The worst decision, according to the report, was combining the patients from two dementia wards, which included both COVID-positive and COVID-negative veterans. In fact, the report concludes, there were many decisions and actions taken that were the opposite of what should have been done. When a response team from the state showed up at the home when problems got out of hand, a team member said one of the units looked like a "war zone," with veterans crammed on top of each other. The report finds the home's superintendent, Bennett Walsh, lacked medical and technical expertise, playing a significant role in the devastating sequence of events. It also faults the absence of a clear chain of command and a breakdown in communication involving Walsh, Massachusetts Secretary of Veterans' Services Francisco Urena, Gov. Charlie Baker and Secretary of Health and Human Services Marylou Sudders.