The residents of the Holyoke Soldiers’ Home stormed Normandy, stood guard at the Nuremberg trials at the end of World War II, and fought through the jungles of Vietnam.
But in late March, many of these veterans again faced conditions that investigators likened to a “war zone,” this time inside the state-run long-term care facility where they had sought dignity and care in their final years.
The findings of a scathing independent investigation released Wednesday show that leaders at the home made “utterly baffling” mistakes in responding to a devastating coronavirus outbreak that killed at least 76 elderly residents.
The 174-page report, ordered by Governor Charlie Baker and conducted by former federal prosecutor Mark W. Pearlstein, chronicles a profound government failure, laying blame on a facility devoid of leadership during the most consequential days of the outbreak and plagued by long-festering management issues that came to a head during the pandemic.
“Even the best preparations and most careful response cannot eliminate the threat of COVID-19,” the report said. “But this does not excuse a failure to plan and execute on longstanding infection control principles and to seek outside help when it is required to keep patients safe — indeed, the extraordinary danger of COVID-19 makes these steps all the more important.”
”Veterans who deserve the best from state government got exactly the opposite,” Baker said at a news conference Wednesday. “And there’s no excuse or plausible explanation for that.”
The superintendent of the home, Bennett Walsh, was placed on leave in March. The state’s secretary of veterans’ services, Francisco Urena, resigned Tuesday. Urena directly oversaw Walsh.
The report concluded that Walsh was unqualified to lead the home and that the Baker administration, which appointed Walsh and his overseers, knew of his shortcomings well before the outbreak, one of the worst in the country.
His administration’s failure to properly supervise Walsh contributed to “the tragic failure” at the home, Baker said.
In the most glaring failure to contain the virus, management merged two locked dementia units on March 27, a decision investigators described as a catastrophe. The report called the conditions in the combined unit “deplorable” with insufficient amounts of morphine and comfort medications to tend to dying veterans.
The decision meant 40 veterans were crowded into a space designed to hold 25, providing what the report called the “opposite of infection control.” A recreational therapist who was instructed to help with the move said she felt like she was “walking [the veterans] to their death,” the report said.
One staff member said she “will never get those images out of my mind — what we did, what was done to those veterans,” and thought: “My God, where is the respect and dignity for these men?”
A social worker staffed in the combined unit described suffering veterans crowded together in cots in hot rooms.
“I was sitting with a veteran holding his hand, rubbing his chest a little bit,” the social worker told investigators. “Across from him is a veteran moaning and actively dying. Next to me is another veteran who is alert and oriented, even though he is on a locked dementia unit. There is not a curtain to shield him from the man across from him actively dying and moaning.”
After the units were consolidated, the death toll accelerated at an alarming rate, a surge the home’s leadership partially anticipated, the report found.
An employee, whom the report did not name but the Globe confirmed to be 62-year-old Luis Rodriguez, was asked to deliver 13 body bags to a dementia unit, shortly before it was consolidated with another unit. A day later, a refrigerated truck arrived to accommodate the anticipated body count.
“I almost dropped to the floor in shock,” Rodriguez recalled of the request. “I usually keep one (body bag) in my cart. But 13, that’s crazy.”
Social worker Terri Gustafson, who has worked at the home for 21 years, told investigators she saw assistant director of nursing Celeste Surreira point to a room and say, “All this room will be dead by tomorrow,” according to the report.
Investigators placed most of the blame for the mishandling of the outbreak on the home’s leadership team, which included Walsh, medical director David Clinton, director of nursing Vanessa Lauziere and Surreira. Investigators said no one at the Soldiers’ Home, other than Lauziere, would admit to being involved in the decision to consolidate the two units. Clinton, Lauziere, and Surreira have resigned or been fired. Baker said Wednesday that state officials are working to end Walsh’s employment.
Union officials, who have long complained about conditions at the facility, said the report’s findings were appalling.
“The report has these people openly admitting that they knew there was COVID-19 rampant in these units and still bullying staffers and idling by while veterans die,” said Corey Brombredi of SEIU 888, which represents most of the home’s care staff. “It is criminal to me.”
The report also detailed the rocky tenure of Walsh, who investigators say was ill-suited for his job as manager of one of the largest long-term care facilities in New England. As previously reported by the Globe, Walsh had no previous health care experience and is believed to have been tapped by the Baker administration in part through his family’s deep political connections in the region.
Investigators found that Walsh was a divisive leader who saw massive staff turnover during his tenure and had to attend anger management classes. The Globe reported in May that Walsh got into a dispute with a fellow employee in March 2018 and threatened to “belt” him while clenching his fists. During Walsh’s tenure, which began in June 2016, 274 employees left the Soldiers’ Home, according to documents obtained by the Globe.
The report also criticizes Urena for failing to take proper steps to address substantial and longstanding concerns about Walsh. Veterans’ Services general counsel Stuart Ivimey also resigned as a result of the report.
William Bennett, Walsh’s attorney and uncle, said in a statement that Walsh disputes “many of the statements and conclusions in the report” and argues he was not given the chance to respond to them, though he did not specify which findings he would challenge.
“We are also disappointed that the report contains many baseless accusations that are immaterial to the issues under consideration,” Bennett said, adding that he and Walsh are “reviewing legal options.‘'
Urena indicated in a message to a reporter that he would send a statement on the report but had not done so by Wednesday evening.
The report also addresses the issue of when the state was informed about the severity of the outbreak. The governor said previously that he was “appalled” by the lack of reporting from the facility and that his office quickly deployed the National Guard after learning of the situation.
But investigators found that while Walsh sometimes reported information that was inaccurate and incomplete, he did not purposefully conceal coronavirus cases or deaths and updated Urena throughout the outbreak.
Baker said Wednesday that “the full extent of what was going on there was not made clear” in Walsh’s reports, a complaint echoed by staffers and family members after Walsh publicly released a batch of e-mails in May in an attempt to exonerate himself of wrongdoing.
“There was a rapidly escalating crisis situation, and Mr. Walsh does not appear to have appreciated its urgency and certainly could have done more to alert others,” the report concluded.
Baker called the findings “gut-wrenching.‘'
“I think the thing the report makes absolutely clear to all of us is that the Department of Veterans’ Services, our administration, did not do the job we should have done in overseeing Bennett Walsh and the Soldiers’ Home,” he said. “That’s on us.”
House Speaker Robert A. DeLeo said he was “disturbed” by the report and will ask the House to create a special oversight committee to conduct its own probe. Attorney General Maura Healey, the Justice Department, and the state inspector general all have ongoing investigations into the home.
Healey said the report “lays bare systemic failures of oversight by the Baker Administration in adequately preparing, staffing, and responding to this crisis to protect our veterans.”
Staffers who endured the chaos of the outbreak and family members whose loved ones were ravaged by the virus said they appreciate some of the truth coming to light, but acknowledge it brings little solace.
“The Pearlstein report hits you right in the face. It’s the truth,” said Sue Perez, whose father, James Miller, lived in one of the dementia units that was merged. “But it comes a little too late.”
Miller died March 30 at 96 from complications of the virus.
Travis Andersen of the Globe staff contributed to this report.
Hanna Krueger can be reached at firstname.lastname@example.org. Follow her on Twitter @hannaskrueger. Matt Stout can be reached at email@example.com. Follow him on Twitter @mattpstout.