The inspector general’s report on the deadly COVID-19 outbreak at the Illinois Department of Veterans’ Affairs LaSalle Veterans’ Home is a maddening story of incompetence and chaos at every level.

The IG report tells the story of an allegedly AWOL agency director; an in-over-his-head chief of staff; a crucial failure to fill an important upper management position; an unconscionably delayed IDVA management response at all levels to a clearly and rapidly deteriorating situation both in the surrounding communities outside the home and when the virus inevitably spread inside the facility; an unprepared and woefully uninformed management on multiple issues, including basics about personal protection equipment; an abject failure to properly train and equip staff; multiple failures to ask for outside help and accept it when offered; and staff infighting and managerial timidity.

36 veterans died during the LaSalle catastrophe last year, a quarter of the facility’s population. Frankly, after reading the report, I was surprised more people didn’t die. It’s that bad.

The trouble started with Gov. J.B. Pritzker’s hasty appointment of a state legislator to fill the IDVA director job after his initial appointee abruptly dropped out – a mystery that he has not explained to this day.

According to the report, after state Rep. Linda Chapa LaVia became IDVA director, she apparently “abdicated” her responsibilities to her chief of staff, Tony Kolbeck. Kolbeck’s heart was in the right place but he should not have been given that job, partly because he didn’t have the requisite knowledge and experience, but also because the administration never appointed a Senior Homes Administrator for the agency. That administrator would’ve had the “medical understanding to provide meaningful leadership,” according to the IG report. Kolbeck essentially served as the director, the chief of staff and the Senior Homes Administrator all at once, a near impossibility during “normal” times, let alone during a deadly crisis.