Investigators commissioned by Gov. Tom Wolf’s office have condemned the former managers of the Southeastern Veterans’ Center, a state-run nursing home in Chester County, for inadequate precautions against COVID-19, which “swept through the facility like wildfire” this spring and caused the deaths of 42 residents.

The report, released Thursday, said the staff at the facility, then led by Commandant Rohan Blackwood, and Deborah Mullane, the director of nursing, failed to properly plan for the virus, did not stop communal dining early enough, and did not properly isolate its residents to slow the spread of COVID-19 within the facility, among other critical errors.

“The response at SEVC was not well-planned, coordinated, or effective,” the report said. “On the contrary, SEVC mishandled its response to COVID-19 in many significant ways, which contributed tragically to the heartrending events that occurred there.”

Blackwood and Mullane were fired on Dec. 23.

The two had been suspended since May after reports in The Inquirer, citing internal documents, on the high number of coronavirus deaths at the East Vincent Township nursing home during the first wave of the virus — as many as four a day. Residents’ families, meanwhile, were largely kept in the dark.

» READ MORE: ‘It’s a sinking ship’: COVID-19 deaths triple at state-run vets nursing home in Chester County as families clamor for information

Blackwood’s management style was described by more than a dozen former and current employees in the articles as autocratic, and often inept. In the five years he ran Southeastern Veterans’ Center, the facility recorded several high-profile incidents, including residents escaping and a fight between two dementia patients that left one with fatal injuries.

Investigators exonerated Blackwood and his subordinates in one area: There was no evidence, they wrote, to substantiate accusations by staffers at the facility that supervisors had altered medical records related to COVID-19 or attempted to underreport the number of deaths from the virus at the facility.

The report released Thursday, completed by Morgan, Lewis & Bockius LLP, makes similar observations as the articles, finding that the management culture at the facility seemed “concerned more with managing perception than getting things done,” had “a woeful lack of accountability,” and practiced poor communication both internally among its staff and with residents’ families.

“While the toll of COVID-19 could not have been avoided in its entirety, there is little doubt that this horrible tragedy could have meaningfully been ameliorated and mitigated if not for these failures,” the report said.

» READ MORE: Sources: Two top officials at a Pa. veterans nursing home hit by 37 coronavirus deaths are suspended amid an investigation

The release of the report, on New Year’s Eve, comes a week after the families of five SEVC residents who died of COVID-19 filed a lawsuit in federal court, alleging that the operators of the facility had failed to protect them and dozens of other residents who succumbed to the virus.

The lawsuit names as defendants the Pennsylvania Department of Military and Veterans Affairs (DMVA), which runs the state’s six nursing homes for veterans, as well as Blackwood and Mullane.

» READ MORE: Pa. auditor general confirms botched coronavirus efforts at veterans’ nursing home, calls on Gov. Wolf to finish investigation

Last month, Pennsylvania Auditor General Eugene DePasquale released a report confirming the key findings of Inquirer articles in April and May that reported that the 238-bed home had taken a lax approach to the pandemic, with supervisors discouraging nurses and aides from wearing masks to avoid frightening the service veterans.

DePasquale’s report also backs a state and federal health inspection report, published in July, which found that SEVC officials placed elderly residents in “immediate jeopardy” by ignoring infection-control guidelines, while instilling a fear of retaliation that discouraged staffers from speaking out.

As details about this mismanagement came to light in the spring, Maj. Gen. Anthony Carrelli, who as adjutant general for Pennsylvania oversaw the state’s six veterans’ homes, told a state Senate committee that he was concerned by The Inquirer’s articles about conditions at SEVC and asked the state and county to inspect the facility.

But Carrelli’s tenure with the state ended before that inspection was completed — he retired abruptly on Dec. 5.

» READ MORE: Pa. National Guard leader abruptly retires amid investigations into veterans’ nursing home, Horsham air base

Neither Wolf nor Carrelli provided an explanation for his retirement, but Carrelli was embroiled at the time in two simultaneous investigations over facilities he oversaw: the deaths at SEVC, and reports of sexual harassment and retaliation at a National Guard station in Horsham.

Blackwood and Mullane, through their attorney, David Heim, rejected many of the report’s findings and said they had been “purposely deprived” of the opportunity to respond fully because they had only recently been shown the report.

In a written response, Heim wrote that the report “omits numerous material facts and is completely lacking factual context.” He described it as a case of “clear political scapegoating of Mr. Blackwood and Nurse Mullane, all designed to detract attention from the systematic failures of the Governor’s Office, the Department of Health and the leadership of the Department of Veteran’s Military Affairs in properly responding to this pandemic’s catastrophic effects on the elderly veterans residing in the Department’s nursing homes.”

Heim also said Blackwood and Mullane, who had previously received high marks on their performance reviews, had repeatedly asked state leaders for more staffing and the deployment of the National Guard, but they had been essentially ignored until the National Guard arrived on April 15.

The Pennsylvania Department of Military and Veterans Affairs, which oversees SEVC and the five other state-run homes for veterans, released a statement saying it has put in place “most of the recommendations in this report that could be implemented immediately and is now in the process of reviewing and implementing additional recommendations, to include a review of its organizational structure; crisis management; communications; and infection control procedures.”