The New Hampshire Veterans’ Home

The New Hampshire Veterans Home, shown on Nov. 18.

A state examination of infection control at the Tilton Veterans Home, released Thursday, offers no insight into what went wrong in November and December as one of the state’s deadliest COVID-19 outbreaks raged.

Ninety-two residents were infected, out of about 130 who lived in the Veterans Home last November, when the outbreak began.

The outbreak left 37 veterans dead — more than a quarter of those who lived in the facility. Only the outbreaks at the much-larger Hillsborough County Nursing Home in Goffstown have claimed more lives.

The Veterans Home outbreak finally ended on Jan. 25, a few days after most residents had received the second dose of a COVID-19 vaccine. The report noted 96% of all the Veterans Home residents have been vaccinated.

At private and county nursing homes, federal inspectors from the Centers for Medicare and Medicaid Services have visited in the days after an outbreak ends, reviewing records of patient care and assessing the nursing home’s safety.

Officials from the Bureau of Infectious Disease Control within the state Department of Health and Human Services visited the Veterans Home on March 12, almost two months after the outbreak ended.

Using a rubric from the Centers for Disease Control and Prevention, state officials ran through the home’s current infection control measures. The inspection did not look back to the time of the outbreak.

The report covers use of protective gear, cleaning practices, and the isolation of residents who are infected with COVID-19 or suspected to be sick with the virus.

N-95 respirators, the tight-fitting masks that health care workers use to block virus particles, are still in short supply, the report said. Veterans Home staff still re-use the respirators for five days, the report noted.

The Veterans Home staff, the report said, do not always follow infection control procedures, and the report noted that “staff compliance” with infection control measures has been the biggest challenge.

According to the report, just one staff member has been trained in infection control. That staff member is not an administrator, but is engaged in direct patient care.

The report did not address staffing levels,

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