A subsequent independent report found that poor infection control practices and chaotic decisionmaking promoted the spread of the virus within the home.

[2] In response to the outbreak the facility is implementing a $2 million overhaul to redesign its floors, reducing the number of beds to 160 in compliance with distancing guidelines.

[3][4] The creation of the Soldiers' Home was a prolonged seven-year process; following the end of World War II, the Commonwealth saw an influx of wounded veterans requiring longterm care.

However funding and regulations had led the project to stall, and incoming Governor Paul A. Dever promised to make its construction a priority of his administration.

[6] Several years later, the Soldiers' Home was dedicated on April 27, 1952 before a crowd of 15,000, including units from Westover Air Force Base, and former AMVETS national commander Harold Russell.

At the facilities opening Governor Dever remarked "the scissors of false economy will never be used to cut the appropriations needed for the maintenance of this outstanding institution erected for the veterans of Massachusetts".

[10] The report also determined that Massachusetts Secretary of Veteran Affairs Francisco Urena had failed to exercise proper oversight over the home to correct problems.

[12] On September 25, 2020, Attorney General Maura Healey announced that the former superintendent Bennett Walsh, and former medical director, David Clinton, were indicted by a grand jury on 5 charges each of "Wanton or Reckless Bodily Injury to an Elder or Disabled Person", related to practices alleged to have contributed to the deaths of 84 veterans in the facility's care.