Donald Bushey rarely talked about his military service. The Air Force veteran served for 14 years, including one in the Vietnam War, but he preferred to focus on hunting, fishing and his other passions.

His military service, however, provided a lifeline to his family in recent years. As a veteran, Bushey qualified for a spot in the Soldiers’ Home in Holyoke, a state-run facility in western Massachusetts. Bushey’s placement in the home in January 2019 eased some of the pressure on his wife of 63 years, Jean, and their six children after he was diagnosed with Parkinson’s disease and suffered a stroke, one of their daughters said.

But the home’s reputation has plummeted in recent weeks amid investigations and political recriminations prompted by one of the deadliest coronavirus outbreaks at a long-term-care facility in the country.

At least 74 residents at the Holyoke home who tested positive for the novel coronavirus have died since late March, as have several others who exhibited symptoms. Eighty-four employees and 77 additional residents tested positive and survived.

The crisis led the Massachusetts National Guard to intervene, and guard members have done everything from disinfecting to administrating to stabilize conditions at the home.

Residential centers for the aged of all kinds have been hit hard by the virus, but the disaster in Holyoke has highlighted gaps in the patchwork oversight of state-run veterans’ homes.

Among the dead was Bushey, 83, of Springfield, Mass.

As he lay unresponsive, staff members invited his wife to sit at his bedside as a part of end-of-life care, said his daughter, Colleen Croteau. On one visit, Jean Bushey was offered only a surgical mask for protection from infection. Employees nearby had no face coverings, said Croteau, who connected on video with her mother during the visit.

Bushey died March 27. His widow, 81, was hospitalized with a fever and pneumonia on April 6. She tested positive for the coronavirus and is in recovery.

“It is my hope that some sort of justice will be served to the people responsible for the negligence,” Croteau said.

The severity of the outbreak at the home was compounded by shortages of protective equipment, chronic staff vacancies and lapses in the proper management of infected residents, according to several current and former employees.

A dysfunctional relationship between senior officials at the home and state officials also appears to have played a role.

State officials removed the home’s superintendent, Bennett Walsh, on March 30 after, they said, they became aware of the extent of the outbreak. Eight people had died at the facility within the previous five days, but neither the home nor the state had disclosed the outbreak to the public.

Walsh, a retired Marine officer, has denied wrongdoing and accused the state of letting a “lie” persist that he had not kept the state apprised. In a statement, he said that he had requested National Guard assistance March 27 and told state officials that 28 residents had coronavirus symptoms.

“State officials knew that Holyoke needed as much help as possible,” Walsh, who declined requests for an interview, said in the statement. “No one was kept in the dark.”

Officials at the home referred questions to state officials. At least four investigations, including a federal probe, about conditions at the home have been launched.

“The tragic situation at the Holyoke Soldiers’ Home is a reminder of the insidious nature of covid-19, a virus that is having a devastating impact in our communities,” said Brooke Karanovich, a state spokeswoman. “We are deeply saddened by the extent of the outbreak and the loss of life.”

This account of the meltdown at the Soldiers’ Home in Holyoke is based on emails, memos and other documents obtained by The Washington Post, along with interviews with 23 people with knowledge of the outbreak and the home’s long-standing troubles. They include family members, current and former employees, and state officials. A few employees spoke on the condition of anonymity, citing concerns about retaliation.

Collectively, they paint a picture of a facility that was operating with unaddressed problems, even as it was lauded as a beacon of support for veterans. The Department of Veterans Affairs had recently found that the home met or provisionally met federal health-care guidelines for the third year in a row.

An outbreak begins

It’s not clear how the virus entered the home. But the first resident with symptoms was tested in mid-March, as visitors were banned until further notice.A positive result came back March 21 but was not reported to employees and families until the following day. Most received the news in an email.

“I write this letter to inform you that one of our long-term care residents tested positive for COVID-19,” Walsh told staff members, referencing the disease caused by the coronavirus. “The Veteran is currently in quarantine. We have identified other Veterans who were in close contact with the Veteran and they too have been isolated and have been tested for COVID-19.”

But several employees said that the man who tested positive lived in a unit that cared for those with dementia and that he was allowed to continue roaming the facility.

“They all go into each other’s rooms and don’t understand what social distancing is,” one employee said in an interview.

Even with an infected patient, staff members continued to “float” between units, with some moving in and out of the area with the coronavirus outbreak.

One certified nursing assistant, Kwesi Ablordeppey, said he was disciplined for putting on a mask and gown after he had spent time in the infected unit.

“Your actions are disruptive, extremely inappropriate and have caused unnecessary resources to be deployed that may be needed in the future,” the chief nursing officer, Vanessa Lauziere, wrote in a March 20 reprimand, according to a copy that Ablordeppey provided. Lauziere did not respond to requests for comment.

Ablordeppey called the reprimand “nonsense.”

On March 17, Walsh told employees that their “core function” had been deemed essential, meaning they were all needed at work. He urged them to be “mindful of supplies.”

A rising death toll

As other residents were tested for the virus, some employees stayed home.

On March 22, staff members were told in an email that any workers who had been in the unit with the infected resident must wear a mask.

By March 25, an employee had tested positive for the virus, Walsh told staff members in another email.

From there, the problem spiraled out of control.

On March 27, residents from a wing on the second floor of the home were moved to a section on the first floor, putting more than 40 people in a unit with space for about 25, employees said. Nine were put just a few feet apart in a dining room that was turned into a makeshift care center. Some had the coronavirus and others did not, employees said.

That night, the staff received a memo saying nine residents and an employee had tested positive for the coronavirus.

More patients died that weekend.

“It was insanity. They kept saying: ‘What else are we supposed to do? We don’t have the staff,’ ” said one employee who worked in the dining room. “There were people dying at the same time that others were in that room.”

More frustrations

Families and employees now wonder why state officials did not move faster to address concerns about overcrowding and staffing.

Brian Corridan, who recently completed five years on the home’s board of trustees, said that Walsh, the home’s former superintendent, has been scapegoated and that a funding gap is the main source of the problem.

State budgets show that another state-run home for veterans across the state in Chelsea historically has received about $28 million per year while the home in Holyoke received about $24 million. The long-term residents in Holyoke outnumber those in Chelsea about 235 to 135.

Corridan and another former official at the home said a previous superintendent in Holyoke had proposed a project in 2011 that included an expansion. The Department of Veterans Affairs would have covered about $80 million for a new wing if the state paid $40 million, they recalled.

The state tabled the project, citing a lack of funding.

Francisco Ureña, who oversees the home from Boston as the state’s veterans’ services secretary, did not respond to questions about the criticism but issued a statement that said, in part, that the impact of the coronavirus has been “heartbreaking” and that his department is committed to supporting veterans.

The new interim administrator in Holyoke, Val Liptak, told the board of trustees that the home is likely to decrease the number of long-term residents to about 170 and is beginning a search to fill vacant senior positions.

Families, meanwhile, are seeking answers to questions about when the home might find a new normal, with a return of services such as physical therapy.

One family member, Cheryl Turgeon, said her father lost 30 pounds and developed pneumonia during the crisis despite testing negative for the coronavirus several times. She has asked to visit him outdoors and with social distancing and has been told it is not possible. National Guard members assisted in bringing some other veterans out for similar meetings, but the practice was curtailed for safety reasons, a state official said.

Turgeon said her father, Dennis Thresher, 89, has been mostly alone in his room for weeks. Thresher, who served in the Air Force during the Korean War, has lived in the home more than three years.

“The emotional roller coaster,” she said, “is unbelievable.”