SPRINGFIELD, Ill. (CBS/AP) — A scathing watchdog report detailed the “inefficient, reactive and chaotic” response to a COVID-19 outbreak last fall at the LaSalle Veterans’ Home in central Illinois, resulting in 36 deaths.

The 50-page report by the Illinois Department of Human Services’ Office of the Inspector General and the law firm of Armstrong Teasdale determined former Illinois Department of Veterans Affairs Linda Chapa LaVia “abdicated her authority” to her chief of staff, who has no experience in long-term care, infection control procedures, or medicine in general; and was essentially handling the duties of the senior homes administrator post that had been left vacant for two years.

READ MORE: Elmhurst University Student Charged With Making Up Story About Man With Gun That Sent Campus Into Lockdown For Hours

The report said Chapa LaVia’s chief of staff essentially allowed each of the state’s veterans’ homes to manage itself, and the department’s leadership team did not provide staff at the homes with “cohesive directives or guidelines related to COVID-19.”

Consistent statewide procedures and ongoing drills that target infection response and other emergencies now will be routine at Illinois veterans’ homes after that outbreak at the LaSalle Veterans’ home led to 36 deaths, the state’s newly appointed director said.

Illinois Republican Party Chairman Don Tracy said the inspector general’s report “outlines a simply unforgivable lack of judgment and leadership on the part of Governor Pritzker, his administration, and the head of his veterans’ care agency.”

“While there were failures at all levels in containing and responding to this devastating outbreak, the Governor must answer for his appointment of an unqualified political ally as Director of the Illinois Department of Veterans’ Affairs and why she was still on the job weeks after deadly decisions by her department were made public. The public and the families of these American heroes deserve answers now,” he said in a statement.

Gov. JB Pritzker, who hired Chapa La Via to run IDVA after he took office in 2019, said he chose Chapa LaVia to run IDVA after he took office in 2019, because she had led an investigation into a deadly Legionnaire’s disease outbreak at the Quincy Veterans’ Home in 2015.

“So she seemed like an ideal person to be able to root out the problems in our veterans’ homes, but I have to admit that if I knew then what I know now I would not have hired her,” Pritzker said Friday morning.

Pritzker said every death from COVID has been a tragedy, “but nothing is more devastating to me than knowing that 36 of our veterans – our heroes – died of COVID in a single veterans’ home.”

The governor said the recommendations in the IG report confirmed changes need to be made, and he said IDVA began making reforms months ago in response to the deadly outbreak at the LaSalle Veterans’ Home.

After Chapa LaVia resigned in January, Pritzker appointed Terry Prince, a 31-year Navy veteran and former senior adviser to the U.S. Surgeon General,  to run IDVA. Prince has issued a six-point plan for improving readiness at the state’s veterans’ homes in Anna, Manteno, Quincy and LaSalle.

The report by the inspector general of the Illinois Department of Human Services, released Friday, noted that despite escaping all traces of the deadly respiratory illness for eight months after it entered Illinois, there was little done to devise protocols for preventing or managing infections. After the first four cases were reported Nov. 1 at the LaSalle home, the virus spread to dozens of residents and employees as confused staff operated in an environment that was “inefficient, reactive and chaotic,” the report said.

READ MORE: City Panel Backs $97 Million Sale Of Vacant Michael Reese Hospital Site For Massive 'Bronzeville Lakefront' Development

“We need to train as if it’s always happening,” said Prince, who arrived in Illinois on April 1 from his post as superintendent of the Ohio Veterans Homes, where he administered three facilities. “When there is an absence of the virus we train even harder, so that when something does come to fruition, our people know exactly what to do and how to do it.”

The review found ineffective, alcohol-free hand sanitizer in abundant use and no one responsible for replacing it, staff members reporting for duty by taking their own temperatures and initialing results, and scant availability and use of personal protective equipment such as face coverings.

Confusion over evacuating a wing to prepare it for quarantining and other errors such as placing residents who tested positive for the coronavirus in a room with others who were not sick, then not monitoring the newly exposed residents afterward, compounded the problem.

Among Prince’s other initiatives are plans to develop clear, statewide policies applicable to each home; restructuring senior leadership with chain-of-command clarity and assurances that the homes are receiving proper clinical and administrative direction; filling key positions whose vacancies have doubled work for others; and providing all employees with an email address for receiving agency-wide notices and communicating their concerns.

Infection control will be a priority with the hiring of a director and creation infection-control committees at each home following standardized guidelines, Prince said.

“It’s always been important but it did come to light, over the course of this crisis, the significant amount of work that’s involved in being an infection control specialist,” Prince said. “Prior to COVID-19 you would deal with things like pneumonia, flu, MRSA … they were often a case-by-case basis. When COVID hit, you’re not only monitoring residents you’re monitoring every staff member who works there.”

The crisis struck LaSalle well into the period of COVID-19 entrenchment, and a year-and-a-half after a state audit recommended adopting consistent statewide policies as a result of a Legionnaire’s disease outbreak at the Quincy Veterans’ Home which led to 14 deaths and sickened more than 70 others. In December, the home’s director, Angela Mehlbrech, was fired and at Gov. J.B. Pritzker’s behest, the investigation was underway.

After three hours of critical questioning by a House committee in early January, director Linda Chapa Lavia, an Army veteran who had been a long-tenured member of the House herself, resigned.

LaSalle was not alone. There have been 15 COVID-19 deaths at Manteno and 25 at Quincy. Prince noted the enormity of dealing with “a worldwide virus that doesn’t play fair.”

“It spread across the country with a fierceness that no one could have ever predicted and unfortunately veterans homes across the nation were struggling in the same situation,” he said.

MORE NEWS: Stimulus Check Update: Is A Fourth Relief Payment Coming?

(© Copyright 2021 CBS Broadcasting Inc. All Rights Reserved. The Associated Press contributed to this report.)

CBS 2 Chicago Staff