A report the deadly coronavirus outbreak at a state-run nursing home for veterans in Western Massachusetts was released this week. It found that the home’s leadership team made “substantial errors” that “likely contributed to the death toll.

Miriam Wasser/WBUR

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Miriam Wasser/WBUR

A report the deadly coronavirus outbreak at a state-run nursing home for veterans in Western Massachusetts was released this week. It found that the home’s leadership team made “substantial errors” that “likely contributed to the death toll.

Miriam Wasser/WBUR

The first independent investigation into the deadly coronavirus outbreak at a state-run nursing home for veterans in Western Massachusetts was released this week. The scathing report found no evidence that top officials at the Holyoke Soldiers’ Home tried to cover-up the crisis, but concluded that the home’s leadership team made “substantial errors” that “likely contributed to the death toll during the outbreak,” and that the state’s Department of Veteran Services failed to provide oversight.

Since the outbreak began in mid-March, at least 76 veterans in the 247-bed home have died from COVID-19, while another 80 veterans and 84 employees contracted the virus. It is one of the deadliest examples of how the coronavirus has devastated long-term care facilities during the pandemic.

Massachusetts Gov. Charlie Baker, who ordered the report in early April, called the findings “nothing short of gut-wrenching,” and promised reforms.

The report identified a number of long-term issues that contributed to the crisis — chronic staffing problems, for example — but placed most of the blame on the home’s superintendent, a retired Marine named Bennett Walsh, and the secretary of the state’s Department of Veteran Services, another retired marine named Francisco Ureña.

According to the report, Walsh wasn’t qualified for the job and had poor leadership and communication skills — one employee described his management style as being characterized by “retaliation, bullying, unnecessary commentary, and not enough training.”

Under Walsh’s watch, the home made several “utterly baffling” decisions investigators wrote. The most alarming example was the decision on March 27 to combine two floors of residents, a move that wound up mixing veterans who had the virus with those who did not.

“The consolidation of these two units resulted in more than 40 veterans crowded into a space designed to hold 25,” the report stated. “This overcrowding was the opposite of infection control.”

One employee who participated in the move said she felt like she was “walking [the veterans] to their death.”

Three days later, when news broke about the crisis in the home, Walsh was put on paid administrative leave. He was fired this week. (Walsh’s attorney says his client disagrees with how he was characterized in the report and is reviewing his legal options.)

The state also fired Veteran Services Secretary Ureña this week. According to the report, Ureña had serious concerns about Walsh’s capabilities, but failed to provide adequate oversight.

Employees of the Soldiers’ Home and family members who lost loved ones say that while the report is difficult to read, they’re relieved investigators provided a blunt and honest analysis. Families have called on the governor to increase oversight and state funding at the home, and yesterday, he outlined a reform

Massachusetts’ Attorney General Maura Healey, the U.S. Justice Department and the state inspector general are also investigating the outbreak at the home. And on Friday, federal lawmakers called for an investigation into the Chelsea Soldiers’ Home, the other state-run home for veterans in Massachusetts