When COVID hit the Veterans Memorial Homes at Menlo Park and Paramus, workers began a mass exodus, according to a state report released Tuesday.

And as the crisis mounted, there was nobody to take their place.

In a critical new report issued Tuesday on the troubled state-run nursing facilities that care for veterans and their families, the State Commission on Investigation said administrators were unprepared for the massive absenteeism by frontline staff in the initial weeks of the pandemic. At the same time, the SCI said those in charge had mismanaged securing replacement staff, “leaving existing employees overwhelmed.”

The state called in the National Guard in April 2020 to help feed residents and transport residents and perform other non-medical tasks.

SCI Chair Tiffany Williams Brewer said their investigation revealed that the pandemic presented “a perfect storm of circumstances that exposed systemic and, in some cases, enduring problems in the administration and supervision of the veterans homes.”

Veterans and their relatives who live in these facilities, she said, deserve better.

The SCI’s findings come just weeks after the U.S. Justice Department and its Division of Civil Rights found that New Jersey “systematically violated the rights of residents at the two nursing homes.

In a scathing report, the U.S. Attorney’s office said that as COVID-19 was spreading through many of the nation’s long-term care facilities, the state itself failed to implement adequate infection control protocols, provide adequate clinical care, or “provide oversight of the facilities in a manner that keeps the residents of the veterans homes safe from harm.”

Problems with management, accountability and staff skill levels persist to this day, the report added. It also found that “the facilities’ inability to communicate and implement crucial clinical care policies — and the Department of Military and Veterans Affairs’ failure to ensure that this happens — harmed residents and places them at risk of harm.”

Gov. Phil Murphy called the earlier federal report “a deeply disturbing reminder that the treatment received by our heroic veterans is unacceptable and, quite frankly, appalling.” He added that although his administration has instituted improvements, including recently securing private management and assistance for the two homes, “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.”

Murphy’s spokeswoman Christ Peace credited the latest report with providing “additional insights and will be taken into consideration as the Administration works diligently alongside our partners in the Legislature to improve the care we deliver to our heroes.”

“While progress has been made in recent years to improve operations and procedures within the veterans homes, we understand more work must be done to fully address those challenges on behalf of the residents and staff,” Peace said. “All options remain on the table to ensure New Jersey’s veterans receive the exceptional services and support they deserve.”

The SCI report also said problems persist. It found that the homes’ residents “did not, and still do not, receive the level of care they are entitled to from the State of New Jersey.”

The SCI began looking at the veterans homes three years ago, but said that inquiry was put on pause in the wake of separate state and federal investigations — some of which remain ongoing.

The two state homes reported some of the highest numbers of publicly reported resident COVID deaths of all long-term care facilities in New Jersey. Overall, COVID claimed the lives of more than 200 residents and staff in all Menlo Park, Paramus and a third facility in Vineland, according to state data. Federal officials said the actual number of COVID deaths was likely much higher.

The 16-page report it released Tuesday focused largely on the staffing issues.

In Menlo Park in Edison, there was a 480% increase in “call-outs” by workers in the weeks after COVID arrived at the home, the SCI found. At the same time, the commission said there had been no realistic strategy to get employees to report to work or to find replacement staff.

It noted that one administrator testified that when COVID hit in March 2020, “40 to 50 employees called out all at one time,” which meant that “all of a sudden” they had their “entire workforce walk out the door.”

Staffing agencies, however, were unwilling to send nurses and other medical personnel to the veterans homes to replace absent staff because the daily rates paid by the state were fixed. As a result, nurses and other support staff could make far more at private health care facilities, noted the SCI.

Under the veterans homes’ infectious disease outbreak plan, the SCI said the first strategy used to address the staffing shortages was to offer overtime shifts to current staff.

“However, the concept of overtime pay was not a sufficient incentive for employees who could stay home and receive their salaries without the need to use leave time,” the report said.

The commission recommended that the state “clarify the essential employee status of nurses and frontline staff at the veterans homes and uphold the requirement for those workers to report to duty in emergencies.”

In addition, it said the contract rates paid for temporary health care workers to supplement staff should also be suspended or temporarily increased to allow the veterans homes to remain competitive with the private sector.

But lack of staff was only one of the problems the SCI cited.

The physical layout and outdated infrastructure of the Menlo Park and Paramus were not designed or equipped to handle isolation or quarantine situations. And according to the commission, the rapidly changing guidance on virus management from the Centers for Disease Control and Prevention was not well communicated by state health officials to the veterans homes’ managers or within the homes, “creating confusion and upending planned strategies.”

At the same time, it said no system existed to ensure family members of the residents received regular and reliable communication from the homes’ staff with information on their loved ones.

It called upon the Legislature and governor consider the creation of a new cabinet-level agency or commission with specific authority for the homes.

“At a minimum, any government entity responsible for overseeing the veterans homes should be led and staffed by professionals with significant clinical experience,” said the commission in its report.

Sen. Joe Cryan, D- Union, chairman of the Senate Military and Veterans Affairs Committee, said the latest report emphasized the need to create a new state agency that focuses on the needs of veterans, especially those living in the three state-run nursing homes.

He said the revelations about the chronic absenteeism stunned him.

“I didn’t know it was that bad,” he said.

But he added that it was important to note the Department of Military and Veterans Affairs has been making some positive changes.

“The report really brought into focus that there is still a significant amount of work that needs to be done on improving staffing levels. We have not solved it.”

Attorneys representing workers, residents and their families, though, felt that the findings fell far short of providing a full accounting of what happened at the veterans homes during the pandemic.

Attorney Paul M. da Costa of Roseland, who has represented many families whose loved ones died at Paramus and Menlo Park, said report was further corroboration of what his clients have been claiming for the past three years. But he said it also unfairly, in part, sought to scapegoat employees.

“It certainly is not the reason there was a massive wave of death at the facilities,” he argued, noting that employees, as the report confirmed, had been threatened with discipline for wearing masks when the pandemic spread unchecked through nursing homes across the state.

What the report does not speak to, da Costa added, was why there was ever a mask insubordination policy initiated in the first place.

David Cohen of Cohen Kolodny Abuse Analytics of Red Bank, who also represents veterans and families, called it “beyond shocking we needed a commission to recommend that a nursing home responsible for the safety and welfare of our heroes have their safety protected by people who are medical professionals and have clinical experience.

Cohen, who represented 15 families as part of the original settlement with the state.

“One would have hoped and expected that what turned into 200 deaths, there would have been meaningful change to make these buildings safer for our heroes,” he said.

Cohen recently filed additional lawsuits against the state on behalf of veterans families, some of whom suffered from poor care prior to the pandemic. He said the SCI’s findings of systemic shortcomings confirm his clients’ concerns.

“The problems were not limited to COVID. We had cases with pressure ulcers, cleanliness and nutrition,” Cohen said. “To have to tell the operators of these facilities they need to provide ‘uninterrupted care’ is shocking. Continuity of care is one of the most important interventions you need to keep people safe.”

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