Failure of command

Governor Charlie Baker was indignant last June, as he outlined the results of an investigation into the crisis at the Holyoke Soldiers' Home.

“It’s a very special place, and has always held a special place in my heart,” Baker said of the state-run home, where a COVID-19 outbreak had killed 76 veterans that spring — one of the highest death tolls of any senior-care center in the country.

The report by Boston attorney Mark Pearlstein was “nothing short of gut wrenching,” Baker said. The chaos and carnage at the Soldiers’ Home was “truly horrific and tragic.” There had been inexcusable failures of leadership by superintendent Bennett Walsh and of oversight by Secretary of Veterans’ Services Francisco Ureña, Baker said. So they both had to go.

At that press conference, Baker and Health and Human Services Secretary Marylou Sudders took no personal responsibility for the massive loss of life at a facility they oversaw. Instead, they laid blame solely on officials below them, particularly Walsh and Ureña, in what a Boston Globe Spotlight Team investigation has found was an often misleading narrative marked by omissions and false assertions.

The governor distanced himself from the decision to hire superintendent Walsh, who now faces charges of criminal neglect during the pandemic. Baker said Walsh had been appointed by the Soldiers’ Home board of trustees, which “really wanted Bennett Walsh to have that job. And I can tell you that the first time I ever met him or talked to him was when we swore him in.”

That wasn’t true. Baker interviewed Walsh before naming him superintendent in 2016, despite Walsh’s lack of health care management experience, an administration spokesperson recently confirmed.

Baker also indicated that he and Sudders knew little about how badly Walsh was “in over his head,” as one Veterans’ Services official described his tenure to Pearlstein. When a reporter asked if knowledge of Walsh’s shortcomings ever “got to the level of Secretary Sudders or your office,” Baker replied, “I think the report kind of speaks for itself.”

So the answer is no? “Yeah.”

That wasn’t true, either. Sudders had been directly involved in supervising Walsh before the outbreak, according to people with knowledge of the situation, and Sudders had to address serious management problems under what current and former employees described as Walsh’s inept, volatile, and ego-driven leadership — problems evident long before the pandemic hit.

In fact, the reality behind the Soldiers’ Home crisis is stark: Walsh was a politically connected hire by Baker that went disastrously wrong. When COVID struck, his lack of fitness for the post was exposed as the disaster unfolded. Yet Walsh, the son of an influential Massachusetts family, was protected from repercussions until it was too late.

Baker has long cultivated a reputation for technocratic good government, a can-do persona that helped make him, for several years, the most popular governor in the country. Sudders, too, is widely viewed as a hard-working public servant committed to effective government.

They are a formidable team, and their performance in the face of the COVID outbreak’s unprecedented demands has drawn considerable praise. They have made mistakes, some of them large, but corrected course as needs shifted — the mark, many say, of good management. Witness the state’s journey from a vaccination rollout disaster to having one of the best inoculation rates in the country.

But the Holyoke crisis is the story of something else, of government failure at every level, beginning with Walsh’s appointment to a job for which he lacked crucial qualifications.

In its wake, Baker and Sudders have relied on the Pearlstein report — commissioned by the governor — as a thorough, unstinting review of what went wrong at the home. But a Spotlight review of the report found it to be marred by key errors and omissions that helped shield Baker and Sudders from blame.

Baker, Sudders, and Walsh all declined to be interviewed about the Soldiers’ Home. Walsh’s attorneys also declined to respond to written questions. Baker and Sudders did not answer numerous detailed written questions, while deflecting others by referring to the Pearlstein report or previous public statements.

Citing ongoing investigations, privacy, and other grounds, the administration has also failed to provide documents in response to more than 10 public records requests by the Globe related to Walsh’s hiring and tenure.

In a statement, the administration defended the integrity of Pearlstein’s report and Walsh’s appointment. “Politics played no role in his hiring,” Baker spokesperson Sarah Finlaw said of Walsh. “The Baker-Polito Administration has taken accountability for this gut-wrenching tragedy and immediately implemented new leadership and filed legislative reforms to improve the safety of the Home for all residents, staff and families.”

Sudders spokesperson Brooke Karanovich said, “When issues with Bennett Walsh’s management were brought to the attention of [Sudders] by the Department of Veterans’ Services leadership — who is responsible for the oversight of the Home — resources were provided to address those concerns.”

“Given the open criminal investigation and the ongoing investigations with the Office of the Inspector General and the U.S. Attorney’s Office, we’re not able to comment further,” Karanovich also said. The US attorney’s office is investigating allegations of mismanagement and neglect at the home during the pandemic, while the Inspector General is investigating alleged financial misconduct there.

For many connected to the Soldiers’ Home tragedy, the pain remains deep. “There are just so many hands with blood on them,” said Sue Perez, daughter of James Miller, a World War II Army veteran who died at the home last spring. “Walsh makes my blood boil, but it is all about nepotism. Baker appointed him. So, you know, he is in it, too. They all have a part.”

But as families and staff grapple with lingering trauma, the case also sheds light on realities with far broader implications: the corrosive effect — and, in a care facility, potentially tragic consequences — of unqualified patronage hires in leadership roles.

More than a dozen current and former Holyoke employees and other officials told the Globe that Walsh was unfit for his job, in terms of both skills and temperament. Many of those interviewed asked for anonymity out of concern for professional repercussions.

“I think they thought if they had the right setup, he could do very little harm,” said one former top staffer at the Soldiers’ Home.

Sudders’ office “knew he was a ticking time bomb,” said the staffer, explaining that people feared Walsh, known to have a short temper, might strike a subordinate in anger. “But I don’t think anyone expected a pandemic to come along,” the staffer said. “We had no way of knowing it would be as tragic.”

A candidate blessed with political connections

It was a wintry day in early 2016 in Westfield, and a Marine Corps officer with an easy smile was looking for a job.

John Velis, a state representative from Westfield, had never met Bennett Walsh before. When Velis slid into a booth at the Friendly's in this city some 100 miles west of Boston, the outgoing man sitting across from him was accompanied by his mother, longtime Springfield City Councilor Kateri Walsh, along with a constituent of Velis who’d suggested he meet Walsh for coffee.

“Before this, I didn’t know the earth had an individual named Bennett Walsh on it,” said Velis, now a state senator.

Walsh, 45, was a lieutenant colonel retiring from active duty after 24 years and planning to apply for the Holyoke superintendent’s job, he told Velis. He had master’s degrees in international relations and strategic studies, and the position had traditionally been filled by a military veteran.

But despite his graduate education and service record, Walsh told Velis he was worried about his qualifications, and for good reason: The state’s job posting emphasized health care experience.

“The ideal candidate will have a proven track record in supervising professional staff and clinicians, operating a residential and outpatient facility, managing a budget, planning and developing medical, residential, long-term and acute care programs,” the posting read.

Walsh’s service had included overseas deployments as well as stateside stretches in roles including, most recently, executive officer at Parris Island, S.C., directing a unit delivering support services for a Marine Corps recruit training program, according to Walsh’s LinkedIn page.

He had no health care background — no experience overseeing medical or long-term care facilities, programs, or staff, he acknowledged.

But Walsh was blessed with connections, growing up in a large, politically active Springfield family whose roots traced to a grandfather who served on the Massachusetts Governor's Council in 1941-43. Kateri Walsh, a moderate Democrat whom her son affectionately called "Momster," first won her City Council seat in 1987, and ran unsuccessfully for several higher offices. Walsh's father, Daniel, was a former Springfield City Council president and retired director of veterans services for the city. His uncle William Bennett had been the Hampden County district attorney for two decades.

The family’s butter-yellow house in the historic Forest Park Heights neighborhood even served as a hub for others’ political ambitions. Three Democratic candidates who went on to win 2014 elections shot TV commercials there, including Maura Healey, in her first campaign for attorney general.

Baker, a former health insurance executive, campaigned in 2014 vowing to "root out patronage." But in the case of Walsh's appointment, substantial evidence suggests that political connections played an outsized role — reaching all the way to the governor's office.

State law calls for the home’s seven-member board to appoint its superintendent — a position that carried a salary of about $124,000 in Walsh’s last year. But Baker wielded considerable influence. The governor named three of the trustees who oversaw the search, including the board chair. And after the board recommended that he choose from the top three superintendent candidates, Baker made the final call to hire Walsh. Interviews with former trustees, officials, and others, including seasoned political observers in Western Massachusetts, suggest the path was smoothed for Walsh.

"That was an inside baseball move. You know and I know there was a reason why Bennett got in there,” said Steven Como, who stepped down as Holyoke Soldiers’ Home board chair in 2016, believing Baker should be able to appoint his own chair to oversee the search. “It was a political appointment."

“Bennett’s family is very well connected in Springfield. There were a lot of people pushing for Bennett to get this position who were hosting fund-raisers for the governor the year before,” said Aaron Vega, a former Democratic state representative who is now Holyoke’s director of planning and economic development.

Kateri Walsh enlisted support for her son. Representative Carlos Gonzalez of Springfield, a Democrat, said he recommended Bennett Walsh to the Veterans’ Services secretary because he knew the family. Kateri Walsh did not respond to Globe requests for comment.

One of her colleagues, then-longtime Springfield City Councilor Tim Rooke, appears to have played a key role. Rooke, a Democrat who first crossed party lines to support Baker in 2010, had become Baker's highly visible — if unofficial — regional campaign coordinator in 2014, doing "daily campaign activity, team building, outreach, fundraising," according to Rooke's LinkedIn page.

“He was Baker and [Karyn] Polito’s point person in Western Mass.,” said Como of Rooke. “He was very, very close to Governor Baker. Fund-raising activities, everything went through him. ... If he’s calling the governor’s office, somebody is picking up right away.”

After Baker’s victory, one of Rooke's first recommendations for the new governor was a trustee for the Holyoke Soldiers' Home board: Brian Corridan, a friend of the Rooke family. Corridan confirmed to the Globe that Rooke had recommended his appointment by Baker to the Holyoke board in 2015. He said Rooke told him, "'Put together something about your family's military background,' and next thing you know I was getting sworn in."

Corridan had known Walsh’s parents for years, he told the Globe, and he would go on to champion Walsh’s candidacy during the superintendent search.

Rooke declined to respond to repeated requests for comment on his connections to the Holyoke Soldiers’ Home, including written questions that explicitly asked about his role in Walsh’s candidacy.

Baker did not answer a written question from the Globe asking if Rooke had recommended Walsh as superintendent to him.

Hiring Walsh enabled Baker to form ties with a politically influential Democratic family in Western Massachusetts, where residents often felt overlooked by Boston's power brokers, and in a blue state, where the Republican governor has had to base much of his appeal on reaching out to Democrats and independents.

For Baker, the appointment was also a chance to exert firmer control over the Soldiers’ Home, where the previous superintendent, Paul Barabani, had openly confronted his administration over a lack of state support. Barabani announced his retirement in December 2015; he told legislators last fall that he had felt forced out.

Baker asserted his authority: Amid a backdrop of debate over who had ultimate hiring and firing power over the superintendent — the Holyoke board or the governor — Baker sent trustees a letter, soon made public, saying they and the superintendent “serve under the governor,” asking them to recommend appropriate candidates to him.

Baker also installed a new board chair to oversee the search: Michael Case, a military veteran, former Pittsfield police officer, and influential GOP political figure. At the same time, Baker gave Case an administrative job at the Department of Conservation and Recreation. Case resigned from both posts within a year because of a computer porn scandal and did not respond to requests for comment.

Led by Case, the board winnowed some two dozen candidates to seven finalists. But one applicant who might have posed a serious threat to Walsh's candidacy never got an interview: John Crotty, who stood out as both a military veteran and a state-licensed nursing home administrator — a credential required at nursing homes across Massachusetts, but not at the Soldiers' Home.

A gruff, old-school administrator, Crotty had for several years led a nursing home in nearby Agawam. An Air Force veteran with an MBA, he had also served in the Air Force Reserve as a health services administrator, directing the transport of wounded troops from Iraq and Afghanistan.

Crotty had applied in January 2016 for the superintendent post, but Baker administration officials apparently decided they wanted to install him as deputy, not in the top job.

“Crotty was somebody that the governor was trying to get me to put in as deputy superintendent,” said Como, who stepped down on Feb. 15, recalling an urgent call from an aide to Ureña urging Crotty’s hiring. “They wanted him in right away.”

By the time trustees sorted through superintendent applications, Crotty’s resume was out of the picture. Three former trustees said they don’t recall seeing his application.

Ureña said he was unaware his aide had intervened and urged the board to interview Crotty. But contacted on short notice, Crotty was about to leave for an overseas trip, and trustees wouldn’t wait a week for his return. Crotty would be hired as Walsh’s deputy a year later.

The path for Walsh was clear. When he arrived for his interview, trustee Corridan acted as his “spokesperson,” introducing him to board members, Ureña recalled. “From that minute, I had the feeling he was given the questions in advance,” Ureña said. “There was a sense of familiarity and chattiness when Bennett Walsh walked into the room. … He had a degree of comfort in answering the questions the others didn’t have.”

Afterward, some trustees hesitated because Walsh lacked a health care background. But Corridan emphasized that the home already had doctors and nurses on staff.

“We had the health care aspect pretty well covered. What that place needed was a leader. And this Marine was a leader,” Corridan told the Globe last fall. “This is not a man who runs away from battle. He runs into it.”

Walsh’s military record featured multiple promotions. Yet Walsh would later joke on more than one occasion to Soldiers’ Home managers, “I’ve been fired from every job I ever had in the military,” one of the managers recounted.

Walsh's Iraq deployment also offers one revealing snapshot of his combat service. Walsh was commander of the Weapons Company, First Battalion of the 25th Marines, in 2006. At the time, Lieutenant Colonel Christopher Landro, the battalion's commander, praised Walsh's sacrifice in leading Marines into combat despite a basal-cell carcinoma diagnosis that would cut his deployment short. Walsh earned two end-of-tour awards for service and achievement, including a medal for valor in combat operations, according to his LinkedIn page.

But several Marines who served with Walsh told the Globe he elicited mixed feelings as a commander, with some saying he was not up to the job and describing one troubling incident when troops came under fire in Fallujah, and his quick reaction force responded.

"He got so amped up," said Cody Hill of Oklahoma, the gunner manning the turret in Walsh's Humvee. "He forgot to bring a gun to a gunfight."

Hill laughed at the memory, saying, “Anybody can make a mistake.” But in this case, it was a serious matter: Walsh had left his rifle at the base “and took another Marine’s rifle so he could run around and look like he had one, and left that Marine unarmed,” said another Marine on the scene who asked for anonymity because of career concerns. It was an “egregious” failure of command, this Marine said, that “should have gotten him fired.”

“[Bennett Walsh] got so amped up, he forgot to bring a gun to a gunfight.”

Landro could not be reached for comment. The administration denied a Globe request to see Walsh’s military records, and a federal official, citing the pandemic, said the National Personnel Records Center was unable to respond.

Walsh and his attorneys declined to respond to questions about this and other allegations, with his attorneys stating that “[t]he current total focus of our attention is the criminal case and its many components now pending before the Superior Court.”

When it came time for the trustees to refer the top three candidates to Baker, Walsh was ranked first among them, though it took three rounds of voting to reach that consensus, said former trustee Cesar Lopez.

Walsh went on to meet with Sudders. Baker then interviewed him for 20 to 30 minutes on April 27, 2016, according to William Bennett, Walsh’s uncle and attorney. An administration spokesperson confirmed both meetings took place.

The job was his.

“Congratulations,” Sudders wrote by hand on the appointment letter she and Baker sent Walsh. “Thanks,” scribbled the governor.

“Lt. Col. Walsh is an outstanding leader in our communities and well qualified to become the Holyoke Soldiers’ Home[’s] next superintendent,” Baker said in a press release on May 19, 2016.

Addressing the news media soon afterward, Baker said, "He demonstrated what I would consider all the right kinds of skills and experiences to take on that role, and we're very excited to have him."

‘Sudders knew the kind of person he was’

Bennett Walsh's face was red, his teeth clenched, his hands balled into tight fists.

“I want to deck Scott Zacharie,” he said angrily.

The managers in the Holyoke Soldiers’ Home executive suite were stunned. Walsh had just been wrangling with Zacharie, the home’s admissions coordinator, whom Walsh would repeatedly push to admit veterans out of order on the waiting list.

With a price tag typically topping out at $30 a day — less than 10 percent of the average cost of a private Massachusetts nursing home stay — Holyoke Soldiers’ Home beds were coveted. But admissions were supposed to be free from political pressure. Walsh sometimes ordered shortcuts for favored applicants, current and former staff said.

“He said that in front of me, the legal counsel, and the secretary,” then-deputy superintendent John Crotty recalled of Walsh’s expression of rage that August day in 2017. “We all looked at each other, ‘Oh my God, what did we just hear?’”

Crotty had arrived at the Soldiers’ Home early that year, hired when Sudders directed that the inexperienced Walsh should have a deputy who knew how to run a nursing home.

“I went to my office and typed out my resignation,” recalled Crotty. “I didn’t go there to work for a crazy person.”

Instead of submitting it, however, Crotty teamed with the other witnesses to ensure Walsh’s behavior was reported to Sudders’ Executive Office of Health and Human Services. The report became part of a years-long management challenge involving Walsh in which Sudders was directly involved, according to people with knowledge of the situation.

As health secretary, Marylou Sudders is one of the most powerful officials in Massachusetts, overseeing 12 agencies and MassHealth. Her direct involvement in supervising Walsh suggests the importance she attached to this personnel problem.

Sudders, at one point, summoned Walsh and Ureña to her Beacon Hill office.

Francisco Ureña was in his dream job as Veterans' Services secretary, his first statewide post — appointed at age 34 by Baker to serve nearly 400,000 veterans across the Commonwealth. A Marine Corps veteran and Purple Heart recipient after an enemy van blew up in 2005 and shrapnel pierced his face, Ureña had returned from Iraq and quickly risen to become the veterans service chief for Lawrence, then Boston.

He had no idea what Sudders had in mind for the superintendent at the meeting.

“We want to give you an opportunity and management skills you didn’t receive in the military,” Sudders told Walsh, according to Ureña.

“I’m thinking this is great — he’s getting a professional coach. Companies spend big money to promote their CEOs,” said Ureña.

Walsh was relieved, too. “I thought I was getting fired today,” Ureña said Walsh told him afterward.

Instead, Sudders sent Walsh to weekly anger-management sessions with Bruce Cedar, a psychologist who practices in Newton. After another complaint about Walsh’s behavior, Sudders extended the training, Ureña said.

Walsh’s anger problems became well-known among staff. “He’s almost like a kid. If he doesn’t get his way, he has a temper tantrum,” said Luis Rodriguez, who worked there for decades and was managing inventory before a COVID infection forced his early retirement.

Visitors, veterans, and others across the Commonwealth often saw a very different side of Walsh, however: friendly and effusive, eager to talk about sports and his favorite movies.

“He was like a used-car salesman. He would ‘Hoorah!’ the veterans and joke with the Navy guys that he was a Marine. He was there literally to shake hands and kiss babies,” said Cory Bombredi, a union representative for SEIU Local 888, which represents many of the home’s staff. “He knew nothing of the day-to-day operations of the facility.”

Walsh stood proudly at the governor’s side when Baker visited for Veterans Day and Memorial Day celebrations.

But the superintendent was also often away to attend parades, conferences, and other public events. Afterward, he often posted photos of himself on social media. He’d load up PowerPoint presentations to Holyoke trustees with selfies, current and former staff said.

Walsh’s promotional activities raised alarms in Boston. “Bennett would talk about free lunches he had to go to, to promote the home. “There are 100 people on the waiting list. How much promotion does the home need?” Ureña said. “Twice Marylou [Sudders] brought him into the office. She told him to spend more time at the home.”

Meanwhile staff couldn’t help noticing Walsh’s lack of management skills. “I don’t think he was ever prepared for what the job entailed,” said Sue Popp, a longtime nurse who retired in 2017.

Walsh relied on Crotty to oversee operations. “You handle everything on the inside, I’ll handle everything on the outside,” Walsh told his deputy, according to Crotty. Among his duties, Crotty made sure to walk the halls each day, visiting veterans and checking in with nursing staff — sometimes spotting infractions in ways that ruffled feathers.

“That’s what we’re paid to do,” said Crotty, now 67. “The captain of a ship can’t run the ship unless they fully understand how things run, from the bottom up.”

Crotty was the only licensed nursing home administrator in the building, and numerous employees praised him for his hands-on management. “I think at first a lot of people thought he was gruff, maybe trying to be a tough guy. But as you got to know him, you had to like him,” said a current staffer. “I feel like he was keeping the place together. Keeping us from unraveling.”

But Crotty clashed with Walsh and nursing director Randy Stone, whom some staffers viewed as another well-connected hire, and whom caregivers said they rarely saw on the floors. Stone was the spouse of Westfield State University’s then-president; he arrived in April 2017, just as Rooke, Baker’s supporter, began a job as assistant to the university’s president. Stone could not be reached for comment.

Staffing problems intensified during Walsh's tenure. In the fall of 2017, negative headlines highlighted state data showing an increase in residents' falls, as well as employee complaints of understaffing and mandated overtime. The next year brought a petition of no confidence in the home's nursing leadership.

Sudders and her team began meeting with union representatives, who made quarterly visits to her agency on Beacon Hill to detail and discuss the problems.

“She was very well aware of how dysfunctional it was. How inadequate and inexperienced Bennett was, and unable to run the home,” said Joe Ramirez, a certified nursing assistant and official for SEIU Local 888 who attended the meetings.

Sudders also commissioned a 2019 staffing study. “The staff was overworked,” said Nicole Rivers, principal investigator for the study at Suffolk University’s Moakley Center for Public Management. “They were physically exhausted.”

Chronic understaffing was jeopardizing patient care, employees warned. Yet little was done. It was a staff shortage that — when later exacerbated by the pandemic — would debilitate the Soldiers’ Home.

"I took my case to Marylou Sudders regarding understaffing," said Kwesi Ablordeppey, a certified nursing assistant for two decades, and chapter president for SEIU Local 888. "Sudders told Bennett, 'Go and fix it.' "

Rooke, meanwhile, helped shore up Walsh’s public image. (He had personal reasons to be grateful to the superintendent: Rooke’s father, who had Alzheimer’s disease, had entered the home in early 2017. His admissions file had been marked “PRIORITY.” “He got bumped up on the list,” Crotty confirmed.)

He and his brother penned a letter in January 2018 to the Springfield Republican praising the home’s care under Walsh. Walsh was so pleased, he sent the published letter to employees, telling them he had forwarded it to state officials to be included in a Commonwealth wide newsletter.

Still, turmoil consumed the management team; Walsh reduced some staffers to tears.

“If you disagree with Bennett ... you will pay the price.”

“If you disagree with Bennett,” Crotty said, “you will pay the price.”

Walsh kicked several top staffers out of their offices, according to current and former employees, including executive assistant Lori Beswick — moving her into an old coat closet.

Walsh “just mentally terrorized her,” said a former member of the managerial team. “She gave up a 25-year career because of him.”

Beswick, who declined to speak with the Globe, filed a complaint with Sudders’ agency, leading an investigator to interview other managers, they said. Staffers also spoke with Sudders’ human resources director about Walsh.

Ureña regularly brought concerns about Walsh to Sudders, including his use of the Holyoke trustees’ accounts, which accepted donations and operated separately from state funding.

When Walsh requested a debit card that would draw on the accounts, “I told Marylou immediately. She made it a big point — we’ll take care of it. This isn’t how we operate,” Ureña said.

But Walsh got a card anyway, and his travel and other expenses to attend functions worried administration officials, Urena said.

Walsh also allegedly approved falsified attendance records for favored employees, adding up to over $10,000 in payroll expenses, according to Crotty, who gathered records documenting his allegation.

In his oversight of the Soldiers’ Home, Ureña was seen by some critics as passive, taking orders from his superiors.

But Ureña said he felt largely powerless to oversee Walsh, and had no authority to fire him. Sudders and her team had taken over supervision of Walsh, Ureña believed, with Sudders contacting Walsh directly, and Walsh contacting Sudders and her team.

“She was running the show. The Soldiers’ Home reports directly to her,” said a person with knowledge of the situation who asked for anonymity out of career concerns. “She knew everything that was going on.”

“Francisco [Ureña] was a figurehead when it came to the Holyoke Soldiers’ Home,” the person said. “This idea there was a chain of command that went to Francisco’s office was a complete fiction.”

In desperation, Ureña visited Baker’s then-chief secretary, Ryan Coleman, at the State House in 2018. But Coleman, he said, told him there was nothing they could do. Walsh came from a politically powerful family, Coleman said, according to Ureña, and in the runup to the gubernatorial election, Baker’s team wanted to make sure the Walshes and their Western Massachusetts allies didn’t support Democrat Jay Gonzalez.

“I felt frustrated. I went there looking for help and I got shut down,” Ureña said.

Coleman denied that this conversation took place. When asked about the Ureña visit and Coleman’s reported rebuff, Finlaw, the Baker spokesperson, simply said, “This claim is false.”

An exodus of top Soldiers’ Home staff took place in 2019, including Beswick, chief financial officer Erin Spaulding, and legal counsel Alice Pizzi. John Crotty’s last day as deputy was June 28.

After departing, Crotty sent an anonymous package of records documenting Walsh’s alleged fiscal and behavioral misconduct directly to Sudders, via certified mail.

“Sudders knew the kind of person he was in September 2019,” Crotty said. “I wanted to tell Sudders that this guy is tearing the heart out of a treasured institution.”

On Sept. 17, Walsh called a meeting of nurse managers to tell them Stone, the nursing director, had resigned.

What he said after that was even more startling: “I’m going to be the director of nursing.”

“Oh hell no, you’re not,” blurted Dan Daley, a nurse manager who recounted the story and his retort. “First, you’re superintendent. Second, you have no medical knowledge at all.”

As 2020 dawned, Walsh had a fresh preoccupation: New board chair Kevin Jourdain had launched an independent review of the trustee accounts, with help from Ureña's office. But Walsh resisted, according to the firm that conducted the review. When Jourdain met with him about it, Walsh brought the director of Baker's Western Massachusetts office with him, which Jourdain took as a suggestion that Walsh answered to the governor, not the board, Ureña recounted. Jourdain declined a request for comment.

Soon there were ominous public health warnings around the world — and a sign that long-term care facilities were in particular danger. On Feb. 29, news broke of a COVID-19 outbreak in a nursing home in Kirkland, Wash., with dozens of residents and staff already showing symptoms.

The virus was coming.

Yet at the Holyoke Soldiers' Home, there was a leadership vacuum of grave consequence. Dr. David Clinton, the medical director, worked half time. Chief nursing officer Vanessa Lauziere had only just been promoted to that role, replacing Stone. Crucially, after Crotty's exit, there was no licensed nursing home administrator in the building. The deputy superintendent post he vacated would go unfilled for nine months, despite Ureña's push for Walsh to hire a qualified candidate.

On March 10, Baker declared a state of emergency in Massachusetts, warning vulnerable people to avoid large gatherings. The next day, the World Health Organization made it official: The COVID-19 outbreak was a pandemic.

That day, an SEIU Local 888 meeting was scheduled at the Soldiers’ Home. The union expected up to 200 people to discuss staffing problems that were years in the making. In the morning, union representative Bombredi canceled “due to the potential health risk,” he texted fellow organizers. “Our message today was Protect our Veterans, we need to put them first.”

Yet a striking scene unfolded that same day in a fifth-floor conference room: a 50th-birthday party for Bennett Walsh, with a theme from one of his favorite movies: “Elf.” Invited partygoers enjoyed pizza and cake, and as clips played on a big screen, they read lines from the comedy. Everyone had “Elf”-style masks. But instead of depicting the movie’s star, Will Ferrell, the masks had a twist: As a delighted Walsh gazed at his employees, all the faces were his.

‘You could hear the panic in people’s voices’

The day of March 27, 2020, brought an acute staffing crisis. Twenty-one people called in sick for the first shift, according to records obtained by the Globe. For the evening shift, 18 more.

An outbreak was sweeping through the building. One veteran had died of COVID-19, while multiple others were COVID-positive or awaiting test results.

“For the second shift, they were missing way too many people,” recalled one worker of that fateful day. “You could hear the panic in people’s voices: ‘What are we supposed to do?’”

Help was desperately needed, and Walsh sought it from the National Guard, making the formal request in an e-mail to Ureña at 1:24 p.m. and cc-ing others, including two officials from Sudders’ agency.

According to e-mails obtained by the Globe, six minutes later, Ureña forwarded the request to two other Sudders staffers, assistant secretary Alda Rego and human resources officer Catherine Starr, asking to discuss it.

Replying, Rego and Starr appeared to give little urgency to the request. Rego said she wasn’t available to discuss it until 6 p.m. Starr suggested “perhaps it makes sense to make a preliminary inquiry,” but suggested rehiring staff who had resigned “before we get too far down that path.”

Walsh’s request never reached the National Guard, according to Gary Keefe, adjutant general of the Massachusetts National Guard and now the home’s board chair.

Instead, Walsh was told in a conference call that the National Guard was supplying only “logistics support,” not medical personnel, according to Walsh’s attorney. The hastily arranged 3 p.m. call was triggered by news of a COVID death, according to texts obtained by the Globe. Four officials from Sudders’ agency, including Rego and Starr, as well as Ureña, were on that call, according to the Pearlstein report.

The home was on its own — and disaster followed swiftly.

Violating core principles of infection control, the home’s leaders decided to merge two dementia units to concentrate scarce staff resources, combining COVID-positive with asymptomatic veterans. Amid a tangle of finger-pointing, no one would take ultimate responsibility for that decision, though Walsh has acknowledged, to Pearlstein and others, being informed of it.

“As of 3:27 on 3/27, I will remember that day for as long as I have my memory,” said one longtime staffer. “We were all getting mandated to move the dementia unit on the second floor to the first floor. … That day will always haunt me.”

In the ensuing catastrophe, dozens were stricken with COVID. Morphine was in such short supply, staff struggled to find enough for dying patients. Bodies of dead veterans were carried through the housekeepers’ break room during lunch. National Guard medical staff finally arrived March 30, the day the state took control of the facility and Walsh was placed on administrative leave.

By early May, the virus had claimed more than 70 veterans' lives. Walsh resigned from his post last fall.

A year after the crisis, employees are still grappling with the trauma.

“I have sleepless nights,” said Ablordeppey, the nursing assistant. “I go to bed, and sometimes the dreams that happen are too much. … I put some of the veterans in body bags, I put them in the refrigerator.

“How can you be a normal person again?” he asked. “I am embarrassed. Sometimes I cry and I don’t want my kids to see. I go to my room and cry. I cry over what I saw.”

An investigation marred by errors, omissions

Francisco Ureña was at home working remotely on June 22, 2020, when he got the call. Secretary Sudders wants to meet with you, his aide said. It's about the Pearlstein report, and it's too sensitive to discuss on the phone or Zoom.

After nearly three months of investigation, the report on the horror that engulfed the Soldiers’ Home was ready. Mark Pearlstein, a former federal prosecutor and partner at McDermott Will & Emery, had interviewed 100 people, including Baker and Sudders, and reviewed more than 17,000 documents. The result would be a 174-page report with over 900 footnotes.

Ever the dutiful Marine, with respect for the chain of command, Ureña asked no questions. The next day, he put on a suit and tie and drove to Beacon Hill.

When he arrived at Ashburton Place, steps from the State House, Sudders was sitting at one end of a table in her 11th-floor office with its panoramic views and the governor’s chief legal counsel, Bob Ross, was at the other end. Ross told him: The report is coming out.

“It’s very serious,” Sudders said, as Ureña recalled. “She paused, went silent, got teary-eyed and said, ‘I regret to tell you, but I’m going to have to ask for your resignation.’”

Ureña was thunderstruck.

“You know I did everything I could,” he told Sudders. “She said, ‘I know. I know. But the report says you didn’t do enough.’”

“That was the last thing I expected to hear,” said Ureña. “As I walked away from the table, she said, ‘Thank you for your service.’ That possibly offended me the most.”

Ureña walked to his office on Washington Street in a daze, then trudged back up the hill with a resignation letter and handed it to Sudders.

“I submit this resignation with a firm belief that I only functioned in the best interest of my fellow veterans and their families from my first day leading this department until my departure from this office,” Ureña wrote.

“I was in a lot of emotional pain,” he said. “Everything I had worked for, for 14 years, was culminating in this?”

Pearlstein said his report, released the next day, resulted from an independent investigation into the causes of the tragedy. His team worked pro bono, and he said he didn’t know Baker personally before the governor retained him. Neither Baker nor his team “made any effort to prescribe the scope, methods, or conclusions in this report. No one in state government has made or requested any changes or redactions to it,” Pearlstein stated. In March, he told a legislative committee he had followed the evidence wherever it had taken him.

The Pearlstein report slams Walsh and his team at the Soldiers' Home for a series of egregious errors that "were utterly baffling from an infection-control perspective."

Turning to the Baker administration, Pearlstein faults the Department of Veterans’ Services led by Ureña, saying, “Walsh was not qualified to manage a long-term care facility, and his shortcomings were well known” to Ureña, “yet the agency failed to effectively oversee the Home during his tenure.”

Throughout the report, critical findings are reserved solely for employees and lower-ranking officials, including Clinton, the Holyoke medical director, and Veterans’ Services general counsel Stuart Ivimey, who were asked to resign from their posts. Like Walsh, Clinton now also faces charges in Hampden County Superior Court of criminal neglect. His lawyer, John Lawler, said Clinton denies all charges.

“Dr. Clinton has been wrongfully accused in a situation that was unforeseen and he did his best to provide care to the veterans whom he deeply cared about,” he said.

Documents obtained by the Globe and interviews with current and former Soldiers’ Home employees and others indicate that the Pearlstein report contains significant errors and omissions. Several key shortcomings fall into a pattern that shields Baker and Sudders, who face no criticism in the report.

The Pearlstein report’s flaws begin with the section on the appointment of Walsh. Pearlstein incorrectly suggests that Baker merely “formally appointed” the trustees’ choice. Instead of exploring how family and political ties may have influenced Walsh’s hiring, Pearlstein inaccurately asserts that Walsh applied for the job because state legislator John Velis “reached out” to him and put the idea in his head.

Angered and confused by the statement, Velis said a constituent had simply suggested the coffee with Walsh at Friendly’s. “I didn’t reach out to him,” said Velis. The constituent, a friend of Walsh’s mother named Dennis Akins, confirmed Velis’s account. No one from Pearlstein’s team called Velis to check the claim, which the report attributed to Walsh.

“We didn’t do a forensic investigation of the hiring process,” Pearlstein told the Globe last month. “That was beyond what we defined as being the scope of our work.”

Where Pearlstein’s report addresses the home’s oversight, Pearlstein presents a narrative that finds extensive fault with Ureña — with virtually no exploration of the roles of Baker and Sudders. The report states, for example, that Ureña sent Walsh to an anger-management coach, and should have done more “to address Mr. Walsh’s deficits.” But Sudders and her team had taken over Walsh’s management to a large extent, Ureña said. Sudders arranged for the coach and did not share details of any staff complaints about his anger with Ureña, he said.

Sudders declined to answer detailed questions about the hiring of the coach and any other steps she took to address Walsh’s shortcomings.

When asked about the treatment of Sudders’ involvement, Pearlstein defended his report. “The front-line statutory responsibility for overseeing the home was the Department of Veterans’ Services,” he said.

In the report, Pearlstein blames Ureña for allowing the deputy superintendent role to remain unfilled after Crotty resigned. But Ureña repeatedly pressed Walsh over many months to hire a qualified deputy, he said. In February 2020, with the pandemic looming, Ureña finally called the governor’s office. “Can we bring someone in on a preliminary status?” he urged. “Within 24 hours [they] gave Bennett authority to hire [David] Laplante.” Yet Walsh didn’t bring him on board for weeks.

Pearlstein says a new Veterans’ Services position created by the Legislature with oversight for the Holyoke and Chelsea soldiers’ homes should have been filled, but Ureña did not do so. Ureña said he wanted to fill it, but the Baker administration was opposed to the idea and would not provide additional funding for the job.

The Pearlstein report also implies that Ureña failed to act on Walsh’s request for staffing help from the National Guard. The report mentions Walsh’s request to Ureña, but drops the subject there, and never examines what happened next — Ureña quickly alerting superiors in Sudders’ agency. It is a stark omission on a matter that had the potential to save dozens of lives.

In legislative testimony, Pearlstein went even further, falsely stating that Ureña had turned down the request — that it had ended with him. When challenged, Pearlstein said Ureña told him that himself.

Ureña is adamant that is flat wrong: He said he had no authority to turn down the request, never told Pearlstein he had, and didn’t know what happened to the request.

Another person with knowledge of the situation backed Ureña: “He doesn’t have the power to make that decision,” said the person, who asked for anonymity out of career concerns.

Pearlstein confirmed he did not interview the two Sudders deputies who had received the National Guard request from Ureña. Pearlstein said he did not record his interviews with Ureña or anyone else, relying on notes.

“We stand by what is in the report,” Pearlstein said.

Baker and Sudders declined to answer questions about any role they or their staff had in the home’s failed request for National Guard help. Instead Karanovich, the Sudders spokesperson, referred to Pearlstein’s report and testimony about the National Guard.

“They’re blaming the superintendent, the medical director, the secretary of veterans services. [But] it goes right up to Secretary Sudders. … Someone at the state level had to go. Ureña was the sacrificial lamb.”

“The game they’re playing now is don’t blame us, we’re not responsible,” said Corridan, the former Holyoke trustee. “Blame somebody else. They’re blaming the superintendent, the medical director, the secretary of veterans’ services. [But] it goes right up to Secretary Sudders.”

“Someone at the state level had to go. Ureña was the sacrificial lamb,” Corridan said.

With criminal and civil cases springing from the Holyoke crisis underway, and other investigations ongoing, the Baker administration appears eager to close the books on the tragedy and move on.

Lawmakers have approved a bond bill, designed to finance the construction of a new building on the home's scenic hilltop site. A new superintendent — Rick Holloway of Idaho, a licensed nursing home administrator — was selected by the board last month, then abruptly decided not to take the job.

Crotty, the former Holyoke deputy, reapplied for the open superintendent position last year, but once again never got an interview. A recruiter from Sudders’ agency scheduled an interview with him for the position, only to cancel it at the last minute. Now the administrator of a private nursing home in Holyoke, Crotty believes he has been blackballed for speaking out.

These days, Walsh has five attorneys working on his criminal neglect and civil cases, including a class-action lawsuit he and others face from families who lost loved ones at the Holyoke Soldiers’ Home.

On Walsh’s updated LinkedIn page, he notes he’s looking for work and describes himself as an “innately positive visionary.” His profile says he’s “Steering Toward Excellence.”

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