Inadequate care at two state-run nursing homes for military veterans in New Jersey left residents at high risk for serious infections and illness during the COVID-19 pandemic, according to a scathing report released Thursday by the U.S. Justice Department.

The 43-page report is the first government investigation into the administration of New Jersey Gov. Phil Murphy and its management of the pandemic at the homes in Paramus and Menlo Park, which had among the highest COVID death tolls nationally for nursing homes.

The report was a result of a three year investigation into the homes where more than 200 residents died during the pandemic after infection control issues led to outbreaks. And while U.S. agencies declared the end of the COVID emergency in May, the report noted that poor conditions in the homes continue to persist today.

"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 report states.

Although Murphy fired four key officials of the Department of Military and Veterans Affairs, including the two homes' CEOs, his administration "did not charge its new leadership with examining what went wrong in 2020 or how the veterans homes should learn from those failures to prevent future crises," the report says.

Numerous states had received scrutiny for their management of nursing homes amid the pandemic where tens of thousands of people died.

Hundreds of veterans fell victim to mismanagement and a lack of infection control protocols as the virus rapidly spread through these homes. Similar to New Jersey, federal investigations were opened into veterans homes across the country, including in Massachusetts, Virginia, Texas and Illinois, among others.

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'Deficient basic medical care' persists

The report said the two New Jersey homes continue to provide "deficient basic medical care," including failure to:

• monitor residents for acute changes in condition.
• create care plans that adequately guide clinical care.
• prevent falls.
• administer medications properly.
• treat pressure injuries and wounds adequately.

Those failures had real consequences, the report says. When the COVID omicron variant spread in late 2021 and early 2022, the veterans homes had the third- and fourth-highest death rates of 44 similarly sized facilities in the region, according to the report.

Kimberly Peck, whose father Vernon fought in Vietnam and died at the Menlo Park home at the height of the pandemic, felt vindicated that the report acknowledged the "horrendous treatment" of the veterans but was angered that significant problems linger.

"Governor Murphy has said over and over again how serious he takes the loss of life at these homes, however time and time again we have seen that nothing has changed there," she said. "What else needs to happen to these people for someone to care and make real effective change?"

The New Jersey Veterans of Foreign Wars renewed its call Thursday for single rooms and better ventilation systems at the homes.

"This report validates what the VFW has been saying for years — lack of leadership, lack of transparency as well as a culture of intimidation," said Jay Boxwell, VFW legislative director. "We do not celebrate this report. This is a sad day for the most disenfranchised veterans and families that call our veterans homes 'home.'"

State impeded federal investigation

The administration has hired an outside vendor to manage the Menlo Park home and plans to do so with the Paramus home. In a statement, Murphy said the federal report “is a deeply disturbing reminder that the treatment received by our heroic veterans is unacceptable and, quite frankly, appalling."

"In an effort to provide our veterans with the care they deserve, over the past three years, our administration has instituted numerous processes and procedures to improve conditions, including most recently securing private management and assistance for these two homes," Murphy said. "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."

Murphy said he would work with the Legislature to "provide world-class care and services to our heroes" but did not specify what that would entail.

But in its report Thursday, the Justice Department said the Department of Military and Veterans Affairs impeded its investigation during visits to the homes.

Staff attorneys and facility management followed department staff around the facility "far beyond what was necessary to provide direction, standing nearby as DOJ staff spoke to witnesses, and knocking on the doors of offices and rooms where witnesses were being interviewed," the report states.

"Witnesses reported that supervisors and managers inquired about what questions DOJ personnel had asked and specifically discouraged staff members from speaking with DOJ," the report added.

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Told masks would scare residents

As with many nursing homes, COVID quickly spread through the two veterans homes at the beginning of the pandemic in March 2020.

An inspection by federal Medicare officials, first reported by NorthJersey.com, found that the homes were slow to close common areas. They allowed infected or symptomatic residents to mingle with those who were not ill or who were awaiting test results more than a month into the pandemic.

Staff had inadequate personal protective gear and went in and out of rooms among patients who were sick with COVID and those who were asymptomatic or uninfected.

Staff members were also told at the outset of the pandemic not to wear protective masks because it would scare residents. With the help of Murphy's office, managers even devised a series of penalties for nurses who used the homes' supply of masks.

In 2022, the Murphy administration agreed to pay $53 million to families of 119 veterans who died in the homes. Dozens of employees have sued the administration, saying they were put at risk unnecessarily.

Pervasive failures in VA state nursing homes

The VA's health care infrastructure and oversight has long been questioned by watchdogs.

Prior to the pandemic, the Government Accountability Office said the VA spent $5.7 billion in 2017 on nursing home care for about 39,000 veterans. But the GAO also noted that VA inspections in these homes had "opportunities to enhance its oversight."

And when COVID made its way through the United States, veterans in nursing homes were among the hardest hit. Deaths in long-term care facilities across the country accounted for a third of coronavirus deaths during the first year of the pandemic.

Residents in VA state nursing homes died due to issues with testing, personal protective equipment and infection control. Reported COVID infections doubled in months as residents often died in clusters — dozens of veterans died in outbreaks at VA facilities.

A 2021 GAO examination found that there were 3,944 cases and 327 deaths among residents of VA nursing homes from March 2020 through mid-February.

Contributing: Donovan Slack, USA TODAY