The leadership of a home for aging veterans in Massachusetts where nearly 80 residents sickened with the coronavirus have died packed dementia patients into a crowded unit as the virus spread, one of several “utterly baffling” decisions that helped the disease run rampant, investigators said in a report released Wednesday. The superintendent of the Holyoke Soldiers’ Home was not qualified to run a long-term care facility and “substantial errors and failures” he and his team made likely contributed to the high death toll there, investigators found. Among them was a decision prompted by staffing shortages to combine two locked dementia units, both of which already housed some residents with the virus.
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