,” said the spokeswoman, Christi Peace.
The New Jersey Department of Military and Veterans Affairs, through its spokeswoman, Maj. Amelia Thatcher, declined to comment.
'Bodies would just pile up'
Ofshinsky contacted NorthJersey.com in April 2020 because “I knew, working for the state system, that nothing would happen,” he said in a recent interview. “Bodies would just pile up.”
After writing his own post-mortem this fall on the COVID catastrophe in Paramus, he agreed to an interview with two reporters and a videographer at his New York home.
“What were the reasons? Why did this happen?” he asked. “Once you know that, maybe you can think about preventing it from happening again.”
As business manager at the Paramus veterans home, Ofshinsky was responsible for billing, budgeting, purchases and payments, as well as the operations of the reception desk, security and the information technology department.
More:Veterans group blasts Murphy over scathing COVID inspection report at veterans home
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He was at the home every workday from the first COVID-19 infections through mid-April 2020, he said. Then he obtained a six-week medical leave as a cancer survivor and returned in June 2020. He said he was forced out a year later.
Ofshinsky is 66 and a Vietnam-era veteran. A former resident of West Milford who was active in Democratic politics, he served three years on the borough’s Board of Education, as well as on its utilities authority and environmental and economic development commissions. He grew up in Paramus and moved to New York State in April.
He compares his veterans home experiences to earlier stints working for nonprofit organizations in behavioral health and for another state agency that oversees child welfare. His sarcasm, when describing what he considers the mediocrity and inefficiency of the state bureaucracy, is biting.
While some of his behind-the-scenes factual details are new, such as the cuts made to the medical staff and the vacancy in the Paramus home’s position of infection-prevention coordinator amid the pandemic, it is his description of the panic inside that is most gripping.
“Lack of leadership, integrity and transparency has put the staff into a demoralized, panic state,” he wrote in April 2020. The CEO and assistant CEO “spend their days locked in their offices offering no support.” Efforts to reach former CEO Matt Schottlander at his new job were unsuccessful.
In Ofshinsky's view, the COVID crisis at the state-run veterans homes was the culmination of years of neglect by the division responsible for long-term care of elderly and vulnerable veterans within the state Department of Military and Veterans Affairs.
Led by an “old boys network” of military and ex-military insiders with scant experience or training in health care, the homes were culturally and physically ill-prepared to respond to the pandemic, he said. Lack of leadership, skills and preparation allowed the virus to run rampant, infecting residents and staff members alike, as staff worked with inadequate protection and infected, uninfected and untested residents mingled together.
'Greater horrors under his watch'
In one sign of increased transparency, the homes in Paramus, Menlo Park and Vineland posted their “outbreak prevention plans” online last February. But an extended inspection of the Menlo Park home in August and September found that the most basic prevention strategies were not followed: Testing was not conducted after a new case of COVID was identified last year, and there was no contact tracing.
Brig. Gen. Lisa Hou, a physician and combat surgeon with service in Iraq and Afghanistan, has led the Department of Military and Veterans Affairs since October 2020, after the ouster of Gen. Jemal Beale in what Murphy called “a leadership transition” after the worst of the pandemic was over.
At the time he fired Beale, Murphy also fired the CEOs of the Paramus and Menlo Park veterans homes, Matthew Schottlander and Elizabeth Schiff-Heedles, as well as their boss, Sean Van Lew, director of DMAVA’s division of veterans health services.
Investigations by the U.S. Department of Justice and the New Jersey Attorney General’s Office have so far produced no charges, and the state Commission on Investigation has not issued a report on the events.
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Settlements reached with the veterans’ families have precluded the presentation of evidence and testimony about the handling of the pandemic in open court and left many questions unanswered.
And 2½ years later, there’s been no sign of Murphy’s oft-promised post-mortem. A consultant’s report and recommendations about reforms to New Jersey’s nursing home regulations never mentioned the veterans homes.
The governor “was so quick to condemn the private nursing homes,” Ofshinsky said in his recent interview, “but greater horrors were happening right under his watch."
“The fact that nothing has come about after two years really tells me that nothing much is going to happen,” Ofshinsky said. Murphy’s “response to it, as I see it, is to try to sweep it under the cash carpet and hope it goes away.”
'People were really terrified'
In the beginning, Ofshinsky said, the administrators viewed the coronavirus as something “over there, in Asia,” far from the Paramus veterans home, a facility with beds for 336 high-risk elderly residents. The staff joked about a “beer virus” with the name “Corona.” Few even acknowledged the 18 deaths reported at a Seattle-area nursing home, or the mounting cases in nearby New York City.
Then, on March 28, 2020, test results showed that a resident of the Paramus home who had been hospitalized with a fever had COVID.
“Deaths started shooting up, six or seven a day,” Ofshinsky said. “People were really terrified.” They realized that “this mysterious illness not only is killing people outside, but it’s killing people inside here. And modern medicine doesn’t contain it or know what to do.”
The facility didn’t have enough masks, gloves or gowns for employees to protect themselves as they cared for patients, much less to swap out protective gear as they moved from one resident’s room to another. N-95 masks, the most effective protection against viral particles in the air, were in especially short supply, he said.
When the state Treasury Department authorized Ofshinsky to go outside normal state purchasing channels to buy supplies, he turned to Google and searched for N-95 masks. “It was crazy,” he said. “Every man for himself.”
But before releasing funds to pay for the purchases, he recalled, a Treasury Department reviewer asked him for justification. “I said, ‘How about a whole bunch of death certificates?’” he recounted. The request was escalated and approved, he said.
More:New details reveal how Paramus veterans home became the worst of the worst during pandemic
But “it’s not enough just to give someone an N-95,” he added. “You have to be fit-tested. You have to have the right size, the right type.”
And you have to be trained how to don and doff it and use it properly. It took weeks — and the arrival of a federal Veterans Affairs strike team on April 18 with infection-prevention expertise — to adequately equip and train the staff.
Meanwhile, Paramus home CEO Matthew Schottlander and his clinical team spent hours “secluded in meetings,” Ofshinsky said, but communicated little.
The employees, understandably, “started going into a panic,” Ofshinsky said. “They did not have trust and faith in their supervisors and leadership. They’re not well paid … It was like ‘Gee, I’m going to risk my life for this?’”
For many, the answer was no. They began to find reasons not to come to work.
By April 6, more than 30 staff members were ill, though not all could get tested for COVID, emails obtained by NorthJersey.com showed. Others, who were at higher risk of complications from COVID, sought doctors’ letters so they could stay home.
Rules for excused absences were confusing and changed quickly, Ofshinsky said. “It became a mess. So management became punitive: ‘If you don’t come into work, we’re going to fire you.’” Some people didn’t want to lose their jobs and came in sick. “It was chaos.”
In an effort to prevent workers, visitors and vendors from bringing the virus into the building, all entrances were closed except one. At that door, the reception staff was supposed to check the temperature of everyone who entered.
“But they didn’t have the adequate thermometers to do it,” Ofshinsky said. And the schedule for monitoring the entrance had gaps in it — periods when no one was available to perform the screening.
Chronic struggles with infection control
Even before the pandemic, the veterans home had struggled with infection control, Ofshinsky said.
Outbreaks of the flu, norovirus — a gastrointestinal virus — and scabies had previously led to lockdowns of various units and prohibitions on visitors.
In 2015, for instance, inspectors for the U.S. Occupational Safety and Health Administration had found three serious violations at the Paramus home, including problems with personal protective equipment, first-aid kits and directions for employees on handling hazardous materials. The home was penalized more than $11,000.
And in October 2017, inspectors for Medicare and Medicaid found that the Paramus home violated infection-control standards and placed some residents in immediate jeopardy by sharing a device for testing blood sugar levels among multiple residents, including one with HIV and another with hepatitis C. It was the only nursing home in New Jersey to receive an immediate-jeopardy citation that year.
That same inspection found problems that would prove deadly 2½ years later, when COVID ravaged the facility.
“There was no Personal Protective Equipment (PPE), no indications of precautions, and no consistent staff awareness/education as to how to protect themselves and others,” the inspector wrote after observing a nurses’ aide clean the open wound of an HIV-positive resident without wearing a gown or mask during the 2017 inspection. When the inspector then asked for personal protective gowns, they were found in a locked storage closet.
It was a portent of things to come.
As recently as December 2019, a norovirus outbreak had led to a temporary halt in admissions at the facility.
A 2019 state law, passed in reaction to the deaths of 11 children at a Wanaque nursing home, required all long-term care facilities to have outbreak plans. But it had a negligible impact. “You might have some procedures in a book somewhere,” Ofshinsky said, but they were “not really being followed.”
And the pandemic arrived when the position of infection-prevention coordinator was vacant. The nurse assigned left in April 2020, he said.
In late April 2020, inspectors from the federal Centers for Medicare and Medicaid Services arrived after media reports of the unfolding COVID disaster and found conditions at the facility so dire they scored it at the most severe level of deficiency.
Dave Ofshinsky:Systemic problems at NJ veterans home endure after COVID-19 deaths | Opinion
All of the residents and staff, the surveyors’ report said, were in "immediate jeopardy.” The report described some of the findings:
Residents who had tested positive for COVID-19 mingled in the dementia unit with others who awaited test results.
Nurses’ aides didn’t know which residents had tested positive and which were waiting for results, and often cared for each wearing the same gown, gloves and mask, which could have spread the virus.
A janitor mopped the floor of room after room, unaware that "STOP" signs on the doors meant an infected person was inside.
Caregivers received just one set of personal protective equipment each day that was described as “a dollar-store poncho, a plastic apron."
By then, 46 residents were dead. Eventually, the home was fined more than $21,000.
“It’s kind of mind-boggling how lackadaisical things were,” Ofshinsky said.
Change needed beyond a new CEO
To Ofshinsky, the problems at the state veterans homes are rooted in their location withina state agency — the Department of Military and Veterans Affairs — whose priority was the first half of its name, the military. Health care is not the agency’s focus. The state’s National Guard and the Air National Guard units received more attention than its veterans, he said.
The residents of the state veterans homes had very particular needs as well — their age and medical conditions rendered them so frail they needed the round-the-clock supervision of a nursing home. Their families couldn’t care for them, and they couldn’t care for themselves. Some were amputees. Some had dementia-related behavioral problems. Most had multiple chronic conditions.
DMAVA leaders, Ofshinsky said, “love the veterans, but they really did not know how to run long-term-care facilities or nursing homes.”
As health care facilities, the veterans homes needed qualified medical staff and infection-control protocols and sophisticated systems for medical records and management.
But the director of the division of veterans health services, Sean Van Lew, had no background in health care. An infantryman in Operation Desert Shield/Desert Storm with six years in the Army National Guard, he graduated from Kean College with a bachelor’s degree in English and secondary education, according to his official biography. At DMAVA, he previously was assistant superintendent and then superintendent of two facilities for homeless veterans.
Many DMAVA leaders were retired military drawing a military pension while they worked on the state payroll. Agency managers who were concurrently in the National Guard were sometimes called up for active duty, vacating their state positions for months at a time, Ofshinsky said.
Leadership of the Paramus veterans home turned over frequently — eight CEOs, or nursing home administrators, in Ofshinsky’s 5½ years. Schottlander, who presided during the pandemic, had comparatively little experience.
“There was no guidance to lead the facilities to where they should be: into the future, what was right, what needed to be done,” Ofshinsky said. “A lot of things are old-school, not kept up to date.” For example, he said:
The Paramus home lacks a modern electronic medical recordkeeping system.
Its management information system is woefully out of date, and managers have been waiting years for an upgrade.
Wi-Fi access for residents has been established only within the past year — a technology whose absence during the pandemic’s months-long ban on visitors was particularly painful.
Ofshinsky contrasted the death rate at the Paramus home with the death rate at one of the state’s largest long-term-care facilities, Bergen New Bridge Medical Center, across the street in Paramus. That 562-bed division of the county-owned medical campus had 69 COVID deaths during the pandemic, a death rate less than half that at the veterans home.
The appointment of Hou, the general who heads DMAVA, is bound to bring improvement, Ofshinsky said. “But she’s stuck with an infrastructure that makes it difficult.”
Veterans services should become a separate department, Ofshinsky suggested. At the least, operation of the veterans homes would be better managed by the state Department of Health or through a contract with a private or nonprofit health care company, he said.
Ofshinsky has made that suggestion before.
In August 2020, he wrote anonymously to state Sens. Joe Vitale, the Woodbridge Democrat who heads the Senate Health Committee, and Joseph Pennacchio, a Montville Republican, asking them to do something to resolve the underlying issues at the veterans homes.
“Big change is needed,” Ofshinsky wrote — changes that “need to go beyond replacing the CEOs. There is no support, help or oversight from the DMAVA.”
It’s unclear whether anyone was listening. The Democratic-controlled Legislature has held only one hearing into the veterans home deaths.
But Ofshinsky is undeterred, taking some satisfaction in the results of his whistleblowing so far. “I’m sure at least one life was saved, if not more, and that made it all worth it,” he said in the interview.
“I tried to do whatever I could, and I'm still trying.”
This article originally appeared on NorthJersey.com: Exec saw COVID devastate NJ veterans home, says key flaws remain
