Report Details 'Frightening Existence' At NJ Veterans Homes As COVID Deaths Mounted

NEW JERSEY — State officials plan a restructuring of New Jersey’s veteran services, after a new report highlighted “systemic flaws” in management of state-operated Veterans Memorial Homes, where almost 200 people died from COVID-19 related causes.

The State Commission of Investigation (SCI) said it "uncovered heartbreaking accounts" from loved ones of those who died — including a woman whose brother had died without the employees knowing, and a daughter who was given the wrong belongings after her mother died.

The SCI report, released this week, detailed how the state was unprepared for how many frontline staff were absent in the initial weeks of the pandemic "and mismanaged securing replacement staff, leaving existing employees overwhelmed," especially at the homes in Edison (Menlo Park) and Paramus.

Gov. Phil Murphy and four senators announced Wednesday that officials will pursue a series of “necessary” structural reforms, and said the state anticipates “the appointment of a federal monitor to oversee improvements” at the Menlo Park ad Paramus homes, and the third in Vineland.

There were 572 residents of the veterans homes as of September 2023, according to the Department of Military and Veterans Affairs. These veteran-specific nursing homes have a capacity to house 948 people according to state estimates; they are home to military veterans, their spouses, and Gold Star parents.

The SCI investigation “reveals how 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,” said commission chair Tiffany Williams Brewer. “The veterans and their relatives who live in these facilities deserve better.”

The report detailed how the guidance enabling state government workers, including those designated as essential employees, to stay home disrupted how the veterans homes were supposed to operate during an emergency.

"Even when CDC guidance allowed asymptomatic workers to report to work, DOH (the Department of Health) purportedly reiterated in a conference call that State employees could not be compelled to report to work and could only be incentivized with overtime, the report said.

The attendance rate of those reporting to work at the Menlo Park and Paramus homes in the early weeks of the pandemic "dropped by nearly half," personnel and former administrators said. Communication breakdowns, constantly-changing guidance, and the employee shortage exacerbated conditions, along with a lack of communication tools and technology, the DCI report said.

There was also a lack of personal protective equipment in Paramus and Menlo Park, with one staff member telling investigators "that in the pandemic’s initial days, some workers were wearing plastic bags over their heads."

"In contrast, Vineland, where COVID infection rates were far lower, had a warehouse full of equipment with no shortages," the report said.

During the pandemic, one woman said she "had to beg the staff" at the Menlo Park residence to test her mother for COVID:

"At the end of her life, her mother had bed sores and the staff had lost her dentures," the commission report said. "In a final blow, when the daughter picked up her mother’s belongings following her October 2020 death, she was given teeth that belonged to someone else."

The son of a man who died at the Paramus facility from COVID in April 2020 said his father's life "became solitary and frightening existence once the virus arrived and the facility was locked down."

Communication from staff to relatives "dwindled to the point it was nearly nonexistent," the man said. "When he inquired about his father’s health status, the staff could not provide answers," the SCI report said.

The man only found out his father had COVID-19 after he died, the report said.

And, one woman whose brother died of COVID-related causes at the Menlo Park home in April 2020 said she did not know if he was okay during the early weeks.

"When she finally reached a doctor at the home, she was told her brother did not have COVID and was okay," the report said. "Yet, shortly after that, he was taken to the hospital and died."

The woman went to the home to collect his belongings. Staff there were looking for him, and did not know he had died, the man's sister said.

"Three years later, with the federal public health emergency now over and more than 35,000 New Jerseyans’ lives lost to COVID-related causes, the public deserves a full accounting of what led to the extreme devastation inside the veterans homes," the report said.

The SCI recommended that the state reassign the homes from the Department of Military and Veterans Affairs to a new cabinet-level agency or commission.

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

The commission recommended several other changes, including upgrading IT infrastructure at the veterans homes, offering competitive rates for replacement healthcare staff, and establishing better collaboration and equity among the three homes.

Also, a report released Sept. 7 by the United States Department of Justice Civil Rights Division and the U.S. Attorney’s Office for the District of New Jersey found reasonable cause that the state “has systematically violated the Fourteenth Amendment rights of the residents” at the Menlo Park and Paramus homes.

Gov. Phil Murphy and Democrat senators Joseph Vitale, Joseph Cryan, Patrick Diegnan, and Joseph Lagana said legislators are working on legislation to create a veterans-centric cabinet level position, elevating the services currently provided by the Department of Military and Veterans Affairs.

Murphy and legislators also said they will establish a veterans advocate to investigate complaints, and streamline responses to more vulnerable veterans.

“We anticipate that matters related to active members of the military will remain under the purview of the presently-named Department of Military and Veterans Affairs,” the lawmakers said.

“Our collective aim is ensuring the best possible care for our veterans, and we remain dedicated to this objective.”

The commissioner of veterans affairs, U.S. Army Brigadier General Lisa J. Hou, D.O., said that the agency welcomes “additional opportunities to enhance the support veterans receive from our state, both in and out of these three homes.”

Hou, who also serves as Adjutant General of New Jersey, said that independent inspections done this year by the U.S. Department of Veterans Affairs and the U.S. Centers for Medicare and Medicaid Services have reflected the changes already in progress.

“Elevating veterans’ services to a veterans-centric, cabinet-level position will help build on these and other crucial efforts, including the ongoing upgrade of resident rooms from dual to single occupancy and the expansion of veteran services activities across all twenty-one counties,” she said.

After the SCI report, Assembly Republican Leader John DiMaio (NJ-23) said Murphy needs "to take responsibility."

“We give the governor enormous executive powers during health emergencies and the federal government handed Murphy a ton of money to help fix big problems,” said DiMaio. “It’s a shame he did not put it to better use by correcting administrative problems at our veterans facilities and preventing deaths that could have been avoided.”

Republican senators Joe Pennacchio and Kristin Corrado (NJ-40) are renewing their calls for more investigation into the state’s management of the veterans homes. Pennacchio has been pushing for a special legislative investigation into the deaths at veterans homes and nursing homes since 2020, and Corrado sponsors a bipartisan bill to establish an Office of Inspector General for Veterans’ Facilities.

“Every nursing home and assisted living facility in this state was affected in some way by the Murphy Administration’s disastrous COVID policies,” Pennacchio said. “The residents that were in these facilities have families, and they deserve answers.”