Governor Baker addresses investigation report on Soldiers’ Home in Holyoke

Boston Statehouse

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BOSTON (WWLP) – Governor Baker is scheduled to hold a news conference on the findings of an independent investigation at the Soldiers’ Home in Holyoke Wednesday afternoon.

REPORT: Independent Investigation at Holyoke Soldier’s Home

Former federal prosecutor Attorney Mark Pearlstein was retained by Governor Baker to investigate the numerous amounts of deaths in the Soldiers’ Home during the pandemic. The investigation and report have been completed independently by the Baker-Polito Administration.

81 Holyoke Soldiers’ Home veterans recover from Covid-19

Governor Baker called for an independent and thorough investigation at the home in efforts to get to the bottom of what happened and take immediate action.

“This report 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.”

Governor Baker

Watch Governor Baker’s full press conference below:

The report focuses on the COVID-19 tragedy that occurred at the home which resulted in at least 76 veteran deaths and an additional 84 veterans and over 80 staff members who tested positive for the virus. The report reveals substantial errors and failures by the home’s leadership including Superintendent Walsh by the Massachusetts Department of Veterans’ Services which likely contributed to the death toll during the outbreak.

The report also states Walsh was not qualified to manage a long-term care facility and his shortcomings were notified to the Department of Veterans Services, however, the agency failed to effectively oversee the home during his tenure.

The biggest error made by the leadership team was the decision to move all veterans from one of the two locked dementia units into another locked dementia unit where they would be crowded in with veterans already living there. That decision was made on March 27, during the first initial surge of COVID-19 cases. Instead of isolating those with the virus from those who were a-symptomatic, the decision to combine the two groups resulted in 40 veterans crowded into a space that only holds 25 people.

Overall, the investigation concluded the following findings:

  • The Soldiers’ Home leadership team made substantial errors in responding to the COVID-19 outbreak
  1. Combining two locked dementia units containing veterans with a mix of COVID-19 statuses, and failing to ensure an appropriate standard of care on the combined unit.
  2. Failure to promptly isolate patients suspected of COVID-19 using the rooms set aside for isolation.
  3. Delays in testing additional veterans for COVID-19 when they were showing symptoms.
  4. Delays in closing common spaces.
  5. Failure to stop rotation of staff among units.
  6. Inconsistent policies and practices with respect to personal protective equipment.
  7. Recordkeeping and documentation failures.
  • The Department of Veterans’ Services did not take steps to address substantial and long-standing concerns regarding the leadership of the Soldiers’ Home.
  • Although Mr. Walsh reported other information that was inaccurate and incomplete, we have not identified any material violations of the reporting requirements concerning COVID-19 test results and deaths.

Lastly, the report included suggestions for a number of staffing, technology, and physical plant improvements, and a recommendation that the Soldiers’ Home should not be exempt from the requirements for licensing and inspection that apply to other long-term care facilities in Massachusetts.

Attorney General Maura Healey released the following statement on Pearlstein’s Holyoke Soldiers’ Home report:

“The Pearlstein report provides a heart-wrenching account of what went wrong during the response to the COVID-19 outbreak at the Holyoke Soldiers’ Home. The report reveals that serious failures by leadership at the home contributed to the tragic loss of life there. It also lays bare systemic failures of oversight by the Baker Administration inadequately preparing, staffing, and responding to this crisis to protect our veterans. These veterans served our country and risked their lives to protect us, and our state wholly failed to protect them. Our ongoing investigation will determine whether these missteps and errors warrant legal action.

I urge the Baker Administration to adopt recommendations from the Pearlstein report to improve oversight at Holyoke Soldiers’ Home, including common-sense practices like having DPH inspect the facility regularly, implementing a streamlined reporting structure, and appointing experienced healthcare leaders to oversee the facility, which in my view, should have already been happening.”

AG Maura Healey

In addition, the Massachusetts Democratic Party Chair Gus Bickford on Baker Administration released the following statement:


“Today’s report reveals that there is plenty of blame to go around within the Baker administration for the tragedy that took place at the Holyoke Soldiers’ Home. This administration installed and left in place as Superintendent an individual that was not qualified and was looked upon with caution by one top Baker official. Over the four years, the Superintendent was in place, multiple red flags were raised as to his suitability, yet the Baker administration did nothing. Who knows how many veterans would still be alive if the Baker administration demonstrated basic leadership and management skills.”

MDP Gus Bickford

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