SPRINGFIELD, Ill. (AP) — Sluggishness, poor compliance with existing rules and little help from state public health officials crippled the response by Gov. J.B. Pritzker’s administration to a November 2020 COVID-19 outbreak at a northern Illinois veterans home that claimed 36 lives, according to a state audit released Thursday.

The review by Auditor General Frank Mautino contends the Illinois Department of Public Health “did not identify and respond to the seriousness of the outbreak.” For nearly two weeks after the problem was identified Nov. 1 at the LaSalle Veterans Home, IDPH officials failed to visit the site and offered no assistance. LaSalle staff testing for the virus was slow and poorly coordinated, the review said.

In total, 85% of the home’s 128 residents and 38% of its 231 staff members contracted the illness during the outbreak, which Mautino noted occurred when infections statewide were rising rapidly and there was yet no preventive vaccine.

Pritzker, a Democrat, blamed Republicans who opposed tactics to stop the spread of COVID-19.

“We were working against Republican elected officials who told people to defy mitigation efforts. We told people that they needed to follow those mitigations,” Pritzker told reporters at the Capitol. “Republicans told them that they did not need to wear masks. They told people that they didn’t need to get vaccinated. They told people that COVID wasn’t serious. Those lies put people’s lives at risk, especially the most vulnerable.”

Pritzker suggested LaSalle visitors who refused to comply with safety measures such as face coverings and social distancing unwittingly carried the virus into the LaSalle nursing home.

An April 2021 report by the inspector general of the Department of Human Services reported that during an onsite visit, which didn’t occur until Nov. 12, officials discovered 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.

Pritzker, who later acknowledged “some management faults” were to blame and said that as governor, “I understand that these agencies are my responsibility,” maintained that he held staff accountable, including firing LaSalle director Angela Mehlbrech in December 2020.

However, he said that to the extent that IDPH is at fault for not providing more assistance, the agency controlled the entire state response during the pandemic’s worst surge and was dealing with hot spots in every direction. But at no time during the fall of 2020 or at any time during the pandemic did Pritzker or his team suggest IDPH was couldn’t keep up.

Rep. Lance Yednock, an Ottawa Democrat who led the House call for Mautino’s audit, lamented a breakdown in inter-agency coordination to respond rapidly and which “very likely led to more sickness and deaths. It also underscores the terrifying speed of infection we saw at COVID-19’s peak and acknowledges even the best preparation and planning might not have been enough to prevent more infection.”

Mautino’s auditors found fault with last year’s inspector general’s report, contending it was over-reliant on investigative interviews and paid too little attention to paper trails, the auditor general’s forte.

It resulted in a stunning turnabout in the assessment of then-Veterans Affairs chief of staff Anthony Kolbeck. While the inspector general’s review tainted him for insufficient tracking of the problem, Mautino reviewed scores of emails and determined that Kolbeck was in regular contact with the Public Health Department the first two weeks of November. When IDPH didn’t act, the audit said Kolbeck requested the agency make a site visit and sought information on rapid tests and antibody treatments.

Kolbeck nonetheless resigned in the weeks following the outbreak’s fallout. So did then-Veterans Affairs Director Linda Chapa LaVia, whom Pritzker replaced in spring 2021 with Terry Prince, a 31-year Navy veteran and former senior adviser to the U.S. Surgeon General.

The inspector general’s report blamed the “absence of any standard operating procedures” for dealing with COVID-19. Conversely, Mautino said that in addition to general infection control policies in place prior to the pandemic, his team uncovered hundreds of pages of COVID-19-specific guidance from IDPH and the federal Centers for Disease Control and Prevention and specific guidelines for LaSalle developed as early as March 2020.