In September, Gov. Mike Parson praised the Missouri Veterans Commission (MVC) for setting the standard nationwide for safety protocols in veterans homes during the pandemic.

This week, an outside investigation found that an “absence of leadership” by the MVC ultimately contributed to the deaths of more than 100 residents in Missouri’s seven veterans homes.

So much for setting the bar for nationwide standards of safety.

The external review, requested by Parson after the veterans homes experienced a surge of coronavirus cases shortly after he made his initial comments, depicts a state agency that was largely inept in managing the virus and which failed to carry out its primary mission of protecting the health and safety of veterans.

Specifically, the report says the MVC leadership and staff failed to recognize and appreciate the problem at the first sign of the outbreak, failed to plan for the outbreak and failed to properly respond to the outbreak. Call it a cavalcade of failure.

MVC dropped the ball. There is no other conclusion. After cases began to surge, MVC’s response could be characterized as too little, too late, to prevent or slow COVID-19 outbreaks in its facilities.

“The lack of a comprehensive outbreak plan led to confusion and inefficiencies, and it almost certainly contributed to the inability to contain the spread of COVID-19 once it was introduced into the homes,” the report states.

The report suggests that through the early months of the pandemic, the MVC took appropriate action to protect veterans and staff from infection. The MVC’s leadership acted quickly in March to stock up on personal protective equipment, shore up supply lines and change procedures, including banning outside visitors. The report notes the MVC evaluated and adjusted nearly every aspect of the delivery of care to veterans in order to protect its residents.

Then, as cases started appearing, things quickly fell apart in our state’s veterans homes.

Despite taking effective steps early in the pandemic, MVC leadership was lulled into “a false sense of security and failed to capitalize on its early successes,” the report explains.

How does this happen? The report portrays a tragic and unacceptable breakdown in leadership during a public health crisis. It places the blame not on staff, which it describes as dedicated and compassionate, but squarely on leadership, which was ill-prepared and slow to respond.

On Thursday, Parson told reporters that “there are some things in that report that are going to have to be addressed and going to have to be explained.” Parson deserves credit for ordering an outside investigation and not trying to whitewash the findings.

But the real issue is how to go forward to ensure this doesn’t happen again.

Parson, a veteran, has a record of taking swift action when it comes to substandard care at the veterans homes. While serving as lieutenant governor, he investigated complaints of mistreatment of patients at the state veterans home in St. Louis and called for the removal of its administrator. Gov. Eric Greitens responded by appointing five new members to the Missouri Veterans Commission and directing them to fire the administrator.

Our governor needs to take the same swift measures now. What happened at the state’s veterans homes is unacceptable. The report clearly demonstrates more could and should have been done to protect these veterans.