Recently, the Department of Veterans Affairs released inspection reports of 99 VA nursing homes across the country, and the results are staggering. Out of the 99 VA nursing homes inspected, 52 were cited for deficiencies that caused “actual harm” to veterans.

Inspectors the nursing homes from April through December 2018. Eight facilities were found to have caused “harm” to veterans as well as put the veterans’ health and safety in “jeopardy.” In three facilities, the inspectors found the veterans’ health and safety was in “immediately jeopardy.”

The inspectors found that the staff at over two dozen VA nursing homes failed to take steps to ensure that their residents’ pressure ulcers had properly healed or to prevent new ones from developing. In a VA facility in Cincinnati, a resident had five bedsores in six months, but in spite of this the inspectors found that no one had moved him for several hours.

In more than 50 veterans’ homes, inspectors found that the residents weren’t being properly monitored by staff or were exposed to hazardous conditions. In addition, many VA nursing homes failed at taking steps to prevent and control infection, arguably one of the most fundamental responsibilities in caring for already at-risk patients.

Inspectors found that two out three VA nursing homes the staff often didn’t follow simple infection prevention protocols, like wearing sterile gowns and gloves when treating residents. They also cited several VA nursing home for failing to meet standards of care in as many as 10 key categories, such as treating residents with dignity.

More than seven years ago, the Government Accountability Office had published a report to the U.S. Senate, which found that a high percentage of veterans at the facilities were in pain. Unfortunately, this trend does not seem to have changed much, as inspectors in 2018 cited 29 VA facilities for failing to ensure their residents weren’t suffering from serious pain.