(CNN) An investigation into a Massachusetts veterans' home during the Covid-19 outbreak found errors that Gov. Charlie Baker called "gut-wrenching" and hard to read.
"The events that took place in March are horrific and tragic," Baker told reporters Wednesday of the Soldiers' Home in Holyoke.
The home has been under multiple investigations since April, when nearly 30 residents who tested positive for the coronavirus at the time had died. The mortality rate at the facility is typically 10 to 12 veterans per month, the report said.
The report was the result of an independent investigation conducted for Baker. It outlines errors the home made including delays in testing, delays in closing common spaces, insufficient personal protective equipment and a general lack of compassion for veterans, the report said.
CNN has reached out to Soldiers' Home for comment.
The biggest error came on March 27, the report said, when leadership decided to move two units of veterans into one, including some who tested positive for the coronavirus and those who showed no signs of it.
"Rather than isolating those with the disease from those who were asymptomatic -- a basic tenet of infection control -- the consolidation of these two units resulted in more than 40 veterans crowded into a space designed to hold 25," the report said.
A recreational therapist was instructed to help move veterans, who she said were "terrified," the report said. She said she felt like she was "walking [the veterans] to their death."
And for many the decision was deadly, the report indicated.
"The report also says that in no uncertain terms that many of the decisions made -- and especially that decision to put two cohorts with residents that did not have Covid-19 in the same space of residents who did -- had an incredibly negative impact on the likelihood for survival of those resident," Baker said.
CNN has previously reported that, according to staff and union accounts, the home has been dogged by systemic issues for years. Staffers and a union representative told CNN that chronic short staffing, a lack of access to personal protective equipment, and the home's initial policy of housing veterans who had tested positive for coronavirus in tight quarters with other residents contributed to the outbreak at the home.
The National Guard provided support of the home after the superintendent was placed on administrative leave on March 30. The facility is run by the state's Executive Office of Health and Human Services.