Investigators found the Holyoke Soldiers' Home in Massachusetts had an unqualified leader who supported bad decisions in housing, testing and tracking residents, according to NBC10 website.
A coronavirus outbreak lead to the deaths of at least 76 veterans and the infection of an additional 84 veterans and more than 80 staff members.
A probe found the staff combined two locked dementia units containing veterans with a mix of COVID-19 statuses on March 27.
A command-response leader brought in three days later to stabilize the situation, report that this “hot” unit had veterans “crammed in on top of each other,” some of whom “were clearly dying.”