SPRINGFIELD, Ill. (AP) — An investigative report by an Illinois inspector general found a chain of miscommunication, lax policy and missed opportunities leading up to and during a COVID-19 outbreak last fall at the LaSalle Veterans’ Home.

The report on the deaths of 36 residents was released Friday. The newly appointed director of the Illinois Department of Veterans Affairs, Navy veteran Terry Prince, issued a six-point health and safety improvement plan.

The report found that IDVA had no consistent policies for dealing with the infections that struck in November and staff members worked in an environment that was “reactive and chaotic.”