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Dear Doug Collins

The Holyoke Soldiers' Home: Seventy-Six Veterans, One Merged Unit, No Convictions

The men who lived at the Holyoke Soldiers' Home in the spring of 2020 had already done the dangerous part of their lives. They were veterans of World War II, Korea, and Vietnam, in their seventies, eighties, and nineties, many of them living with dementia behind the locked doors of the home's memory-care units, in a state-run facility whose stated mission was to provide care with honor and dignity. In late March 2020, as COVID-19 moved through the building and staff called out sick, the home's leadership consolidated its two locked dementia units into one — placing, by the attorney general's count, 42 veterans, some of them COVID-positive and others showing no symptoms at all, into a unit built for 25 beds. Within days the home's morgue was full and bodies were being stored in a refrigerated truck. At least 76 veterans died over eleven weeks. This page is the record of who those residents were, of the decisions made over them, and of everything the Commonwealth of Massachusetts did — and did not do — afterward.

The service and the promise

The Soldiers’ Home in Holyoke opened in 1952 at 110 Cherry Street in Holyoke, Massachusetts, about ninety miles west of Boston, to provide health care to eligible veterans of the Commonwealth. It was authorized under Chapter 115A of the Massachusetts General Laws and operated inside the Department of Veterans’ Services, itself nested in the Executive Office of Health and Human Services. Its mission, stated on its own materials, was “to provide care with honor and dignity and the highest quality of personal healthcare services to Massachusetts Veterans.” The main building held a 247-bed long-term care facility with round-the-clock licensed nursing, hospice care, a dental clinic, a veterans’ assistance center, and outpatient services; a separate domiciliary building housed 30 full-time residents. A seven-member board of trustees, appointed by the governor, governed the home, and a superintendent ran it day to day.

The residents, as a defined group, were the Commonwealth’s oldest soldiers. The individual residents who appear in the public record bear that out: Charles Lowell, a 78-year-old Air Force veteran who served from 1960 to 1965; Alfred Healy, a 91-year-old Korean War veteran who served from 1950 to 1952; James Mandeville, an Army veteran who had lived at the home for sixteen years; Joseph Sniadach, a Korean War veteran whose estate filed the federal class action. Attorney General Maura Healey, announcing the criminal case, framed the group’s claim in the terms the men themselves would have recognized: “The veterans risked their lives from the beaches of Normandy, to some the jungles of Vietnam and to know that they died under the most horrific circumstances is truly shocking.” The promise ran in one direction. A veteran who could no longer care for himself, and whose family placed him in the Commonwealth’s own home, was supposed to be the safest long-term care resident in Massachusetts — cared for by the state he had served, in a facility the state itself ran.

The physical plant was already failing that promise a decade before the virus arrived, and the failure is documented, not alleged. A 2010 survey by the U.S. Department of Veterans Affairs found the home’s rooms noncompliant with federal accessibility standards; a 2012 state needs assessment found that of 278 beds, less than 5 percent met VA standards. In 2013 the VA approved a design — developed under Superintendent Paul Barabani, who ran the home from 2011 to 2016 — for private rooms and community-living units, with 65 percent federal funding; in 2014 the VA approved an adult day health care program on the same terms. Both approvals required a 35 percent state match. The Commonwealth never committed it, even as it approved $199 million in November 2017 for a new facility at the sister Soldiers’ Home in Chelsea. Barabani resigned in 2016, he and Congressman Richard Neal later told Congress, because he felt the state was not addressing critical needs at the home, including inadequate staffing and crucial renovations. The home the virus entered in March 2020 was therefore a crowded, aging facility whose problems had been surveyed, designed around, approved for federal money, and left in place — and which sat outside the inspection regimes that applied to ordinary nursing homes: the later reform law’s requirement that the homes be licensed by the Department of Public Health was, legislators noted, a requirement that had not previously been enforced in state law.

What happened

The outbreak began, on the accounts staff gave investigators and reporters, in mid-March 2020, with a resident on one of the memory-care floors who began showing symptoms. Employees told WBUR that they asked about infection-control plans, that management withheld personal protective equipment, and that little effort was made to isolate the man. The first veteran tested positive on March 17. The independent investigation later found that even though he had shown symptoms for weeks, staff “did nothing to isolate” him until his test came back positive — he remained with three roommates, wandered the unit, and spent time in a common room. As residents and employees fell ill, the staffing shortage that had been chronic became acute, and the home could not cover both dementia units.

On Friday, March 27, 2020, the home’s leadership made the decision at the center of every investigation, indictment, and lawsuit that followed. Facing the staffing crisis, Superintendent Bennett Walsh, Medical Director Dr. David Clinton, the chief nursing officer, and others met and consolidated the two locked dementia units of Care Center 1 onto a single floor, 1 North. The attorney general’s office put the number combined at 42 veterans — some COVID-positive, others not even showing symptoms — in a unit that usually accommodated 25 beds. The Supreme Judicial Court’s later summary of the grand jury record described the plan as placing approximately forty-six veterans on the consolidated floor. Either way, the arithmetic required compression: six or seven veterans into rooms meant for four, nine additional beds a few feet apart in the dining room, and residents permitted to mingle regardless of status. The independent report’s judgment is the sentence the case is filed under: “Rather than isolating those with the disease from those who were asymptomatic — a basic tenet of infection control — the consolidation of these two units resulted in more than 40 veterans crowded into a space designed to hold 25. This overcrowding was the opposite of infection control; instead, it put those who were asymptomatic at even greater risk of contracting COVID-19.”

The staff who carried out the move left their own testimony in the same report. When a social worker raised concerns, the chief nursing officer answered that “it didn’t matter because (the veterans) were all exposed anyway and there was not enough staff to cover both units.” One staffer told investigators she felt like she was “walking (the veterans) to their death.” The report also records what leadership expected next: on the day the veterans were moved, more than a dozen additional body bags were sent to the combined unit, and leadership had shifted, in the investigators’ words, from trying to prevent the spread of the virus “to preparing for the deaths of scores of residents.” The next day, a refrigerated truck arrived to hold bodies that would not fit in the home’s morgue; within days the morgue was at capacity and body bags were piling up in the truck outside.

Outside the building, almost none of this was visible — and that invisibility is part of the record. Until March 30 the home had publicly announced only one positive case. Holyoke’s mayor, Alex Morse, said he learned the gravity of the situation from an anonymous tip over the weekend and then from Walsh himself on Sunday: eight veteran deaths between Wednesday and Sunday with no notification to the mayor’s office or to the state. Governor Baker said he and his senior officials first learned of the situation on Sunday night, March 29, in a call with Morse. On March 30 the state took control: Walsh was placed on paid administrative leave, a clinical command team was installed under Val Liptak, the CEO of Western Massachusetts Hospital, and the National Guard was brought in to test and to staff. Prosecutors, describing the command center witnesses in 2024, said visitors found veterans not being hydrated or fed, family members stepping in to hydrate residents themselves, and veterans walking around unclothed — conditions the Commonwealth contended were avoidable if authorities outside the home had been alerted sooner.

The toll, stated carefully, is this. The count used by the independent investigation, the criminal courts, the Legislature, and the State Auditor — who repeated it as recently as January 2026 — is at least 76 veterans dead of COVID-19 over eleven weeks from March into June 2020, out of roughly 210 to 235 residents in the home when the outbreak began; Congressman Neal’s office recorded 158 residents testing positive, and more than 80 employees were also infected. The families’ class action, working from the settlement window of March 1 to June 23, 2020, counted higher: plaintiffs’ counsel Thomas Lesser and Michael Aleo stated at the settlement that 84 residents died and roughly the same number were sickened and survived — the figure the Associated Press, Reuters, and the New York Times carried in May 2022. This page uses 76 as the official floor — the number every government record converges on — and 84 as the families’ documented accounting. What is not in dispute is the proportion: roughly one resident in three who contracted the virus died, in one of the deadliest single-facility outbreaks in the United States.

The families’ experience of those weeks is also testimony, given under their own names to a legislative committee. Susan Kenney, of Ware, heard news reports of deaths, called about her father, Charles Lowell, and heard nothing — no answer from the command center for more than 30 hours. She wrote “Is my dad alive?” in big letters on her car windows and drove to the home. Her father died on April 15. Michael Gaudette, whose father George, an Army veteran with dementia, died in the outbreak, told the committee: “Our soldiers were imprisoned here. They were concentrated into rooms that allowed the COVID virus to take advantage of these people that really were in a weakened state already.”

What the institution did afterward

The Commonwealth answered with investigations first, and the first of them set the terms. In early April 2020 Governor Baker commissioned former federal prosecutor Mark W. Pearlstein of McDermott Will & Emery to investigate independently. The Pearlstein report — released June 24, 2020, running more than 170 pages, built on roughly 100 interviews and 114,000 pages of records — found no evidence that officials had tried to cover up the crisis, but concluded that the home’s leadership team made “substantial errors” that “likely contributed to the death toll,” in decisions it called “utterly baffling,” and that “Mr. Walsh and his team created close to an optimal environment for the spread of COVID-19.” It found Walsh was not qualified to manage a long-term care facility, that his shortcomings were well known to the Department of Veterans’ Services, and that the department failed to oversee him effectively. Baker called the findings “nothing short of gut-wrenching.” Veterans’ Services Secretary Francisco Ureña, who the report found had allowed Walsh to remain despite knowing he was “in over his head,” was asked to resign the night before the report’s release and did; Walsh contested the administration’s power to fire him and resigned that fall. The report’s independence was later contested: a Boston Globe Spotlight investigation in May 2021 reported that the report was full of errors and omissions that shielded Baker and Secretary Marylou Sudders from blame, including that Baker had signed off on Walsh’s 2016 hiring and that Sudders had been told of staff complaints about his management. Pearlstein defended the report, pointing to the department’s frontline statutory responsibility for the home.

The second official account came from the Massachusetts Office of the Inspector General, which had opened its investigation in 2019 — before the pandemic — on an anonymous complaint about Walsh. Its report, Holyoke Soldiers’ Home, May 2016 to February 2020, released in April 2022, deliberately did not re-investigate the outbreak; it documented what preceded it. It found that the governor, the Health and Human Services secretary, and the board of trustees did not follow the statute giving the board the power to appoint the superintendent: the board recommended three candidates, the secretary met only with Walsh, and the governor appointed him. It found Walsh “did not have and did not develop the leadership capacity or temperament for the role,” retaliated against employees he deemed disloyal, demonstrated a lack of engagement in the home’s operations, and circumvented his chain of command — and that his supervisors let it continue. Its recommendations, including public-health clinical oversight and a confidential ombudsperson and hotline, were substantially adopted by the Legislature.

The criminal answer came on September 24, 2020, when a statewide grand jury indicted Walsh and Clinton — ten counts each of elder bodily injury and elder neglect under the caretaker statute, all arising from the March 27 consolidation and five named veterans. Attorney General Healey announced the indictments on September 25: “We believe this is the first criminal case in the country brought against those involved with nursing homes during the COVID-19 pandemic.” The U.S. Attorney’s Office and the U.S. Department of Justice’s Civil Rights Division also opened an inquiry into whether the home had violated residents’ rights; no federal charges appear in the public record located for this page. The civil answer had begun earlier: on July 17, 2020, the estate of Joseph Sniadach filed a federal civil rights class action alleging “deliberate indifference,” seeking $176 million, on behalf of the veterans who had lived at the home between March 1 and June 23, 2020.

The Legislature built the structural answer. Its Special Joint Oversight Committee heard the families in October 2020 and reported in 2021. On August 4, 2022, An Act relative to the governance, structure and care of veterans at the Commonwealth’s veterans’ homes was approved as Chapter 144 of the Acts of 2022, effective March 1, 2023. It created a cabinet-level Executive Office of Veterans’ Services, whose secretary is the appointing authority for superintendents. It required that a superintendent be a licensed nursing home administrator and a veteran or experienced in managing veterans in long-term care — the qualifications whose absence defined the Walsh appointment. It required both homes to be licensed by the Department of Public Health, inspected biannually and monthly during a declared emergency, and certified by the Centers for Medicare and Medicaid Services, and it created a 19-member Veterans’ Homes Council. Governor Healey appointed Jon Santiago, a physician and military veteran, as the first cabinet-level secretary in March 2023.

The money answer closed in 2022. On May 12, 2022, the Commonwealth agreed to pay $56 million to settle the class action, without admitting liability: estates of deceased veterans would receive a minimum of $400,000, and veterans who contracted COVID-19 and survived a minimum of $10,000. U.S. District Judge Mark Mastroianni approved the settlement on November 14, 2022; with three additional plaintiffs added, the approved total was about $58 million, covering 164 plaintiffs, with plaintiffs’ counsel receiving 19.8 percent. “There is no amount of money that can compensate our clients for the loss of their loved ones,” Lesser said, “but our clients are grateful that the Commonwealth has acted to resolve this matter without the need for protracted litigation.” Susan Kenney’s response held both halves of the families’ position: the settlement was “at least some sort of acknowledgement,” and the demand remained that those who could have prevented it be held accountable.

That demand ran into the criminal case’s full path, which took three and a half years. On November 22, 2021, Hampden Superior Court Judge Edward J. McDonough Jr. dismissed all charges. He held that the five named veterans were already exposed to COVID-19 before the merger, that there was “insufficient reasonably trustworthy evidence” that, had the units not been merged, any of the five veterans’ medical condition would have been materially different, and — as Walsh’s counsel summarized the ruling — that neither defendant met the statute’s definition of a “caretaker.” Healey’s office appealed on December 14, 2021, and the Supreme Judicial Court took the case on direct appellate review. On April 27, 2023, in Commonwealth v. Clinton, SJC-13335, the court reversed, 5 to 2: the testimony before the grand jury “constituted probable cause to believe that the defendants violated the elder neglect statute,” administrators responsible for residents’ health and safety could be caretakers under it, and Judge McDonough “erred in dismissing the indictments.” Justices Lowy and Cypher dissented; Lowy wrote that criminalizing blame “will do nothing to prevent further tragedy.”

The case was set for trial in March 2024. On March 26, 2024, in Hampshire Superior Court, Walsh and Clinton withdrew their not guilty pleas and admitted that the facts were sufficient to support a guilty finding on the charges. Prosecutors asked for one year of home confinement with three years of probation. Judge McDonough — the same judge who had dismissed the case — instead accepted the defense request and continued each case without a finding for a three-month period, with conditions barring the men from working in a nursing home and from initiating contact with victims’ families; on compliance, the charges would be dismissed. No conviction was entered, and neither man was sentenced to any time in custody. Attorney General Andrea Campbell, who had inherited the prosecution from Healey, stated: “Today the justice system failed the families who lost their loved ones at the Holyoke Soldiers’ Home. I am disappointed and disheartened with the Court’s decision, and want these families and our veterans to know my office did everything it could to seek accountability.” Susan Kenney, in the courtroom, called the outcome “disgusting, absolutely disgusting,” and said: “It’s just an injustice. There is no accountability.”

Where it stands now

The institution that exists today is not the one that failed in March 2020. The facility is now the Massachusetts Veterans Home at Holyoke, operating under the Executive Office of Veterans’ Services created in March 2023. The Healey administration reports a three-year turnaround: full licensure and certification from the Department of Public Health, the Centers for Medicare & Medicaid Services, and the U.S. Department of Veterans Affairs; a fiscal 2025 allocation of $34.3 million for Holyoke within $87.4 million for the two veterans homes, described as the largest in the home’s history; falls with major injury down 27.4 percent since 2021; restraint use at zero; and a dedicated women veterans unit. Those figures are the administration’s, and they sit alongside a colder document: in January 2026 the State Auditor’s audits of Holyoke (July 2020 through June 2023) and Chelsea found continuing violations — failures in documented rounding, incident handling, emergency-plan posting and drills, and the absence during the audit period of the electronic health record system required of comparable facilities. The same audit record carries an unresolved footnote: the auditor sought the interviews, notes, and underlying records of the Pearlstein investigation, and the Governor’s office — under both administrations — withheld them as attorney-client work product. The auditor concluded the Pearlstein work was a fact-finding management study, not legal work, and that the withholding was improper. The underlying record of the central investigation therefore remains, as of January 2026, outside full public and audit review.

The replacement home is rising on the same hill. After the families’ coalition — organized in 2020 as the Holyoke Soldiers’ Home Coalition and campaigning as Fund the Holyoke Soldiers Home Now — pressed for the project the VA had approved in principle a decade earlier, the Commonwealth committed to a full reconstruction: an eight-story, 350,000-square-foot facility on the Cherry Street site, designed on the VA’s small-house model, with 234 long-term care beds, a 30-bed memory care floor, a 40-person Adult Day Health Program, and a veterans memorial in the design. Ground was broken on August 14, 2023, with Governor Healey meeting privately with families beforehand; Cheryl Turgeon, whose father Dennis Thresher died after contracting COVID-19 at the home, said the new building on the same site “provides some sense of closure that I didn’t have previously.” The program cost is put at $482 to $483 million by the administration, with $263.5 million in federal VA grant funding secured — 65 percent of the cost; the capital agency lists the project cost at $465,407,441. The structure topped off in November 2024, ahead of schedule. On timing, the public sources divide and this page reports both: the administration has said the new facility will welcome its first residents in the fall of 2026, with full completion, including demolition of the 1952 building, by the summer of 2028; the capital agency’s project page lists estimated construction substantial completion in the fall of 2028. As of this writing the new home is under construction, not yet open, and current residents are still cared for in the building where the outbreak occurred.

The criminal ledger is closed. The settlement the Commonwealth has in practice reached with itself is this: the failure will be memorialized in the new building, compensated in the settlement, and governed against in the statute, and it will not be punished in any individual. The families’ coalition continues as an organized presence in the home’s oversight politics. The demand it carried from 2020 forward — criminal accountability for the March 27 decision — was tested through indictment, dismissal, reinstatement by the Commonwealth’s highest court, and an admission of sufficient facts, and it ended with a continuance without a finding. That is where it stands.

The ledger

The accounting, in three lines — what the record shows has been done, what it shows has not, and what is still being sought.

What has been done

What has not been done

What is being sought

The record, on video

The Holyoke record was made in hearings and on a construction site more than in documentaries. Three films, in that order: the Western Mass News report on the January 2021 oversight hearing, preserved as embedded by Senator John Velis’s office; and the Division of Capital Asset Management and Maintenance’s official work-in-progress films of the new Veterans Home, published on the Commonwealth’s project page.

The oversight hearing. Western Mass News (WGGB/WSHM) reports the Special Joint Oversight Committee hearing of January 2021 — Secretary Marylou Sudders answering for staffing, scheduling, and oversight, with Senator John Velis questioning. Reported by Audrey Russo and Morgyn Joubert. (Western Mass News.)

The rebuilding, in progress. The Commonwealth's project film of construction on the 110 Cherry Street site — the 350,000-square-foot replacement home going up beside the 1952 building it will replace. (Executive Office for Administration and Finance, Commonwealth of Massachusetts.)

The rebuilding, earlier phase. The earlier work-in-progress film published on the same Mass.gov project page for the Holyoke Veterans' Home reconstruction. (Executive Office for Administration and Finance, Commonwealth of Massachusetts.)

Sources

Part of Betrayed, Not Forgotten — this site's accounting for the service members and veterans their own institutions failed. Videos are embedded from their publishers; nothing here is re-hosted.