Paramus Veterans Home How it Became the Worst of The Worst

The New Jersey Veterans Memorial Home in Paramus claimed to provide “the very finest healthcare service.” But when federal inspectors arrived in April — after 46 residents had died from the coronavirus in a month — what they found was among the very worst.

Residents who had tested positive for COVID-19 mingled in the dementia unit with others who awaited test results. Nurses’ aides wore the same set of protective garb without changing as they moved among patients who were COVID-positive, were COVID-negative or had tests pending. A janitor mopped the floor of room after room, unaware that STOP signs on the doors meant an infected person was inside.

An account of the federal inspection, reported here for the first time, shows how the staff at the state-run institution home was so poorly equipped and trained, and infection control proceduresthere were so lax, that all residents and staff were found to be in “immediate jeopardy” of the life-threatening illness.

The report, and more than 150 emails between administrators of the home and their superiors at the state Department of Military and Veterans Affairs, were obtained by NorthJersey.com and the USA TODAY NETWORK New Jersey through an Open Public Records Act request.

The emails show that for days before the inspectors arrived, scores of nurses and nurses’ aides had been calling out sick — including a majority of patient-care staff in the “Valor” unit, the epicenter of infection. Even more clinical care staff were staying home because of child care needs, exposure to the virus, or fear that health conditions such as diabetes or high blood pressure put them at increased risk — “vague” excuses that Matthew Schottlander, the home’s CEO, told his bosses could “cripple our operation.”

One nurses’ aide had already died of coronavirus complications, though the administrators didn’t yet know it.

Combined, the documents paint a picture of how the virus ran rampant through an institution operated, regulated, and overseen by the state of New Jersey with taxpayer dollars.

The Paramus facility, home to more than 250 elderly residents, many of whom had served in World War II and the Korean War, has had more COVID deaths than any other nursing home in New Jersey — and now has reported more than any other state-run veterans’ home in the United States.

To date, 81 residents and one aide have died there.

Today, 3½ months after the inspection team arrived, the state’s veterans’ homes are “better prepared, … better stocked and ready to be sure that our most precious national resource, our veterans, is number one in our priorities,” Sean Patrick Van Lew Sr., director of the division of veterans’ health services, said in a video update for families on July 28.

The Paramus veterans’ home, he said, had gone more than 35 days without a new case of COVID-19.

In fact, the home may provide an unfortunate experiment in herd immunity — nearly two-thirds of its current 185 residents have tested positive for COVID-19 during the last few months.

“Were it not for the dedicated work of all of those staff in Paramus, Menlo Park and Vineland, we would not be where we are today,” Van Lew said of the three veterans’ homes he oversees. “The work of these heroes … has helped us to mitigate this virus, to bring it down to a manageable level, control it and be able to move forward in a new normal.”

A plan to correct the deficiencies cited in the inspection on April 22 was accepted on May 26 by officials at the federal Centers for Medicare and Medicaid Services, whose contractors conducted the inspection. No penalties have been assessed.

The inspection team arrived in Paramus on April 19.

By then, more than 40 residents already had died from COVID-19 and a devastating mix-up involving the body of a deceased Korean War veteran had been reported two days earlier by NorthJersey.com.

The veteran, Tom Mastropietro, had been living at the home for only a few weeks when he became sick with COVID-19. A few days before his April 11 death, the 91-year-old had been transferred from the dementia unit to Valor, the designated COVID unit, where the staff didn’t know him.

On the day he died, his family was told during a morning check-in call that he was doing well. In fact, he had died hours earlier; his body already had been taken to a funeral home. Meanwhile, the family of Mastropietro’s roommate had been told erroneously that he was dead.

That mistake led to one of two citations for “immediate jeopardy” — the most severe level of harm in the federal government’s enforcement playbook.

The other citation was for “nursing and housekeeping staff’s failure to follow infection control guidelines” — a failure, inspectors said, that “had the potential to affect all 235 residents in the facility.” Inspectors concluded that the deficiency “has caused, or is likely to cause, serious injury, harm, impairment, or death.”

This is what they observed:

In the Serenity Unit, the locked dementia unit from which Mastropietro had been transferred days earlier, 14 of 32 residents had now tested positive for the virus, the staff told inspectors.

Despite the deaths caused by the pandemic, Serenity’s residents still gathered in the day room and ate their meals together, a nurse told the inspectors. Due to their dementia, they didn’t wear face masks or maintain social distance, the nurse said. Staff had received no special training for infection control, the nurse added.

The inspectors saw 10 residents sitting around the Serenity day room when they looked in at 7:30 p.m. on April 20. None wore masks or stayed a safe distance from the others. One, who had tested positive, sat next to another who had tested negative.

“What are we supposed to do?” a nurse’s aide told an inspector. “This is a dementia unit and they won’t stay in their rooms and wear a mask.”

The next day, 15 residents were sitting in the day room when inspectors looked in again, a little before 1 p.m. Four had tested positive, including the man they’d seen the night before, they learned. None wore a face mask.

“We can’t keep the residents separated because they wander,” the nurse’s aide on duty explained. “This is a dementia unit.”

An expert said this was no excuse.

Interactions among dementia residents “should have been closed down, especially given the inability to enforce masks and social distancing among the cognitively impaired,” said Melissa O’Connor, a professor at Villanova University whose work focuses on geriatric care. O’Connor reviewed the inspection report at the request of NorthJersey.com.

Allowing the gatherings to continue was a “passive response” to a pandemic that required aggressive preventive action, she said.

Steve Mastropietro, the Korean War veteran’s son, said he was shocked to learn that residents of the dementia unit were still congregating in communal areas more than a week after his father, a resident of the unit since February, died.

“How could they continue to let people come together like that in late April?” he asked, when he was told about the contents of the federal inspection. “They should have known better.”

“It’s all through the facility,” a long-time nurse at the home, who asked not to be identified, said at the time. “It’s a beast that’s ravenous and wants more. It’s preying on the weak.”

But it wasn’t over.

Infection control breakdowns

The breakdown in infection-control practices was not limited to the dementia unit.

Elsewhere in the sprawling, two-story facility, the certified nurse’s assistants, or CNAs, who bathed and fed the residents and helped them to the toilet, who got close enough to brush their teeth and shave them, received just one set of personal protective equipment (PPE) a day.

It was “not enough to follow isolation procedures,” three CNAs told the inspectors, according to the report.

Standard infection control procedures require separating nursing home residents and the staff who care for them into three groups, usually indicated with red, yellow and green signs: infected residents; residents with symptoms but whose status is unknown; and residents who are symptom-free.

A state law enacted after 11 children died in a Wanaque long-term-care facility in 2018 requires every nursing home in New Jersey to have such a plan to “cohort” its residents. The Paramus home, if it had such a plan, had not fully implemented it.

To conserve PPE, the director of nursing explained to the inspectors, the aides were supposed to care for COVID-negative patients first, then those who awaited test results, and finally those who tested positive.

The problem was, the aides didn’t know who had tested positive and who was waiting for results. They knew a red STOP sign on the door meant that someone in a two-person room tested positive, but in several cases cited by the inspectors, they weren’t sure if it was the resident by the window or the one by the door.

By treating both roommates as if they were positive, the inspectors wrote, the aides were “increasing the exposure to COVID-19 to the resident awaiting test results.”

Meanwhile, each day when the aides finished their initial round of personal-care duties, they doffed their protective ponchos and proceeded to wear the same isolation gowns for the rest of their shifts as they treated patients without regard to whether the patient was positive, under investigation, or negative.

It’s now understood that microscopic droplets can linger in the air after an infected person talks, sneezes or coughs, spreading disease, and that infectious particles can lurk on frequently touched surfaces such as doorknobs and television remotes. Virus particles have been found in urine and feces. And an infected person can spread the virus even before they show symptoms.

All of this likely contributed to the spread of COVID-19 among staff and residents already considered vulnerable because of their age and underlying conditions.

Other lapses

It wasn’t just the patient-care providers who potentially spread the disease.

A housekeeper mopping residents’ rooms in the L wing was asked by inspectors if he did it in order, starting with rooms where the residents were COVID-negative and then going into the rooms where they were COVID-positive. He did not.

A supervisor explained that the housekeeper usually worked weekends in the laundry. He had been reassigned due to staff absences. The supervisor promised to “reeducate” him.

In the kitchens, an infection-control nurse sent by the federal Veterans Administration shared other concerns.

Hand-washing by the workers was inadequate, she wrote in an email to the department. Food “service workers need to wear masks and gloves” whenever they deliver or handle food, she wrote. Head coverings and masks were needed when preparing meals. Self-service items should be individually wrapped. And the dining hall was full — six tables with four or five people at each — with “no social distancing at all.”

Even the National Guard members who later helped transfer residents from one room to another needed instruction. “Handwashing has to improve at Paramus,” the VA’s infection-control nurse wrote.

‘Not how we intend to use the masks’

The challenges the coronavirus might present to nursing homes should not have come as a surprise. The devastating consequences of the infection at a Kirkland, Washington nursing home, near the first diagnosed case of COVID-19 in the United States, were national news. New Jersey also had a new law to help contain nursing home outbreaks after the much-publicized Wanaque deaths.

The estimate was 10,000 masks per home.

But Van Lew, director of the division of veterans’ health services, said in an email, “That is not how we intend to use the masks.” He predicted the number “will be much lower,” because “only those staff members working with a resident that is positive or presumptive positive for COVID-19 should be wearing the N95 mask.”

His edict matched guidelines from the federal Centers for Disease Control at the time. But it failed to protect the staff as the disease spread from those who hadn’t yet developed symptoms or were awaiting test results.

An anonymous staff member already had notified the federal Occupational Safety and Health Administration that the veterans’ home was “not providing PPE to employees working with patients with confirmed suspected [sic] COVID 19,” according to a March 31 letter Schottlander received from OSHA’s area director.

But the agency, part of the federal Department of Labor charged with protecting worker safety, never inspected.

Schottlander simply responded that the veteran’s home was “not denying anyone PPE.” All staff had been trained in its use, he emailed the agency. “Our facility is following CDC guidelines and our standard operating procedures for appropriate use of PPE” and managing its supply of PPE “strategically.”

In March, before the first cases were reported in Paramus, staff were told not to wear masks because it would scare the residents, staff said in interviews.

A nurse at the Paramus home said in an April interview with NorthJersey.com that when staff were given masks, they were told to use them far longer than the manufacturer recommended. “They gave us a mask to be used for one hour and told us to use it for four weeks.” she said. “Anybody knows it becomes penetrable with moisture.”

Furthermore, there were no in-service training sessions to learn how to use the PPE, she said. It was the outsiders — the Veterans Administration and other health officials — who held “how to wear your protective gear” classes every half hour, the nurse said, starting April 20.

As for the administrators of the Paramus veterans’ home, the nurse said, “They’re like a hundred clicks behind everybody.”

Making improvements

The Paramus home could have lost its ability to receive federal Medicare and Medicaid funding if it did not fix the problems that led to the “immediate jeopardy” citations before the inspectors left.

Veterans Administration nurses were already helping to plug the gaps in staffing, and National Guard troops were on hand to assist in non-clinical roles. They stayed for weeks.

At 6:45 p.m. on April 22, the inspectors observed that the signs were up, the amount of PPE had increased, the day room had been closed and cleaned, and most residents were in their rooms. They lifted the citations and left.

But by then it was too late. Forty six residents had already died.

And another 35 would die before the pandemic ran its course.

Dozens of families of residents and staff have filed notices in recent months of their intent to sue both the Paramus veterans home and another in Menlo Park where 62 residents have died from the virus.

Kryn Westhoven, a spokesman for the state agency overseeing the homes, said he could not comment on questions from NorthJersey.com on the inspection report due to the expected litigation.

Gov. Phil Murphy, whose administration oversees the facility, has said the Paramus home and another at Menlo Park were devastated by “an unfathomable onslaught of this virus.”

He promised a “post-mortem” investigation of what went wrong. But the consultants’ report he commissioned on the impact of COVID-19 at state nursing homes does not mention the state-run veterans homes.

In his recent video address, Van Lew, the division director for the state’s veterans’ homes, acknowledged that his institutions’ trials probably are not over.

He asked for continued support “as we battle through this global pandemic and prepare for the upcoming flu season in the end of August, with the possible resurgence of COVID virus.”

By Scott Fallon & Lindy Washburn