HOLYOKE, Mass. (WPRI) — An independent investigation into the how the Holyoke Soldiers’ Home handled a COVID-19 outbreak at the facility revealed that the lack of oversight caused the deaths of nearly 100 veterans who lived there.

The report, ordered by Gov. Charlie Baker, was made public Wednesday. The investigation began in April when Baker hired former federal prosecutor Mark Pearlstein to look into the facility’s handling of the outbreak, which led to the deaths of 97 veterans, 76 of which tested positive for COVID-19.

The full report of the COVID-19 outbreak at the Holyoke Soldiers’ Home »

Baker said the report “lays out in heartbreaking detail the terrible failures that unfolded at the facility” as Superintendent Bennett Walsh and his team attempted to mitigate the spread of the virus.

“The lack of oversight contributed to the tragic failure to protect the veterans at the soldiers home when COVID-19 struck vulnerable patients in the long term care facility,” Baker said.

Walsh was placed on administrative leave in late March, and the facility’s medical director resigned in May.

In addition, The Boston Globe confirmed Wednesday morning that, prior to the report’s release, Secretary of the Massachusetts Department of Veterans’ Services Francisco Urena, who was tasked with overseeing Walsh and the facility, resigned from his position. In speaking with the Globe, Urena said he was asked to resign.

Francisco Urena, now former Secretary of Massachusetts Veterans’ Services

Cheryl Poppe, the superintendent of the Chelsea Soldiers’ Home, will take Urena’s place until a permanent replacement has been decided on.

The report showed there were delays in testing veterans when they began showing symptoms, delays in closing common spaces to prevent the spread of COVID-19, failure to stop rotating staff between units, inconsistent policies and practices regarding PPE and a failure to keep accurate records.

“The subject matter and details off this report are nothing short of gut wrenching,” Baker said. “In fact, this report is hard to read. Some of the decisions that were made by those in charge at Holyoke are, in Mark Pearlstein’s words, ‘utterly baffling.'”

One of the most devastating failures, according to Baker, was when the home’s senior leadership combined two units of the veterans home, those who had tested positive for the virus with those who had not, into one consolidated unit.

“A social worker’s recollection of this consolidation is one of the most depressing and utterly shameful descriptions of what was supposed to be a care setting that I have ever heard of,” Baker said.

Immediate action was taken to remove inadequate staff from the home and the National Guard was called upon to assist the existing staff at the facility, according to the governor. Holyoke Medical Center opened a unit for the veterans of the home, 26 of which remain at the center.

Baker said the report shows there was a serious failure of leadership at the home and a misrepresentation of what was actually happening there.

As of Tuesday, there are zero veterans at the home testing positive for COVID-19.

Baker says the next measures will be addressing the trauma the staff at the home have endured and implementing all the recommendations outlined in the report.