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Report Details 'Utterly Baffling' Decisions at Holyoke Soldiers' Home

A report released Wednesday into the deaths of at least 76 veterans with COVID-19 at the Holyoke Soldiers' Home flags "substantial errors" the facility's leadership team made in responding to the outbreak.

The report knocks the Department of Veterans Services for not addressing long-standing concerns with the home's leadership, and finds the home's superintendent did not commit "material violations" of reporting violations around COVID-19 test results.

The "worst decision," attorney Mark Pearlstein writes in his report, was combining two locked dementia units that hosted patients with a mix of COVID-19 statuses because of a "looming staff shortage."

Staff quoted in the report describe the move as "total pandemonium," and "when hell broke loose," and one recreational therapist is quoted as saying she felt like she was "walking [the veterans] to their death."

Gov. Charlie Baker on April 1 tapped Pearlstein lead an independent investigation into events that led to COVID-19 deaths of veterans living at the home.

Baker plans a noon media availability to discuss the report. Baker will also likely address the resignation of his veterans affairs secretary, Francisco Urena. A source close to Urena told the News Service Tuesday night that he was being forced out of the post.

The Holyoke Soldiers' Home on May 1, 2020.
Credit Greg Saulmon / The Republican / masslive.com/photos
The Republican / masslive.com
The Holyoke Soldiers' Home on May 1, 2020.

Pearlstein's report says Bennett Walsh, the superintendent of the home who was put on paid administrative leave in March, and his leadership team made some decisions in late March that "were utterly baffling from an infection-control perspective, and were inconsistent with the Home's mission to treat its veterans with honor and dignity." From the report:

While the Home's leadership team bears principal responsibility for the events described in this report, Mr. Walsh was not qualified to manage a long-term care facility, and his shortcomings were well known to the Department of Veterans’ Services — yet the agency failed to effectively oversee the Home during his tenure despite a statutory responsibility to do so.

Attorney General Maura Healey and U.S. Attorney Andrew Lelling are each separately investigating the Holyoke facility.

Baker, in a statement, said the report released Wednesday "lays out in heartbreaking detail the terrible failures that unfolded at the facility, and the tragic outcomes that followed."

"Our emergency response to the COVID-19 outbreak stabilized conditions for residents and staff, and we now have an accurate picture of what went wrong and will take immediate action to deliver the level of care that our veterans deserve," Baker said. 

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