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Dear Doug Collins

The New Jersey Veterans Memorial Homes: The Virus Spread Virtually Unchecked

The residents of the New Jersey Veterans Memorial Homes at Menlo Park and Paramus were a defined and identifiable group: honorably discharged veterans — many elderly, many living with dementia — together with veterans' spouses and Gold Star parents, all living in nursing homes the State of New Jersey itself owned and ran. When COVID-19 arrived in March 2020, the two homes were near capacity, with a combined 648 beds. By the Justice Department's later count, 101 residents at Menlo Park and 89 at Paramus died of probable COVID-19 in the pandemic's first wave — 190 probable deaths — and the department concluded the real number was likely much higher and is, on the homes' own records, impossible to determine. What investigators described was not a facility overwhelmed despite doing the basics. It was, in their words, a systemic inability to implement clinical care policy, poor communication, and a failure to ensure basic staff competency that "let the virus spread virtually unchecked throughout the facilities" — and then a failure to hold the gains after outside help left, so that the same breakdowns were still observed during the Omicron outbreaks of 2021 and 2022. On September 7, 2023, the Justice Department found reasonable cause to believe the conditions violated the Fourteenth Amendment. This page is the record of what the state promised these residents, what happened inside the two homes, and what has — and has not — been done since.

The service and the promise

New Jersey’s obligation to house its veterans predates the modern state bureaucracy: the State Commission of Investigation (SCI), in its October 2023 report, traced it to 1866, when the New Jersey Soldiers’ Home opened in Newark for disabled Civil War soldiers. Today the Department of Military and Veterans Affairs (DMAVA) operates three Veterans Memorial Homes — at Menlo Park, in Edison Township; at Paramus; and at Vineland — providing housing and medical care for up to 948 residents. Eligibility, as the state publishes it, runs to honorably discharged veterans, a veteran’s spouse, and the spouses and parents of service members killed in action; residents pay according to ability, based on income. Paramus, opened in 1986, is the oldest building and can house 336 residents; Menlo Park has 312 beds, on the SCI’s count. Most rooms at both northern homes were double occupancy, with shared bathrooms — a layout the SCI found “was not designed or equipped to handle isolation or quarantine situations.”

The two northern homes are the subject of this page. The third home, at Vineland — rebuilt in 2005, in a part of the state the virus reached later and less severely — recorded far fewer deaths and was not part of the Justice Department’s investigation. The contrast matters: the same agency, under the same emergency, produced a markedly different outcome where the building allowed cohorting. What failed at Menlo Park and Paramus was a specific management, staffing, and oversight structure.

The promise had two layers. The first was the state’s own offer: around-the-clock nursing care in a home run for veterans, at a cost scaled to income. The second was constitutional. As the findings report put it, “the residents of the Veterans Homes have a Fourteenth Amendment right to conditions of reasonable care and safety” — enforceable under the Civil Rights of Institutionalized Persons Act (CRIPA). The homes were licensed by the state health department, surveyed annually by the U.S. Department of Veterans Affairs, and certified by Medicare and Medicaid. Few residents in New Jersey were owed more, by more overseers.

What happened

COVID-19 reached New Jersey in early March 2020, and the two homes within weeks. What the Justice Department’s findings report, the SCI’s investigation, federal Medicare surveyors, and the state’s own settlements together establish is a sequence in which each basic layer of protection failed in turn — protective equipment, separation of the sick from the well, monitoring of the exposed, honest counting, and honest communication with families — while staffing collapsed underneath all of it.

Protective equipment. In the first month, managers at the homes opposed staff wearing masks at all. Reporting based on internal emails, later pleaded in staff lawsuits, described administrators devising penalties for mask use with help from the Governor’s office, on the stated concern that masks might frighten residents. The findings report records that administrators threatened to discipline staff who wore protective gear. A March 18, 2020 email from a Menlo Park nurse to the home’s chief executive, later filed in the staff litigation, read: “residents [are] coughing in our faces … and we don’t have a mask to put on. We cannot care for them six feet away.” On March 30, 2020, the state health commissioner ordered universal masking for all nursing home staff. The Justice Department found neither home “successfully implemented that policy”: VA personnel who came to help observed staff unmasked or masked incorrectly, not changing protective equipment between rooms, and entering COVID-positive rooms without gowns. Days after a hand-washing directive, investigators found “broad deficiencies in handwashing” at both homes; Paramus housekeeping staff had not been trained to disinfect vacated COVID rooms, and at Menlo Park a VA staffer reported dirty nursing stations, uncleaned common areas, and “ants/bugs everywhere.”

Cohorting. The homes failed to group residents by exposure — the cohorting that keeps confirmed cases, exposed residents, and the uninfected apart — and congregate life continued inside units where the virus was already present. The federal administrative record for Paramus is specific: on April 20 and 21, 2020, a Medicare surveyor observed dementia-unit residents — including COVID-positive residents — congregating in the day room without masks or social distancing, while staff said nothing could be done to make them mask or distance. The Department of Health and Human Services decision reviewing the citation records a second finding from the same weeks: on April 11, 2020, Paramus staff incorrectly identified a deceased resident as his roommate, and the living roommate as the deceased — the mix-up, involving a 91-year-old Korean War veteran new to the home, that federal officials cited at the most severe “immediate jeopardy” level. His son told public radio he had been assured that morning that his father was doing well, hours after his father had died.

Monitoring. The homes failed to watch exposed residents for symptoms. The findings report’s fullest case is a former Marine at Menlo Park, identified as Resident C, who in early 2020 was alert, spoke with his family daily, and led an art class. On April 4, 2020, his roommate was hospitalized with suspected COVID-19 and died two days later after testing positive. “There is no evidence that Menlo Park monitored Resident C for COVID, even as his condition declined in the days after his roommate’s positive test,” the report states. On April 5, staff took his scooter without explanation and closed his door, leaving him unable to reach his call buzzer or his cell phone. On April 6 he was noted to be confused, was given antibiotics for pneumonia, and was heard yelling for help; he developed a fever and died on April 16, with no mention of COVID-19 in his chart. When his family later asked whether his roommate had had COVID, they were told “no.”

Staffing. Underneath the clinical failures, the workforce collapsed. The SCI found attendance dropped by nearly half in the early weeks; call-outs rose 100 percent at Paramus and 480 percent at Menlo Park between early March and mid-to-late April 2020, with no realistic replacement strategy — agencies would not send nurses at the state’s fixed per diem rates. The Justice Department recorded Menlo Park shifts on which a nurse was responsible for as many as 100 residents. One worker described Paramus as “pure hell”; another described Menlo Park as “a battlefield.” A certified nursing assistant at Menlo Park, Monemise Romelus, died of COVID-19 in May 2020 at 61; her family said she had not been provided masks or other protective equipment, and her survivors later joined the staff litigation. Emergency help did come — National Guard medics and some 90 VA nurses across the state’s veterans facilities — and conditions improved while it was there. The findings report’s structural conclusion is that the homes “did not maintain improvements achieved after the U.S. Veterans Affairs department came in to help.”

The count, and the families. In April 2020 alone, 98 residents died at Menlo Park and 92 at Paramus — 190 deaths from all causes in one month, in homes where roughly 100 residents a year had died before the pandemic. The COVID figures the state published as of July 2020 — 81 deaths at Paramus and 65 at Menlo Park — understated the toll, the Justice Department found, because testing was scarce early, probable deaths were not systematically tracked, and gravely ill residents were transferred out in ways that further obscured the count. The department’s reconstruction arrived at 101 probable COVID deaths at Menlo Park and 89 at Paramus in the first wave — the first- and fourth-deadliest long-term care facilities in New Jersey on publicly reported numbers — and concluded the exact number “is impossible to determine” and the true number “likely much higher.” The SCI’s footnote states the same figure independently: at least 190 COVID-related deaths at the two homes.

To the families, during the worst weeks, the homes said very little, and some of what they said was wrong. The findings report describes an “information blackout”: a defensive and occasionally hostile posture toward relatives, and families, in its account, lied to about causes of death. The SCI, which interviewed 60 people including relatives of the dead, recorded the same pattern from the other side of the phone: a sister told her brother did not have COVID and was fine, shortly before he died — and who, collecting his belongings, was met by a staff member who said they were looking for him, because the home did not know he had died; a daughter told her father was fine less than 24 hours before his death, who had to press staff to test her mother and who, after her mother’s death, was given dentures that belonged to someone else.

The failures persisted. The finding that distinguishes this case from a first-wave disaster is the Justice Department’s second one: the breakdowns did not end in 2020. The department documented infection-control failures continuing into the Omicron outbreaks of December 2021 and 2022 — including, at Menlo Park in December 2021, multiple staff infections followed shortly by new resident infections on the same units — and, on a February 2022 site visit to Paramus, unmasked security guards at the front door, staff on quarantined units without full protective equipment, and infection-control nurses who misunderstood standard practice. The homes, it concluded, were still not training staff properly or monitoring compliance — “substantial departures from generally accepted standards of care.” Medicare’s inspectors reached the same verdict at Menlo Park: an eight-day survey in August and September 2022, examining an outbreak begun the previous November — 76 residents and 225 staff infected, 17 resident deaths on the state’s outbreak list — found residents in “immediate jeopardy,” with failures in testing, contact tracing, and training, and a nurse who did not know how to remove a urinary catheter — a case in which, the Justice Department recorded, the resident then went 15 days without prescribed antibiotics and acquired further infections including MRSA. Medicare cut off payment for new admissions effective November 22, 2022, and warned the home could be terminated from Medicare and Medicaid by March 2023. Beyond infection control, the department documented deficient ordinary care: care plans not created, fall-prevention protocols not followed, medications not properly administered, and wound and pressure-injury care inadequate to treat or prevent bedsores.

What the institution did afterward

The first institutional response was personnel. In October 2020, with the death toll at the three homes above 140, Governor Phil Murphy removed the leadership: the adjutant general and DMAVA commissioner, Maj. Gen. Jemal Beale, was replaced by Brig. Gen. Lisa Hou, a physician; both homes’ chief executives were dismissed, along with their division director. The Justice Department notified the state on October 27, 2020, that it was opening a CRIPA investigation; the state Attorney General opened its own investigation, with a grand jury reported impaneled. The SCI began its inquiry the same month, then paused for nearly two years in deference to the concurrent criminal investigations.

Money moved faster than findings. In December 2021 the state agreed to pay $52,955,000 to the families of 119 residents who died — an average of roughly $445,000 per family — resolving, before suit was filed, claims accusing the state of gross negligence; the families’ lead attorney, Paul da Costa, noted it was believed to be the first settlement of its kind in the nation, reached despite the broad immunity New Jersey had granted nursing homes acting in good faith. A second settlement, $15.9 million to 71 more families, followed in 2022 — about $69 million to 190 families, without the evidence in those cases ever being presented in open court.

Operational rescue was attempted in layers — a Mission Critical Team to Menlo Park in November 2022, a directed search for an outside vendor to manage systemic change, and, by 2023, private management for the two homes — but none of it ended the violations before the Justice Department reported.

On September 7, 2023, the Civil Rights Division and the U.S. Attorney for the District of New Jersey issued their findings: a 43-page report and formal CRIPA notice concluding there was reasonable cause to believe New Jersey “operates the Veterans Homes in a manner that fails to adhere to basic infection control practices, provide adequate medical care, and ensure competent leadership and oversight,” violating the Fourteenth Amendment, and setting out the minimum remedial measures required. Assistant Attorney General Kristen Clarke said the facilities had provided “inadequate protection from infections and deficient medical care.” U.S. Attorney Philip R. Sellinger said the homes “fail to provide the care required by the U.S. Constitution.” Governor Murphy called the report “a deeply disturbing reminder that the treatment received by our heroic veterans is unacceptable and, quite frankly, appalling,” pointed to his administration’s improvements and private management, and said “it is clear that we have significantly more work to do.” A month later the SCI issued its final report, corroborating the federal account and adding the staffing collapse, the failure to communicate changing CDC guidance to the homes’ managers, and the absence of any system for communicating with families; it recommended prioritizing conversion of both homes to single-bed rooms.

The legal resolution came a year after the findings. In September 2024 the United States filed a civil complaint alleging the deficiencies continued, and jointly with the state filed a proposed consent decree; the court ordered the decree on October 3, 2024, in United States v. State of New Jersey, No. 2:24-cv-09577. The decree records that the state disputes the CRIPA conclusions, and its entry was not an admission of liability. What the state accepted was enforceable: specific standards across twelve areas of care — from general medical and nursing care, care plans, wound and pressure-injury care, medication administration, and falls, to infection prevention, quality assurance, emergency operations, and staffing and organizational accountability — including a full-time on-site infection prevention program, protective-equipment use, testing and isolation protocols, hand hygiene, and a rehearsed outbreak plan. The parties agreed The Hibiscus Group would serve as independent monitor, with announced and unannounced inspections and full access to facilities, staff, and records. The decree’s clock required substantial compliance with a first group of sections within six months, a second within one year, and all provisions within two years of October 3, 2024; it terminates only when the parties certify substantial compliance attained and maintained for a year, with a court hearing as backstop at five years. Sellinger called it “a detailed roadmap and expert oversight”; Clarke stated its purpose in the families’ own terms: veterans deserve appropriate care, “and their families deserve to have confidence that their loved ones’ needs will be met.”

Where it stands now

The monitor’s first-year report — The Hibiscus Group’s second report, the first with paragraph-by-paragraph compliance determinations — was filed on January 23, 2026, after nine on-site visits to Paramus and seven to Menlo Park. Its summary is that “both Veterans Homes continue to make progress toward achieving compliance.” Its determinations are more specific, and they are not a passing grade. At Paramus, the monitor found substantial compliance in three of twelve areas — emergency operations and preparedness, staffing, and organizational accountability — and not yet in the other nine, including infection prevention, detection, and control. At Menlo Park, it found substantial compliance in six — oversight and management of medical care, infection prevention, quality assurance, emergency operations, staffing, and organizational accountability. At both homes, the areas not yet in substantial compliance include the clinical core of the case: general medical and nursing care, monitoring for changes in condition, resident care plans, vascular wound and pressure-injury care, medication administration, and fall prevention. At Paramus the monitor also documented records that did not withstand clinical scrutiny and a resident who refused medication for seven consecutive days without the required physician notification. The decree’s two-year deadline for substantial compliance with all provisions fell on October 3, 2026; on the January 2026 determinations, neither home was on a documented path to have met it in full, and monitoring continues in six-month reporting periods.

Against that, the state can point to narrower, real improvements, recorded here as the state states them. In September 2024 both homes achieved zero deficiencies in no-notice focused infection-control surveys conducted for the federal Medicare agency. DMAVA reports new electronic medical records, thousands of hours of training delivered, higher frontline wages, full-time resident advocates, and the single-occupancy conversion approaching 95 percent design, awaiting a federal decision on the 65 percent construction-grant match. McKnight’s likewise noted a turnaround at Menlo Park including a five-star overall Medicare rating; that rating coexists in the record with the monitor’s finding that Menlo Park had not yet reached substantial compliance in six of twelve areas.

The individual account is the thinnest part of the record. The October 2020 removals were employment actions, announced without reasons beyond a leadership transition. The Attorney General’s investigation and the reported grand jury produced no charges appearing in the public record: as of November 2022, reporting on the Paramus whistleblower David Ofshinsky — the home’s former business manager — recorded that the federal and state investigations “have so far produced no charges,” and the SCI in October 2023 noted only that it had deferred to concurrent criminal investigations, “some of which remain ongoing” at that time. No later announcement of charges, or of a formal declination, has been located for this page. What accountability litigation remains is civil, and it belongs substantially to the staff: the lawsuits by employees who say they were ordered not to wear masks — 42 staff members or their families, including Romelus’s survivors — survived the state’s immunity defenses when a Superior Court judge held immunity was not meant to shield gross negligence, recklessness, or willful misconduct, and that the intentional-wrong question belonged before a jury; McKnight’s reported the order sending that case to trial. Two further whistleblower suits filed in 2025 and 2026 allege retaliation for raising concerns that included decree-compliance problems; they are recorded here as allegations, not findings.

The defined group at the center of this page is smaller than it was. The two homes that were near capacity in March 2020 averaged about 376 residents combined in 2022, and the SCI counted fewer than 200 at Paramus in 2023. The residents who remain live under a federal court order written because the ordinary systems — state management, state licensing, annual VA surveys, Medicare certification — each operated throughout the period in which the Justice Department found constitutional violations, and none of them stopped it. The decree’s test is the one its monitor now applies, area by area: not whether the homes can pass a scheduled survey, but whether the care itself — wounds, medications, falls, infections, and a nurse who notices a change in condition — meets the standard, sustained for a year, under outside eyes.

The ledger

The accounting, in three lines — what the record shows has been done, what it shows has not, and what is still being sought.

What has been done

What has not been done

What is being sought

The record, on video

The video record that could be verified for this page is thinner than the paper record, and this page does not pad it. The U.S. Attorney’s own video statement on the consent decree is linked from the Justice Department’s announcement (and cited in the Sources below), but the film itself could not be verified as publicly playable when this page was built, so it is not embedded. What the wall carries is NBC News’s contemporaneous report on the outbreak, from the summer of 2020 — the event itself, reported while the first-wave toll was still being revised upward. One film.

The outbreak. NBC News's report "NJ Veterans Home COVID-19 Cases," first aired July 3, 2020, as catalogued by the firm that represented the families — contemporaneous coverage while the first-wave toll was still being revised upward. (NBC News.)

Sources

Part of Betrayed, Not Forgotten — this site's accounting for the service members and veterans their own institutions failed. Videos are embedded from their publishers; nothing here is re-hosted.