An investigation into Holyoke Soldiers' Home, a state-run facility for veterans in Massachusetts where 76 residents died from COVID-19, found that the nursing home made 'substantial errors' and “utterly baffling” decisions.
found no evidence that top officials at the Holyoke Soldiers' Home tried to cover-up the crisis, but concluded that the home's leadership team made"substantial errors" that"likely contributed to the death toll during the outbreak," and that the state's Department of Veteran Services failed to provide oversight.
The report identified a number of long-term issues that contributed to the crisis — chronic staffing problems, for example — but placed most of the blame on the home's superintendent, a retired Marine named Bennett Walsh, and the secretary of the state's Department of Veteran Services, another retired marine named Francisco Ureña.
Under Walsh's watch, the home made several"utterly baffling" decisions investigators wrote. The most alarming example was the decision on March 27, a move that wound up mixing veterans who had the virus with those who did not.
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