Conditions at Spring City, Pa.-based Southeastern Veterans' Center placed 128 of 154 residents in immediate jeopardy, a June inspection found, as reported by The Washington Post.
For several months, administration at the nursing home didn't have safety plans for managing sick patients, conducting contact tracing or protecting residents from infection, according to a 92-page report by the Pennsylvania Department of Health.
"We weren't allowed to wear PPE, or we would get written up," a staff member told an inspector, according to the report. "We were told it would scare the residents."
Workers exposed to COVID-19 were placed on units with healthy residents, and a nursing aide came back to work two days after she tested positive for COVID-19, the inspection found. The report also details a lack of hand-washing and a failure to clean equipment and enforce social distancing.
The report tied many of the issues to the home's former commandant and the director of nursing. Both were suspended in May.
Hydroxychloroquine was given to numerous patients, though the new report does not mention the use of the anti-malaria medication, according to the Post. It's not known whether the drug contributed to any fatalities at the facility, which has recorded 42 COVID-19 deaths.
A spokesperson for the state Department of Military and Veterans Affairs, which operates Southeastern, said the department has submitted a request to dispute the report findings.
A temporary outside management team has been hired to help until staff recover to normal operations, Department of Military and Veterans Affairs communications director Joan Zlogar Nissley wrote in an email to the Post.
The facility has filed a plan of correction. It's currently unknown if the home will face fines or other penalties.