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The first day Bennett Walsh reported to work as superintendent of the Holyoke Soldiers’ Home in May 2016, the retired Marine lieutenant colonel wore his uniform to the largest nursing home for veterans in New England.

Richard Connor of the Disabled American Veterans, an advocacy group, left his office inside the Holyoke facility to welcome Walsh and introduce himself. The pleasantries didn’t last long, though, before Walsh questioned why Connor’s group, which helps connect veterans with benefits and services, had been given space in the building.

Four years later, amid a coronavirus outbreak that has killed at least 71 residents of the state-run home, Connor remains startled by the exchange. To Connor and others, the episode betrayed a dismissive mind-set that seemed ill-suited for running a large nursing home, particularly in a time of crisis.

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"If you’ve got to ask that question, you’re in the wrong business,” Connor said.

And now, as nearly every day brings new virus-related deaths to the Soldiers’ Home, many other hard questions are being asked. Four state and federal investigations have been launched into what went wrong. And families of Soldiers’ Home veterans, health workers, and former supervisors say repeated warnings about staffing and other shortfalls have been brushed aside or ignored for years.

"We sounded the alarm several times that the Soldiers’ Home needed greater staffing to provide more advanced care for veterans,” said John Paradis, a former deputy superintendent who resigned in protest four years ago before Walsh was appointed. “The pandemic has revealed in a most horrific manner these failures.”

Paradis and other critics said that what is believed to be the nation’s deadliest coronavirus outbreak at a long-term care facility was a systemic failure years in the making, reflecting a shocking lack of readiness and chronically poor management by senior leadership.

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Their complaints — which ranged from staffing shortages to crowded conditions to a hostile work culture — have long been muted by a bureaucracy that critics say valued patronage and loyalty over candid, public discussion of the home’s needs.

Neither Walsh, who has been placed on paid leave, nor Francisco Urena, the Massachusetts veterans secretary to whom Walsh reports, had any previous background in health care management. Typically, such a background has not been mandatory in those positions.

The pandemic has ravaged a hilltop campus that for 68 years has cared for aging veterans who cannot live safely on their own, a brotherhood that has included men who stormed the beaches on D-Day, battled the Japanese at Midway, and survived firefights in Korea and Vietnam.

"Shame on all of us as citizens for allowing this to happen,” said Paradis, a retired Air Force lieutenant colonel who lives in Northampton. “These are our parents. These are the people who raised us, built our communities, gave us the best years of their lives. And this is the best that we can do?”

Governor Charlie Baker and Holyoke city officials said they did not learn of the first coronavirus deaths at the home until days after they occurred. Nurses said they were sent into infected wards without proper protection and ordered to work even when they were sick.

Only after an anonymous tip landed in the office of Holyoke Mayor Alex Morse, after seven veterans had died in the span of a few days, did the public and the family members of veterans hear of the mounting fatalities and cascading infections.

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As conditions deteriorated, employees said the virus was allowed to spread nearly unchecked through the facility. As more nurses fell ill, managers combined units to conserve and pool staff, putting residents with symptoms in close proximity with the healthy.

In late March, when the first resident died from the coronavirus, 226 residents lived at the elder-care facility. Just over one month later, more than 30 percent of them have died and an additional 83 have tested positive.

Many people suspect Walsh was chosen, at least in part, because of his deep political ties in nearby Springfield. His mother is a longtime Springfield city councilor. Walsh’s father was the city’s veterans agent, and his uncle, William Bennett, served as district attorney of surrounding Hampden County.

“I know there are politics involved, but if you are going to put somebody in charge of this place, at least choose somebody with a medical background," said Kwesi Ablordeppey, who’s been a certified nursing assistant at the home for nearly 20 years.

A posting for the superintendent’s job, placed in the Globe on Jan. 31, 2016, stated that the “ideal candidate has [a] proven track record in supervising, operating a residential/outpatient facility, budget management, [and] planning/developing medical, residential, long-term and acute-care programs for veterans.”

Over a 24-year military career, Walsh served in combat and held a high-level administrative position with the Marine Corps, as well as earned two graduate degrees.

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In an interview Friday, state Attorney General Maura Healey said the superintendent of the Soldiers’ Home should have medical experience.

If not, Healey added, “they better have people around that person with substantial health care experience. I mean, these are medical facilities after all.”

The attorney general said her office will investigate possible criminal and civil violations.

“We’re looking into all these past reports,” said Healey, referring to allegations of quarantine violations, poor management decisions, and chronic understaffing. “We know certain populations are vulnerable, but to see this many veterans die in this way is extremely troubling.”

Walsh, 50, is being paid a salary of $123,752. He donated a total of $950 to Baker and $1,000 to Lieutenant Governor Karyn Polito from 2016 to 2019.

Under Walsh, staff morale has plummeted, health workers said. The union that represents many nurses and maintenance workers at the home reported that 90 of roughly 230 members had left the facility since 2017.

In 2019, the chief financial officer, the legal counsel, the director of nursing, the deputy superintendent, and Walsh’s executive assistant all stepped away.

Employees and supervisors at Holyoke described Walsh as a hands-off leader who seemed out of touch with the job’s demands. On the surface, he was an affable supervisor eager to quote movies and rattle off sports trivia, but these staff members said he was easily angered when things didn’t go his way.

In March 2018, Walsh got into a dispute with a fellow employee and threatened to “belt” him while clenching his fists, according to two workers. The incident was reported by a witness, and Walsh was mandated to attend anger management meetings, the employees said.

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Urena, to whom Walsh reports, also is an Iraq combat veteran with no background in health care management. Baker appointed him secretary of the Department of Veterans’ Services in January 2015 following a four-year stint as Boston’s veterans commissioner.

Urena’s story is one of immigrant striving. A native of the Dominican Republic, he came to the United States at age 4 with his mother and lived in Lawrence before moving to South Florida, where he joined the Marines after graduating from high school in 1998.

After serving in embassy posts in Syria and Kyrgyzstan, Urena was deployed to Iraq, where he was wounded by shrapnel as a tank commander and received the Purple Heart. He left the Marines in 2006 and returned to Lawrence, working as a security guard, at a local-access cable station, and later as the city’s veterans agent.

Paradis said he found Urena, 39, difficult to engage about the needs of the Soldiers’ Home.

The former deputy superintendent recalled Urena’s first visit there as veterans secretary in February 2015. Paradis said he and former superintendent Paul Barabani were excited to brief him on the home’s mission and lobby for more resources. But within minutes, he recalled, their enthusiasm turned to disappointment.

“Urena sat at the head of the table, disinterested, looking at his phone constantly, with very little eye contact. It was just very demoralizing," Paradis said. "We didn’t feel comfortable that this person had our back. After he left, Paul and I just looked at each other and said, ‘We’re not going to get anywhere.’ ”

Paradis also recalled that a candidate for director of nursing, whom he and Barabani had recommended, was summoned to Boston in 2015 for a follow-up interview with Urena. Once there, the candidate was told by Urena that her first loyalty must be to the governor and his administration, according to Paradis, who said he spoke to the candidate afterward.

Paradis said the same loyalty test was administered that year to a prospective hire for chief financial officer.

“They don’t want to hear problems or challenges," Paradis said. “They don’t want you to talk to constituents or legislators or be upfront with family members of veterans whom you’re entrusted with. They want you to parrot what the administration wants you to parrot.

“At the end of the day, you never felt there was anyone who was looking out for that 92-year-old veteran who had dementia or needed end-of-life care,” he said.

In a statement to the Globe, Urena said Friday that "the impact of COVID-19 on our community is heartbreaking, and my deepest condolences go out to all the families who have lost a loved one during this public health crisis.

“DVS continues to monitor Holyoke and provide support through weekly meetings, and the Massachusetts National Guard continues to support staffing needs and testing,” the secretary added.

Walsh, as well as his advocates, argue that the virus’s deadly sweep was nearly inevitable given the facility’s high-risk population. Daniel Smith, an Army veteran and former Holyoke trustee who recommended Walsh for the top position, said he retained confidence in the superintendent.

“I think the criticism is unwarranted. He was dealing with a contagious disease that moves very rapidly,” said Smith, who lived at the Soldiers’ Home for 17 months while recovering from a fall.

Walsh declined to comment on the criticisms leveled at him. But in early April, he refuted Baker’s statement that the superintendent failed to notify his supervisors about the outbreak as it escalated. Walsh said at the time that he had provided daily updates to state officials after the first veteran tested positive.

“There have been widespread reports in the media that state officials were kept in the dark about what was happening at the Soldiers’ Home during the COVID-19 crisis. These reports are false,” Walsh said in the statement.

Many critics say that much responsibility for the home’s poor oversight lies with Urena. The state chapter of the Disabled American Veterans has called for an overhaul at Veterans’ Services.

“This incident represents a catastrophic failure of leadership," the DAV wrote to Baker on March 31. “We hope that your administration will make swift changes at all levels of the Department of Veterans’ Services and the Holyoke Soldiers’ Home.”

Urena received support from Bill LeBeau, the state adjutant for the Veterans of Foreign Wars.

“We feel he’s been a great advocate on behalf of the veterans across the state. He delivers the messaging that the governor wants,” LeBeau said.

Many supporters of the home were frustrated by Walsh’s appointment, in part because they had hoped for a superintendent with medical expertise. During a January 2015 meeting, Cesar Lopez, then a new trustee at the Holyoke home, suggested that the search include someone with experience caring for the elderly.

Former trustees chairman Steve Como, who stepped down in February 2015 to let Baker select his own chairman, said the board leaned on the expertise of Spiros Haritas, president and chief executive officer of Holyoke Medical Center.

Haritas resigned from the board a few days before Baker announced Walsh’s appointment. He declined to comment on the appointment, citing the ongoing investigations.

Barabani, Walsh’s predecessor, was an administrative officer for the chief of staff at the Veterans Administration Medical Center in Northampton when he was named superintendent in 2011. Previously, he had served for 32 years in the Massachusetts Army National Guard and retired as a colonel.

A person familiar with Walsh’s selection process said he was one of three finalists for the job, including two who were administrators of nursing homes. But ultimately, the trustees were swayed by Walsh’s military experience in Somalia and Iraq and recommended him as the top candidate to Baker, Smith said. Walsh also served as executive officer at the Marine Corps recruitment and training facility at Parris Island, S.C.

The Soldiers’ Home has met health care standards set by the US Department of Veterans Affairs for three consecutive years. But Steven Connor, president of the Western Massachusetts Veterans’ Service Officers Association, said he believes the quality of care there has declined.

"It’s not the care it once was, but we’re fighting to get it up to standards,” said Connor, whose brother died at the facility in 2013. "They’ve had beds that weren’t 3 feet apart. There wasn’t even enough room to get a walker through there.”

Unlike the Chelsea Soldiers’ Home, a sister facility where many veterans live independently, the Holyoke home is primarily used for long-term medical care. Last year, about 90 percent — or 232 — of Holyoke’s veterans needed help with daily activities such as eating and using the bathroom, according to a state report.

Chelsea housed 134 long-term patients in 2019, yet received $28.7 million in state funding. Holyoke, with close to twice that high-cost, long-term population, received $23.9 million.

According to a state report, Chelsea had 305 beds last year in its less-expensive program for independent living, which requires minimal assistance for the veterans. Holyoke had 30.

A 2019 study ordered by Marylou Sudders, the state health and human services secretary, found that nurses at Holyoke struggled to find colleagues to help disabled patients out of bed and use the bathroom.

However, management reported that staffing was sufficient and nurses needed to increase their productivity, according to the study. All the while, overworked nurses struggled to get days off for major life events or when they gave ample warning, according to union representatives.

Sue Popp, a longtime hospice nurse at the facility, retired in 2017 after a dispute over time off. Last week, she recounted her parting words to Walsh: “You know, Bennett, I love this place, but I cannot deal with it anymore. You are very lucky that the staff here loves the vets, because we give good care in spite of the way you treat us.”

In January 2016, Barabani retired as superintendent and said publicly the state was failing to adequately fund and staff the home. Walsh dismissed that complaint six months later during an interview with the Springfield Republican.

“The support from Boston to Western Massachusetts is tremendous,” Walsh said. “There’s definitely not a lack of funding from Boston for us. They couldn’t be more supportive of the veterans there.”

But in a March 12 meeting between Walsh and the board, trustee Christopher Dupont questioned why the Soldiers’ Home was asking for just a 1 percent increase in its annual budget.

“Is it being mandated by the Commonwealth of Massachusetts that we can only ask for 1 percent, or is that just what the Soldiers’ Home in Holyoke does on an annual basis?” he said. Walsh was asked to provide an answer at a future meeting.

At Holyoke, the impact has been noticeable.

Laurie Beaudette of Northbridge said she had visited her father, Jim Mandeville, every night in his 16 years at the facility. She would stay for hours, playing cards or just enjoying his company, but noticed a marked decline in the home in recent years.

“The nurses were overworked and constantly really stressed out," Beaudette said.

On Easter Sunday, Beaudette drove to Holyoke Medical Center, where her 83-year-old father had been moved after the outbreak, and sat in the parking lot to be close to him.

That afternoon, the hospital let her visit her father. Typically sharp and alert, Mandeville looked shrunken and disoriented. He died two days later from complications of the coronavirus.

For many staffers, the ongoing tragedy is emblematic of longtime problems.

“My first thought was this is the same pattern that has gone on there for years, except now you can’t hide this many bodies,” Popp said. “It’s a place that the state of Massachusetts could and should be proud of, but instead it’s a tree with rotted roots and a political dumping ground.”


Brian MacQuarrie can be reached at brian.macquarrie@globe.com. Hanna Krueger can be reached at hanna.krueger@globe.com. Follow her on Twitter @hannaskrueger.