The anonymous tip landed Saturday in Holyoke Mayor Alex Morse’s office, a phone complaint about unhealthy conditions at the Soldiers’ Home, a hilltop complex where veterans go for walk-in medicine, long-term care, and occasionally to die in hospice among their comrades.
A nurse with the city’s health board called the Soldiers’ Home that day but got no response. The next day, Morse reached out directly to Bennett Walsh, the facility’s superintendent, and received the devastating news.
The coronavirus outbreak had descended upon the 68-year-old complex, and veterans were dying rapidly. They had been dying since the first of the month, and on Tuesday the toll reached 13 fatalities, with at least six due to the virus. Pending tests could show a link to others of the dead, as well.
Yet somehow, at a time when infection control at elder care facilities is of paramount importance and any trace of the virus poses a systemic threat, the outbreak was apparently kept secret, even as casualties accelerated.
No one at City Hall had been told of the deaths before last weekend, according to Morse. No one at the highest levels of state government had, either, officials said. And neither had family members of the veterans who survive.
The stunning breakdown of public health protocol touched off a swirl of accusations and disbelief Tuesday and a pledge from state leaders to uncover how such a widespread outbreak could have gone undetected for so long.
The deceased were placed in a refrigerated storage truck that was parked in the home’s rear loading area since late last week, three staffers said. A supervisor told staff that federal guidelines required coronavirus-infected bodies to be held for a certain time before being released to avoid spreading the virus. But the sight disturbed several staffers.
“We take care of our veterans with honor and dignity,” said a nurse who spoke on condition of anonymity for fear of retaliation. “It’s emotionally shocking when you have to watch people you’ve cared for for a long time be stored in a refrigeration truck. It’s not dignified.”
Ten additional veterans and seven staff members at the state-run Soldiers’ Home have tested positive for the contagion, and 25 veterans are awaiting test results.
The new details emerged Tuesday as the state reported that the number of deaths statewide rose to 89, a 59 percent increase from the day before. The number of positive cases rose by 868 to 6,620, with 46,935 people tested to date.
As the pandemic continues to spread, Governor Charlie Baker extended his order to close nonessential businesses and his stay-at-home advisory to May 4. An order to limit all gatherings to 10 people or fewer also is being extended to May 4. Baker already had closed all state schools until that date.
But the deaths at the Holyoke Soldiers’ Home — the largest fatal outbreak in the state thus far — stunned state and local officials.
“We were not aware of the gravity of the situation at the Soldiers’ Home. I was shocked,” Morse said Tuesday in a speech live-streamed on Facebook. “If they followed [public health] guidelines, we would have been notified. And we weren’t.”
“The superintendent let me know that there had been eight deaths between Wednesday and Sunday without any public notification, without any notification to my office — and no notification to the state government that oversees the facility in the first place," Morse said.
During the call over the weekend, Morse recounted, Walsh looped in his boss, Secretary of Veterans’ Services Francisco Urena. Morse said that he was not sure if Urena had known previously about the situation in Holyoke but that he did not seem to consider it a significant issue.
“I didn’t leave [the telephone conversation] assured that action would be taken,’’ Morse said.
Frustrated, Morse said, he called Lieutenant Governor Karyn Polito on Sunday and said she responded within minutes. Shortly afterward, Health and Human Services Secretary Mary Lou Sudders told him she would be sending a team of health specialists to the facility the following day.
Walsh was suspended Monday afternoon and did not return a call on Tuesday.
Morse faulted the “lack of transparency” by Walsh and the state’s Department of Veterans’ Services.
“This is just completely unacceptable," Morse said, noting that relatives have not been able to visit family members since a quarantine was ordered in mid-March.
Walsh, a third-generation Marine veteran, has been superintendent since 2016 and comes from a politically prominent family in the area. His mother, Kateri Walsh, is a Springfield city councilor, and his father, Daniel Walsh III, is a former Springfield veterans services officer. The superintendent’s uncle, William Bennett, served as Hampden district attorney.
According to union leaders, Soldiers’ Home employees were notified March 22 that a long-term patient in the dementia unit had tested positive for coronavirus and was being quarantined in a private room. The next day, however, an employee reported to the union that the patient was sharing a room with a noninfected patient, said Brenda Rodrigues, president of the Service Employees International Union Local 888, which represents workers at the facility.
Afterward, veterans from infected areas were mixed with veterans from other floors, she said. A caregiver, speaking on condition of anonymity for fear of retaliation, verified Rodrigues’s account.
“If they could’ve moved that person out immediately and started testing people, they could’ve saved a lot of lives,” the caregiver said. "These are veterans who served this country diligently. We could’ve prevented this.”
Rodrigues said employees had complained since March 14 that management did not seem to be taking the coronavirus seriously. Employees reported being ordered to come to work even if they were sick and not being given enough protective gear, she said.
One caregiver who worked with the first veteran who displayed coronavirus symptoms wore protective gear the next day while serving other veterans. That drew an immediate backlash, she said.
“Management there got really upset and said he was making it a bigger issue than it was, and that he was sparking fear," she said.
The employee sent the Globe a copy of a disciplinary letter he received on March 20, alleging he had “put on a Personal Protection Equipment without permission or need.”
“Your actions are disruptive, extremely inappropriate and have caused unnecessary resources to be deployed that may be needed in the future,” the letter read. “Your behavior unnecessarily disrupted and alarmed staff.”
Nurses were still fighting for protective equipment after the facility’s first positive case was announced, according to a nurse who has worked at the facility for multiple years.
“We had to fight tooth and nail to get basic protection,” said the nurse, who ended up wearing safety glasses from her husband’s workshop.
Staff shortages meant that nurses were “floating” between units and floors and some veterans were put three to four in a room, the nurse said.
On Tuesday, the National Guard arrived and all of the nurses were outfitted with N95 masks that they’d need to wear for the entire week.
In Holyoke and beyond, the Soldiers’ Home deaths sent shock waves through the veterans community and the advocates who support and work with them.
“Nobody called to give us a heads-up. It was like a big, dark secret,” said Jack Downing, the president of Soldier On, a veterans housing and support organization based in Northampton that has 12 clients living at the Soldiers’ Home.
“There’s a board that’s supposed to have oversight, but they don’t take their responsibility seriously," he said.
Kevin Jourdain, a lawyer and chair of the Soldiers’ Home Board of Trustees, said Tuesday that he had been made aware of the situation but declined to comment further, referring questions to state officials.
A spokesman for Urena said his department is “working to support” the response effort.
At an afternoon news conference, Baker said he first learned of the situation on Sunday night when he, Polito, and Sudders spoke with Morse.
“This episode is a gut-wrenching loss that is nothing short of devastating to all of us,” Baker said. “In the short term, our primary focus is going to be on stabilizing and supporting the health and safety of the residents and their families. And we will get to the bottom of what happened and when — and by who.”
Sudders said state officials are still trying to confirm important details, including precisely when the residents died, when they were tested for COVID-19, and who in their families were informed. She said the deaths were not reported to state officials.
Families were also left in the dark. The son of a resident in the home, a World War II veteran in his 90s, said he did not hear about the deaths until the news media reported them Monday night.
“I never received an e-mail. I was never informed that anyone had died,” said the son, a retiree in his 60s who asked not to be named.
Now, the man is concerned that his father also could die from the virus.
“These are the most fragile people. This virus will go through there like wildfire. If my father dies of this ..." he said, his voice trailing off. "I can only imagine the anguish of the people who have lost their loved ones. There are a lot of heroes in that building.”
Emily Sweeney and John R. Ellement of the Globe staff contributed to this report.
Brian MacQuarrie can be reached at email@example.com. Naomi Martin can be reached at firstname.lastname@example.org. Matt Stout can be reached at email@example.com. Follow him on Twitter @mattpstout Hanna can be reached at firstname.lastname@example.org. Follow her on twitter @hannaskrueger.