Systemic Failures in Veteran Care: Widespread Failures and Resident Abuse at the VA New York Harbor Healthcare System in Queens

Timothy Pena • October 1, 2025

Veterans deserve safe, transitional housing with clear reporting procedures, thorough investigations, proper documentation, and staff trained to respond to incidents

New York, NY -- A recent Veterans Affairs Office of Inspector General (OIG) report revealed serious failures at the St. Albans Community Living Center (CLC) in Queens. Delayed investigations, incomplete medical assessments, and a pervasive culture of silence left residents at risk. While the findings focus on long-term medical care, they echo long-standing issues in the Grant & Per Diem (GPD) program at the Borden Avenue Veterans Residence (BAVR).

BAVR provides transitional housing and support for veterans experiencing homelessness. However, multiple reports and firsthand accounts show systemic failures similar to those identified at the CLC. Veterans have described unsafe living conditions, delayed responses to complaints, and inconsistent oversight. Staff often lack training to manage abuse allegations or respond to resident concerns, creating a climate where problems go unreported or are superficially investigated.

A particularly concerning issue at BAVR is the city’s practice of requiring veterans without any mental health or chemical use diagnosis to self-identify as such in order to qualify for VA transitional programs. The GPD program, under federal law (38 U.S.C. § 2012 and Public Law 109 461), does not require veterans to have a mental health or substance use disorder to receive benefits they earned through military service. Forcing self-identification to access housing places veterans at risk, discourages honesty, and perpetuates a “culture of silence” that mirrors the reporting failures seen at the CLC.


Investigations at BAVR are often not conducted due to DHS security which prevents proper Veterans Affairs oversight of the program. Complaints about mismanagement, neglect, and unsafe conditions can take months to resolve, leaving veterans vulnerable. Poor documentation and inconsistent oversight further undermine accountability.


These systemic failures have measurable consequences. Only about 60% of veterans successfully transition to permanent housing from BAVR, while roughly 20% disappear from the program entirely. In contrast, GPD programs with trained staff and supportive environments, such as Samaritan Village in New York or Catholic Charities’ MANA House in Phoenix, achieve 70–90% successful exit rates, even without comparable federal funding. These disparities illustrate how leadership, program integrity, and adherence to protocol directly affect veteran outcomes.


The parallels between the St. Albans CLC and BAVR underscore the need for systemic reform. Veterans deserve safe, structured transitional housing with clear reporting procedures, timely investigations, robust documentation, and staff trained to respond appropriately to incidents. Policies that force veterans to self-identify as mentally ill or chemically dependent violate federal guidelines and put residents at further risk.


Restoring integrity to BAVR and similar programs requires strong oversight, independent audits, and a culture that allows both staff and veterans to report concerns without fear. Only then can GPD transitional programs fulfill their mission: helping honorably discharged veterans move from homelessness toward stability, independence, and safety.


Printable pdf: VAOIG/St. Albins 20251001


Timothy Pena is a service-connected disabled Navy veteran for PTSD and has written about his experiences with mental health, homelessness, and the judicial system. Suffering mental illness, he initially visited NYC to collaborate on a documentary for veteran suicide but decided to stay after realizing he would rather be homeless in NYC than dead in Phoenix. He has been writing stories and blogs about his journey from “homeless to homeness” in the NYC Dept of Homeless Services system and possible corruption within DHS and Veterans Affairs Grant & Per Diem Transitional Program.