page_title: Soldiers' Home in Holyoke
section_title: Outbreak and deaths from COVID-19
hierarchical_section_title: Soldiers' Home in Holyoke / History / Outbreak and deaths from COVID-19
caption_attribution_description: English: Soldiers from the Massachusetts National Guard chat with residents of the Holyoke Soldiers Home in Holyoke, Mass., April 1, 2019. Soldiers from the Mass. National Guard, most of whom are medics or health care providers, are on hand at the long term care facility to augment the staff as they and the residents face an outbreak of COVID-19 cases. (Massachusetts National Guard photo by Army Spc. Samuel D. Keenan)
context_page_description: The Soldiers' Home in Holyoke is a full-service veterans center and hospital located in Holyoke, Massachusetts, which maintains 247 beds in its main nursing facility, and a separate domiciliary care building with 30 full-time residents. The facility provides long-term care and outpatient medical services, as well as dental and social services, and programming and events for veterans. Operated by the Massachusetts Department of Veterans' Services, it is inspected annually by both the state and the United States Department of Veterans' Affairs.
  In April 2020, at least 74 veterans—30 percent of the home's residents—died of COVID-19 in the deadliest outbreak at a long-term care facility in the U.S. during the COVID-19 pandemic. A subsequent independent report found that poor infection control practices and chaotic decisionmaking promoted the spread of the virus within the home. In response to the outbreak the facility is implementing a $2 million dollar overhaul to redesign its floors, reducing the number of beds to 160 in compliance with distancing guidelines.
context_section_description: In April 2020, at least 68 residents of the Soldiers' Home in Holyoke died of the novel coronavirus (COVID-19). It was the deadliest outbreak at a long-term care facility in the United States during the COVID-19 pandemic. Another 82 residents and 81 employees tested positive for the disease. In late March, there were 230 residents at the home; by April 29, only about 100 remained. 
  An 174-page independent report was commissioned by the state in April and released on June 24. It was strongly critical of superintendent Bennett Walsh for mishandling the outbreak by making decisions that were "utterly baffling from an infection-control perspective" and "likely contributed to the death toll during the outbreak." 
  Walsh, a retired U.S. Marine Corps lieutenant colonel, lacked prior experience in nursing homes and had no medical background. He had been superintendent of the home since 2016. The report also determined that Massachusetts Secretary of Veteran Affairs Francisco Urena had failed to exercise proper oversight over the home to correct problems. The report found that in late March, the home combined a floor of veterans with COVID-19 with a floor of veterans who did not have COVID-19, violating "a basic tenet of infection control" and overcrowding 40 veterans in a space designed for 25. The report also identified a number of other substantially faulty decisions, including failing to isolate residents suspected to have been infected; failing to promptly close the facility's common areas; failing to test residents with symptoms, and rotating staff between units. Among other personnel changes, Walsh was placed on administrative leave in March, and was fired in June after the release of the report. Urena was forced to resign.  Governor Charlie Baker accepted all nine reforms proposed by the report and added three more, enacting some with executive action and filing some with the legislature as proposed changes to state law.
caption: Medics from the Massachusetts National Guard speak with sick residents in the Soldiers' Home on April 1, 2020, augmenting a shortage of staff
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