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The report on the investigation into the Holyoke Soldiers’ Home, where at least 76 veterans died from the coronavirus, includes shocking, heartbreaking eyewitness accounts from staff who tried to help veterans — and comfort them as they died.

According to investigators, 42 veterans — most with dementia — were combined into a single unit with 25 beds, a managerial decision that resulted in some veterans with COVID-19 being housed in the same room as those without. The virus swept through the men with ferocity over the next several days.

Social worker Carrie Forrant described what she saw and felt while comforting a veteran whose dementia left him unaware of the medical crisis unfolding around him and the other veterans.

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Report slams handling of coronavirus at Holyoke Soldiers’ Home
An independent report found the leadership team at the Soldiers’ Home in Holyoke to have made “substantial errors” in responding to the COVID-19 outbreak. (Photo: Angela Rowlings/Pool, Video: Handout)

“I was sitting with a veteran holding his hand, rubbing his chest a little bit. 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,” the social worker told investigators. “There is not a curtain to shield him from the man across from him actively dying and moaning, or a curtain to divide me and the veteran I am with at the time, from this alert, oriented veteran from making small talk with the confused little fellow.”

The one veteran was “alert and oriented, pleasantly confused, and talking about the Swedish meatballs at lunch and comparing them with the ones his wife used to make. I am trying to not have him concentrate on the veteran across from him who is actively dying, or the one next to him who I am holding his hand while he is dying,‘' the social worker said.

The scene was “surreal . . . I don’t know how the staff over in that unit, how many of us will ever recover from those images. You want to talk about never wanting this to happen again.”

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One staffer described what it was like for her as she and other workers watched managers order the consolidation of veterans from the two locked wards.

She said she wondered, “How can they do this because this [is] the most insane thing I ever saw in my entire life?” She “felt it was like moving the concentration camp — we are moving these unknowing veterans off to die. I will never get those images out of my mind — what we did, what was done to those veterans.”

Staffers also recounted some chilling conversations: “Social Worker Terri Gustafson (who has worked at the Home for 21 years) reports that she saw Ms. Surreira point to a room and state: ‘All this room will be dead by tomorrow.‘“ Celeste Surreira was the assistant director of nursing, investigators said.

The staff was overwhelmed by the suddenly escalating medical needs of the veterans, especially those with dementia who had been moved out of two locked wards. “We always took pride in our care with honor and dignity, and I thought my god where is the respect and dignity for these men, we are leaving them sitting there in johnnies more confused because there is 40-something of them now,” a nursing aide told investigators.

Investigators, who slammed the home’s leadership and the state Department of Veterans’ Services oversight of the home, were unstinting in their praise of the staffers and their personal commitments to the veterans.

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“The interviews we conducted revealed a remarkable and commendable theme: the front-line staff at the Soldiers’ Home provide quality, compassionate, and affordable care for veterans,” investigators concluded. “These are mission-driven healthcare workers. Working in a nursing home or long-term care facility is challenging, but it is apparent that the Soldiers’ Home staff take great pride in caring for the veterans and providing a nurturing environment.”





John R. Ellement can be reached at john.ellement@globe.com. Follow him on Twitter @JREbosglobe.