Press Release: 1/15/2026
Audit Finds Violations of State Regulation, Gaps in Oversight and Emergency Preparedness at Veterans’ Homes at Holyoke and Chelsea
Holyoke Veterans’ Home Withholds Documentation from State Auditor’s Office, Raising Concerns Around Transparency and Accountability
FOR IMMEDIATE RELEASE:
1/14/2026
MEDIA CONTACT
Andrew Carden, Director of Operations
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Call Andrew Carden, Director of Operations at 617-631-5692
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Email Andrew Carden, Director of Operations at andrew.carden@massauditor.gov
BOSTON — Today, State Auditor Diana DiZoglio’s Office released an audit report of the Veterans’ Home at Holyoke, reviewing the period from July 1, 2020, through June 30, 2023, and the Veterans’ Home at Chelsea, reviewing the period from July 1, 2021, through June 30, 2023.
The Veterans’ Home at Holyoke is a long-term care facility that provides healthcare services to eligible veterans in the Commonwealth. In spring 2020, at least 76 military veterans who lived at Holyoke died of COVID-19, one of the deadliest COVID-19 outbreaks at a long-term care facility in the country. These deaths prompted multiple investigations, terminations and resignations, regulatory reforms, and lawsuits.
The Veterans’ Home at Chelsea is also a nursing facility that provides healthcare services for eligible veterans in the Commonwealth.
The Commonwealth’s Office of the Inspector General (OIG) conducted an investigation for the period May 2016 through February 2020. This investigation was based on a complaint that OIG received about the leadership of the superintendent of Holyoke, who was in charge leading up to and during the initial phases of the COVID-19 outbreak in Holyoke. The OIG conducted an investigation and determined that there were issues concerning the oversight and management of Holyoke.
The Office of the Governor also commissioned the law firm of McDermott Will & Emery, LLP to conduct an independent study, now known as the Pearlstein Report, which focused on the COVID-19 outbreak that led to the deaths of veterans at Holyoke. The report highlighted errors and failures of leadership that likely contributed to the elevated death toll during the outbreak.
The State Auditor’s Office requested access to interview notes and other records that contributed to the development of the Pearlstein Report. Those documents and records were unlawfully withheld. While the State Auditor’s Office was able to examine other issues related to safety, the withholding of requested documentation prevented the office from conducting its audit as intended concerning these matters.
Our office is pursuing legal action, specifically litigation, to compel the production of the improperly withheld documents and records connected to the Holyoke Soldiers’ Home tragedy. Either this was an independent investigation, as was claimed, in which case attorney-client privilege does not apply, or this was legal representation on behalf of the Governor, where Pearlstein was providing legal advice in anticipation of lawsuits. Both can’t be true simultaneously.
While our office certainly respects the sanctity of attorney-client privilege, these records are not protected under attorney-client privilege. Indeed, in a June 26, 2021 article, the Boston Globe reported that Pearlstein himself stated he did not provide private legal advice to the Governor’s Office. Therefore, these records are subject to audit.
“The Governor unlawfully blocked our office’s access to records connected to the tragedy that resulted in over 70 veteran fatalities. This raises serious concerns and warrants strong legal action. Lives were lost and families were devastated. It’s unacceptable to hide these records from auditors who have the legal authority to review them,” said Auditor DiZoglio. “I’m calling on the AG to authorize our office’s appointment of an attorney of our choosing. It’s critical that this matter be adjudicated and litigated by an attorney who is not beholden to this Administration — or the one
prior. Anything less is a denial of justice to all impacted by this tragedy.”
Among the audit’s findings, with respect to information our office was able to access, is that Holyoke could not ensure that nurses performed intentional rounding, a formal means of nursing staff checking the care needs of patients on a regular basis. If intentional rounding is not being completed, it could increase the risk of veterans having falls or other health issues that adversely contribute to veteran safety and well-being. It is reasonable to conclude that the absence of intentional rounding increased the risk—and likely the number of injuries—while reducing the quality of care, for veterans at Holyoke.
The audit also found Holyoke and Chelsea violated state regulations by not conducting simulated emergency drills for all shifts. Without performing simulated emergency drills to test the effectiveness of their emergency operation plans, these veterans’ homes cannot ensure that they have an effective response to disasters and emergencies, thereby jeopardizing the safety of veterans and hospital staff members.
Moreover, Holyoke and Chelsea violated state regulations by not posting their emergency operation plans throughout their facilities as required. Without their emergency operation plans posted, Holyoke and Chelsea are unable to ensure an effective response to disasters and emergencies that impact the environment of care and could impede the safety of veterans and hospital staff members. Their emergency operations plans also did not contain the locations of alarm signals, fire extinguishers, and evacuation routes. This could affect the timely and safe evacuation of veterans, staff members, and visitors in the event of a disaster.
Furthermore, the audit found Holyoke does not use an electronic health record system for veterans as required of other, similarly situated healthcare facilities. According to the Centers for Medicare and Medicaid Services, there are multiple benefits to implementing an electronic health record system, including improved patient care. For example, an electronic health record system allows healthcare providers to access medical records in real time to provide accurate and timely care. An electronic health record system can reduce medical errors and delays in treatment, improve the accuracy and clarity of medical records, and improve the security of medical records.
Among the Chelsea audit’s findings is that it did not always document the need or approval for nursing department overtime, as required by its overtime policy. If Chelsea does not properly document overtime occurrences, there is a higher-than-acceptable risk of Chelsea incurring unnecessary overtime expenses. A large number of overtime occurrences may also indicate staffing shortages at Chelsea.
Moreover, the audit found Chelsea did not always meet the total nursing care needs for its veterans as determined by veterans’ assessments. Failure to meet the needs of veterans can lead to a variety of negative consequences for veterans, including an increased risk of mortality, physical decline, and infections, as well as emotional distress. It can also place excessive burdens on nursing staff who are required to perform duties in excess of what was planned for during various shifts.
The audit also found Chelsea violated state regulations by not always updating its veterans’ assessments. If Chelsea does not complete and review each veteran’s assessment, Chelsea cannot ensure that it meets the nursing needs of each veteran in its care. It also did not always properly maintain nursing department staffing records and incident logs, which may have impacted the quality of care it provided to veterans. Without maintaining proper records, Chelsea cannot ensure that it is properly staffed and can provide necessary care to veterans.
Finally, Chelsea’s audit determined that it did not always train employees to perform assigned duties specifically concerning emergency preparedness. Without training employees on tasks they must complete during an emergency, Chelsea cannot ensure that all employees are properly prepared to respond to disasters and emergencies, which may jeopardize the safety of veterans and employees at Chelsea in the event of an emergency.
“I am confident that the Holyoke and Chelsea Veterans’ Homes are committed to working to ensure that all of our veterans are treated with the dignity, honor, and respect they deserve,” said Auditor DiZoglio. “Both the Holyoke and Chelsea Veterans’ Homes have a noble and worthy mission of providing high-quality personal health care services to Massachusetts veterans. We hope that our audit recommendations are adopted to help ensure that mission is the reality for every veteran relying on these necessary services.”