This past year, as Stephen Mastropietro agonized over whether to put his father in a nursing home. His father, a 91-year-old Korean War veteran, was struggling with dementia and loneliness, and had stopped eating. 

Mastropietro finally decided to place his father in the Veterans Memorial Home in Paramus, N.J., and he felt good about it. His father felt less isolated, and began eating again. It was early February.

Then the pandemic hit. 

In March, the state-run veterans home told Mastropietro the facility was free of coronavirus infections. But Mastropietro saw on the news that 20 residents had died in one week. Soon after, his father got sick. Mastropietro checked in every day, and was told his father was doing fine.

“And then I called Saturday morning, and it was the same conversation again:‘He got up, he walked, he went to the bathroom, he ate.’ And I’m like, wow, maybe he’s doing okay, he’s going to pull through this,” Mastropietro said.  “Two hours later they called me and they say, ‘We made a mistake, your father died this morning.’ So it was rather shocking.”

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Next, Mastropietro learned his father’s body had been delivered to the wrong funeral home, under the wrong name. On one wrist was the ID bracelet that Mastropietro had made for his father when he lived alone, in case he got lost.  On the other wrist was an ID the nursing home had mistakenly attached to his father. That’s when the scope of the catastrophe hit him.

“Overall, they just weren’t honest or transparent on how bad the place was,” Mastropietro said. “And they didn’t give myself or other people the ability to make a decision on what to do properly. Looking back, I would have done it differently, knowing how bad the situation was.”

So far, 78 veterans have died at the home from COVID-19, the largest number for one long-term care facility in New Jersey. But the lack of transparency and chaos characterizes the response at many of the state’s nursing homes. More than 5,000 people connected to long-term care in New Jersey have died from Covid-19 -- half of all the Covid deaths in the state.   

The phone has been ringing off the hook at the office of the New Jersey Long Term Care Ombudswoman, Laurie Facciarossa Brewer. She says she’s getting two types of complaints. 

“One is, ‘I can’t get through on the line, I can’t get a hold of my mother or my father, I think they’re sick,’” Facciarossa Brewer said. “And the other type of call is from residents themselves who are in facilities where staff are calling out, or staff are getting sick and people are not getting fed, people are not getting bathed.”

After 17 bodies were found in a makeshift morgue at the Andover Subacute Care and Rehab Center over the Easter weekend, a federal inspection found improper mask use and a lack of handwashing. But the unions that represent nursing home staff say it’s not fair to blame workers, who weren’t provided protective equipment in the first month of the epidemic and work in facilities with staffing shortages. 

“You have health care workers who go to work every day, who are paid substandard wages, who are looking at people getting sick and thinking, ‘I could make more over there at Amazon,’” said Debbie White, president of the Health Professionals and Allied Employees union. “So now you have a population that's vulnerable and now they're overloaded because they've seen people leave the profession. And it's a recipe for disaster.”

For the past decade, the union has been advocating for more state funding for the New Jersey Department of Health, which regulates and inspects long term care facilities. The New Jersey ombudswoman, Laurie Facciarosso Brewer, agrees that more state oversight is needed, but she says more is needed from the federal government as well. 

“Certainly, if there’s any silver lining to this horrible pandemic, I hope that it is that the federal government decides to step back from loosening the regulations on long term care facilities, which is what they were planning to do before this all hit,” she said. “This is an industry that cannot self police.” 

The nursing homes say this epidemic hit them harder because they care for the frail, the elderly and sick populations, and they do it in close quarters. But this isn’t the first time that problems have surfaced. 

In 2018, an adenovirus outbreak killed 11 children in a long-term care facility in Wanaque, N.J., and the state pledged to do more. The legislature passed new regulations, but balked at spending more money on enforcement

Now Governor Phil Murphy is playing catch up. He’s requiring facilities to test every resident, report their cases to the state and alert family members. And he called in the National Guard to help nursing homes to make meals and provide army medics. His frustration has been apparent during many of his daily press briefings.

“The inconsistent performance by operators in the long-term care facilities space is extremely disappointing, that’s a diplomatic word,” Murphy said at a press briefing recently.  

This week, Murphy has asked the federal Veterans Administration to send a team to the three veterans homes in New Jersey, and he appointed a team of experts to figure out what went wrong across the system.  His health commissioner, Judy Persichilli, acknowledged on Thursday that statewide change is needed, and attributed much of the crisis to the shortage of masks, gloves and gowns. 

“At the end of the day, the tragedy of long term care will haunt us for a long time,” she said. “But we will definitely put things in place to prevent that from happening again.”