Gov. Wes Moore on Wednesday blasted a private health care contractor for abusing and neglecting veterans residing in a state-run assisted living and skilled nursing facility, announcing the state has taken steps to terminate the 21-year relationship.

The state has paid HMR Maryland LLC hundreds of millions of dollars in federal funds to oversee management and operations of the 454-bed facility going back as far as 2002. The governor said the state will look to hire a contractor to replace HMR.

Moore did not provide specific examples but called the conditions at Charlotte Hall Veterans Home in St. Mary’s County a “moral failure of government,” and admonished the administration of his predecessor, Larry Hogan, for not briefing the Moore team on the poor conditions.

Moore’s statement comes as his administration has prioritized rebuilding state government after Hogan’s administration left open an estimated 6,500 state jobs. The term-limited Republican regularly contracted with private firms to perform state work.

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The state contracted with HMR during Hogan’s first term for more than $170 million and opted to renew its relationship in 2021, which tacked on another $85 million.

“Reports available at provide insight into a range of deficiencies [at Charlotte Hall], including abuse, neglect, exploitation, quality of life, and care going back to 2017,” according to a spokeswoman from the Maryland Department of Veterans Affairs.

The situation at Charlotte Hall was “a product of years of poor oversight and mismanagement, a pattern that we are seeing across all of the state of Maryland,” Moore said.

Moore said within “hours” of taking office in January his administration learned of “several cases of abuse and neglect of our veterans, ranging from minor incidences to severe infractions that impacted the health and welfare of its residents.”

“As both a combat veteran myself and as the state’s commander in chief, I’m personally disturbed and professionally enraged to learn the level of disregard that has been given to the treatment of these patients,” Moore said. “Every Marylander deserves better, but particularly those who’ve been willing to risk it all for all of us.”

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In January, the facility had a one-star rating with the Centers for Medicare and Medicaid Services, Moore said. It is not clear how long the facility has had a one-star rating.

“A nursing home cannot earn a lower score than this. That means Charlotte Hall is among the nation’s worst performing nursing home facilities,” Moore said. Moore did not say what the facility’s previous rating was.

In a written statement, Russell Keogler, a vice president of HMR Veterans Services, said they share Moore’s commitment to caring for veterans and will ensure the governor has all the facts at his disposal.

“We are proud of our staff and the service they have provided to our nation’s veterans. Our number one priority continues to be caring for the health and well-being of our veterans and staff, and this priority will continue throughout the transition,” Keogler said.

A 2022 state health inspection report detailed the facility’s failure to keep residents safe from staff, from each other, and in one incident, failed to preserve a veteran’s dignity by infrequently changing their incontinence garments.

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State inspectors found Charlotte Hall failed to thoroughly investigate complaints of physical roughness among residents and other incidents between employees and residents. This means staff investigating incidents did not interview other residents to see if they had witnessed similar wrongful behavior or had experienced it themselves.

During one altercation over where to store pillows, a nursing assistant dislocated a patient’s thumb, according to the inspection report. The employee was eventually terminated. Another resident yelled for help after being left unattended in a whirlpool tub for eight minutes. The resident, whose medical diagnosis caused their muscles to weaken, feared they would slip beneath the water.

In another incident cited in the inspection report, a staff member observed one patient “stomping” on the head of another patient, causing the latter to require hospitalization. Both patients had histories of aggressive behavior toward staff and other residents, according to the report. Investigators found Charlotte Hall staff did not thoroughly investigate the incident.

The Department of Veterans Affairs is seeking registered nurses to assess the safety and baseline mental and physical well-being of patients, while the agency searches for a new contractor to manage the facility.

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The failed private-public partnership and Moore’s announcement that he will hire another contractor gave the leader of the largest state employee’s union pause.

“This is what happens when privatization runs rampant and has little to no oversight, and happens when people are held to the bottom line and and that is their motivation,” said Patrick Moran, who serves as president to the American Federation of State, County and Municipal Employees Maryland Council 3.

“Our veterans are sacred,” Moran said. “We should not be putting their needs and their livelihoods out to the lowest bidder.”

Moran called the situation at Charlotte Hall unacceptable and urged Moore to staff Charlotte Hall with state employees. “The state ought to do the right thing and bring this in-house where we have greater oversight and the ability to change things immediately,” he said.

Officials are working with the U.S. Department of Veterans Affairs, the Maryland Department of Health, the St. Mary’s County Health Department, and other stakeholders, Moore said.

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In a statement, the health department spokesperson said the agency will be investigating and addressing the “long-standing” issues.

“The Office of Health Care Quality will continue its mission to protect the health and safety of Marylanders and to ensure there is public confidence in the health care and community delivery systems,” according to the statement.

Newly appointed Department of Veterans Affairs Secretary Anthony Woods attended the spending board meeting via video conference from Charlotte Hall. He has visited the veterans home several times since starting the job, and happened to be attending a previously scheduled Maryland Veterans Home Commission meeting, according to a spokeswoman.

“We will right the ship,” Moore said. “We will find out what led to this crisis. Under our administration, we will provide our veterans with the care and the support that they need.”

This article has been corrected to reflect that the Department of Veterans Affairs intends to hire nursing staff to perform patient assessments and is still seeking a provider.