A new report commissioned by the Murphy administration is recommending changes to the way nursing homes and long-term care facilities operate in New Jersey.

The report by Mannatt Health details lapses by state agencies and nursing home operators during the COVID-19 pandemic.

“It’s a call for all of us to do better,” Gov. Phil Murphy said Wednesday.

The report found that New Jersey’s long-term care facilities were largely unprepared for the threat of widespread infection prior to COVID-19 and that state agencies did not have sufficient staff to send to long-term care facilities and conduct meaningful oversight once the pandemic struck.

“It is a call for dramatic reforms so the long-term care industry itself can do better, including great transparency and staffing requirements. Reforms, which once enacted, will be key to our goal of protecting our most vulnerable residents,” Murphy said.

More than 5,000 residents and staff at these facilities have died from COVID-19. The Mannatt review found that actions at some of the facilities unintentionally exacerbated the outbreaks. The review also contained 11 different recommendations for reforms.

“Increasing transparency and accountability within the industry, by requiring more data be shared by facility owners and managers,” Murphy said. “New procedures to better regulate and monitor facility ownership, centralizing how that data is managed for greater oversight and for those who fail to keep up, stronger penalties.”

Health Commissioner Judith Persichilli says that the Department of Health will use funds from the coronavirus relief fund to improve inspections, oversight and protections at the facilities.

“As the report states outright, and I quote, ‘COVID-19 didn’t create the problem, it exacerbated the long-standing underlying systemic issues affecting nursing homes care in New Jersey,’” Murphy said.

The review was done over three weeks in May. The report’s authors did not conduct any in-person visits to nursing homes due to stay-at-home orders.