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Inadequate pandemic infection control and medical care at two state-run veterans homes violated the U.S. Constitution and still put residents at risk for Covid-19 and other infections, the Justice Department and U.S. Attorney's Office for New Jersey said Thursday.
The findings at the Menlo Park and Paramus veterans homes deal a heavy blow to New Jersey Gov. Phil Murphy, whose response to the pandemic at those nursing facilities had been heavily criticized since Covid-19 reached New Jersey in March 2020. The two federal agencies detail the administration's early failures as the coronavirus ripped through the homes, in many ways validating the scrutiny on Murphy and the state Department of Military and Veterans Affairs, which run the facilities.
State and federal authorities had investigated similar issues at nursing homes in New York, but never publicly detailed such damning revelations as the Justice Department did in New Jersey on Thursday.
The joint agency report quoted a worker at the Paramus home describing it as "pure hell" and one at Menlo Park as "a battlefield." It said the homes' "dysfunctional management style" and poor communications contributed to staffing shortages, limiting their ability to keep residents safe. At Menlo Park, staff members feared retaliation. And at both homes, veterans affairs leaders "often appeared indifferent and even hostile" to employee concerns.
"Even by the standards of the pandemic’s difficult early days, the facilities were unprepared to keep their residents safe," the agencies said in their 40-page report. "A systemic inability to implement clinical care policy, poor communication between management and staff and a failure to ensure basic staff competency let the virus spread virtually unchecked throughout the facilities."
The homes had among the highest numbers of reported deaths during the first wave of the coronavirus, but the federal agencies noted the figures were likely much higher.
More than three years later, the report said, there are still deficiencies in basic care at the homes, including "failures" to monitor residents for acute changes in condition, administer medications, and treat pressure injuries and wounds adequately. During the Omicron wave of the pandemic in 2021 and 2022, the veterans homes in Paramus and Menlo Park respectively had the third and fourth highest death tolls when compared with similarly sized facilities in the region, according to the investigation.
“The Paramus and Menlo Park veterans’ homes fail to provide the care required by the U.S. Constitution and subject their residents to unacceptable conditions, including inadequate infection control and deficient medical care," New Jersey U.S. Attorney Philip Sellinger said in a statement. "These conditions must swiftly be addressed to ensure that our veterans and their families at these facilities receive the care they so richly deserve. We will not stop working until they do.”
The Murphy administration has hired an outside firm to examine its response to the pandemic. The Department of Military and Veterans Affairs, or DMAVA, did not immediately respond to messages seeking comment on the findings.
“The U.S. Department of Justice’s report on the Veterans homes in Menlo Park and Paramus is a deeply disturbing reminder that the treatment received by our heroic veterans is unacceptable and, quite frankly, appalling," Murphy said in a statement.
The governor highlighted the various actions at the homes the last three years, including private management and assistance there. "However, it is clear that we have significantly more work to do, and we are open to exploring all options to deliver for our veterans the high level of care they deserve and are entitled to under the law."
The Justice Department began its investigation in October 2020, when Donald Trump was president. At the time, the governor’s office suggested that it was politically motivated from the Trump administration, but the investigation continued under the Biden administration, culminating in Thursday's report. The agencies noted that the U.S. Attorney General "may" initiate a lawsuit if state officials "have not satisfactorily addressed our concerns."
Investigators interviewed dozens of witnesses, including current and former staff, home management and veterans affairs leaders, as well as family members, residents and home staff members. They conducted five multiday, onsite visits to the facilities in 2021 and 2022, and reviewed tens of thousands of documents produced by the state.
The DOJ said that “inadequate” cooperation from the state impeded the investigation. Veterans homes management cautioned staff around DOJ investigators, saying things to the effect of: “DOJ can shut us down, staff should be mindful of what they say,” according to the report. Subpoenas from the DOJ to DMAVA were delayed, incomplete, did not include responsive documents or included records out of order.
U.S. Rep. Bill Pascrell (D-N.J.), one of the leading voices calling for an investigation, said the Justice Department's report "lays out in exhaustive detail a chronicle of misdeeds at these homes that should enrage everybody in New Jersey.”
“What happened to our veterans was one of the terrible tragedies of the pandemic," he said in a statement. "Too many times residents at the facilities, seniors who fought for our country, have been left in brutal conditions. The incompetence, negligence and outright recklessness by facility management led to loss of life."
U.S. Rep. Josh Gottheimer (D-N.J.) said he's asked for an "immediate briefing" from the state and federal veterans affairs agencies to understand why the poor conditions remained for so long and how to fix them. He said the handling of the pandemic at the home in Paramus, which unlike Menlo Park is in his congressional district, "is one of the greatest tragedies New Jersey has ever witnessed."
Well-known problems in stark new detail
The failures at the homes has been well documented, both in the news media and in lawsuits that have reportedly cost state taxpayers upwards of $75 million. But the report lays out a damning portrait of the state and local response.
The facilities were short staffed. At one point during the pandemic, the investigation found, the Menlo Park facility, in Edison, had shifts with a ratio of one nurse to one hundred residents.
Staff members at Menlo Park feared retaliation, and mid-level managers at both homes said they felt their supervisors failed to keep them informed. The state veterans affairs agency "took no significant action" to improve communications — and agency leaders "often appeared indifferent and even hostile to the concerns of employees," the report said.
For example, one agency administrator dismissed an email from an employee expressing concerns about infection control as "ridiculous." With the exception of high-risk employees, staffers were banned from wearing masks throughout March 2020 and even faced disciplinary action if they did, according to the report.
The agency and the homes' CEOs "ultimately viewed unauthorized mask wearing as a disciplinary issue, took an adversarial stance toward staff members and contributed to a sense that management did not care about keeping its employees safe," the report said.
Family members faced similar attitudes. Messages did not get returned. Positive cases were not always included or did not offer specifics to ease families' concerns for their loved ones. They pleaded for updates and did not have enough information to decide whether to pull their loved one out of the homes.
"DMAVA’s dysfunctional management style led to a defensive and occasionally hostile stance toward the inquiries of family members attempting to make healthcare decisions for their loved ones," the report said.
In one glimpse of the state's stance toward making information public, the report said that in April 2020 veterans affairs staffers considered hosting a Facebook live session to update families, but agency officials decided it was "too risky as the haters would ... be able to post comments without our ability to hide them if needed.”
Family members of those who died in the first weeks of the pandemic suffered one last indignity in Paramus. Their loved ones’ belongings were piled outside the home in garbage bags and remained there until U.S. Veterans Affairs personnel arrived in late April, according to the report. "Some belongings had been damaged by rain," it said.
Problems persist three years later
Murphy has changed leadership at the veterans affairs agency as well as the two homes, but the report said problems still persist. Their successors “did not charge its new leadership with examining what went wrong in 2020 or how the Veterans Homes should learn from those failures," the report said.
According to site visits from the DOJ from 2022, the Paramus and Menlo Park facilities still do not properly separate Covid-19 positive residents from non-Covid residents. In some instances residents left areas designated for Covid-19 positive patients even when they still showed symptoms.
The report also found no evidence that the veterans homes implemented recommendations from federal officials early in the pandemic.
It said the homes fail to properly train staff, monitor compliance with infection control protocols and regularly implement protective equipment usage, contact tracing, COVID testing, COVID isolation and cleaning.
"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 said.
The report renewed calls from state lawmakers to move the oversight of the veterans homes out of DMAVA and into a new state agency — an idea Democratic lawmakers floated since late 2022. In a text message, state Sen. Joe Vitale (D-Middlesex), chair of the Senate Health, Human Services, and Senior Citizens Committee, said that a new Cabinet-level department or authority should be created for veterans services.
State Sen. Joe Cryan (D-Union), chair of the Military and Veterans' Affairs Committee, agreed DMAVA should no longer oversee the veterans homes.
“It's time for the military to get out of the nursing home business and to focus on military issues,” Cryan said in an interview. “While I'm disappointed and disgusted by the report, I hope it serves as an impetus for change. I hope we begin these steps when we come back from the summer recess.”
The veterans homes could turn into an issue on the campaign trail headed into the Legislature’s 2023 elections.
“These findings are not only devastating to the families who needlessly lost loved ones, but also once again raise the question of Democrat-led legislature's refusal to rein in Governor Murphy's emergency powers during the pandemic, as Republicans consistently urged leaders to do,” GOP state party spokesperson Alex Wilkes said in a statement. “All of the Democrats who did not have the courage to stop Murphy will face voters this November.”
Daniel Han contributed to this report.