It was almost Memorial Day, and retired Army Sgt. Bill Meck was thinking about the dead. It had been nearly a year since COVID-19 had hollowed out Charlotte Hall Veterans Home — the state-run facility for veterans and their spouses where he lived. Before the pandemic, he could usually expect to honor a resident who had recently died. Taps would be played. An American flag would cover the body as it lay on a gurney. Employees and residents could line the hallway and sidewalk for a final salute. “With all of this, none of the guys have gotten that,” Bill said. The pandemic halted so much.

For most of 2020, Charlotte Hall was the site of the largest and deadliest coronavirus outbreak at a Maryland long-term-care facility. It remains the second-deadliest outbreak at a long-term-care facility in the state, and among the largest outbreaks in the country. So far, 66 residents and one staff member have died, and there have been 411 infections.

Among the dead were veterans of World War II, Korea and Vietnam. They were Army and Navy and Marines, fathers and husbands and brothers, recipients of the Purple Heart and the Bronze Star. Some had made a career of the military. Others had served for a few years. In their post-military life, their work varied: a machinist, a bus driver, a federal employee. Many of them had come to Charlotte Hall for the subsidized care it provided, a deep discount from private nursing homes whose costs their families could not afford.

Bill had lived at Charlotte Hall for about a decade, and in two other nursing homes before that. He knew the good and the bad of long-term care, that being close to death was part of it. But not like this. Near the height of the home’s outbreak, when its infection rate reached 50% and dozens of people had died in a matter of weeks, he asked to speak to a mental health professional. “I have been through a lot of s--- in my life, and that’s the first time I talked to a shrink,” he said. They met over Skype from the room where he was isolated.

Bill had not served during wartime, but the battle metaphors still came easy. “One of the other guys, he’s a combat vet. He said it’s like going out on patrol, getting ambushed, and you’re the only one that survived. And you spend the rest of your life asking why.”

Charlotte Hall was not alone in its struggles. Across the country, state veterans homes were among the most dangerous long-term-care facilities during the pandemic. More than 145 veterans died in two homes in New Jersey. One hundred and twenty-one at a New York home. Dozens more in Hawaii, Illinois and Oklahoma. Seventy-six veterans died in one Massachusetts facility, where two officials were later indicted on still-pending charges of criminal neglect.

The death toll raised urgent questions about what is owed to these veterans now and in the future. The country’s 160 state veterans homes are not run by the Department of Veterans Affairs, despite the fact that they are the largest institutional long-term-care provider for veterans. Instead, individual states own and manage them, and the department inspects them annually while paying more than $1 billion per year for their operation. The Maryland Department of Veterans Affairs oversees Charlotte Hall but outsources the facility’s management to a for-profit company, HMR Veterans Services. Last summer, the muddled oversight of state veterans homes — split as it is among federal, state and for-profit entities - prompted a congressional hearing, the title of which asked, “Who’s in charge?”

Bill felt the government had failed Charlotte Hall’s residents. He had spent part of the past year trying to get powerful people to pay attention to what happened there. A natural advocate, he had served for several years as president of the resident council. At 64, he was nearly two decades younger than many of the residents, and he was protective. “These are my guys,” he liked to say.

On Memorial Day this year, the veterans home held a ceremony to honor those who had died during the past year. It was smaller than normal, due to COVID precautions. Staff members gathered to read aloud the names. But if anyone told Bill about the event or that it was broadcast on the home’s televisions, he hadn’t heard them. He missed it. In the video posted online afterward, the reading of the names of the dead had been cut out, for privacy reasons.

For Bill, none of this was good enough. He wanted a list of names of those who had died. He wanted a monument inscribed with them on the campus, a way to commemorate what happened. A larger memorial service. A ringing of bells. Something. “How the hell do I process all this?” he asked. He began to cry. “I didn’t get to say goodbye.” Perhaps most of all, what Bill wanted was an accounting of what had gone wrong at Charlotte Hall. After all, the residents had done a lot for their country. “If anyone deserved better,” he said, “these guys did.”

The first state veterans homes opened in the wake of the Civil War, when the ranks of disabled veterans soared. The homes were a manifestation of Abraham Lincoln’s pledge in his second inaugural address “to care for him who shall have borne the battle,” a quote that is enshrined on a plaque at VA headquarters in Washington.

Charlotte Hall Veterans Home opened in 1985 on the grounds of a former military academy in Southern Maryland. It’s Maryland’s only state veterans home and a community institution, a place where Scout troops drop off donations and the Veterans of Foreign Wars post sends money. A church group hosts a service on Sundays, and every year a car show fundraiser is set up in the parking lot. In obituaries, people in the surrounding towns often ask that memorial donations go to the vets home.

Bill’s journey to Charlotte Hall began in 1982, when he was a young Army sergeant stationed in Germany. He was driving off base when he swerved to miss a car that had slammed on its brakes. The last thing he remembers is hitting the windshield. No one else was seriously hurt in the crash, but he suffered a spinal cord injury. His C4 and C5 vertebrae were fractured, leaving him paralyzed from the chest down. He was 25 years old.

His younger sister, Patty Herrell, remembers waiting at the U.S. base where a transport plane brought him home. “It was shocking, just shocking,” Patty says. “There was a part of me that was like, no, this will get better.” Bill was placed in a Stryker frame; at the hospital, they would turn his whole body in the contraption, and sometimes he would be facing the ground. Patty would lie on the floor of his room, looking up, so they could talk face-to-face.

“We’re total opposites,” Patty says. “He was a brainiac. He was the scholastic guy. He could play any musical instrument you handed him.” Only 13 months older than her, Bill made honor roll and played in a band, while she was the rebel skipping school, giving her parents grief. She often thought about the irony that she was the one “on a fool’s errand all the time and he was such a good guy,” and then something like this happened.

Bill was honorably discharged, and he spent months in rehab at a VA hospital in Richmond, learning how to live as a quadriplegic. Later, he stayed in the area and got a job working for the city as a computer programmer. He married, but the marriage didn’t last. Patty wanted to move him back to Maryland, to be closer to family, and he agreed. They talked a lot about him coming to live with her, about remodeling her house for his wheelchair and hiring caregivers, but the costs were exorbitant, and Patty still had to work. He couldn’t be left alone. What if there was a fire, she thought, and he couldn’t get out?

He went to live in a nursing home, where he had access to round-the-clock care. Years later, he moved to Charlotte Hall because it was only six miles from Patty’s house. She could drop by anytime, bring him a plate of dinner, a steak or some crab meat in the summer. For 30 years, she had visited him every Friday. She and Bill met outside in the parking lot in early March 2020. It would be her last visit for a long time.

Meenakshi Brewster is the head of the health department in St. Mary’s County, where Charlotte Hall is located. She remembers being very impressed with the veterans home’s infection-control protocols. She met with the home’s leadership early in the pandemic. “They were on it,” she recalls. “They had a really solid team.”

The veterans home had vulnerabilities, though, and not just in terms of its at-risk elderly population. For one, it was a large facility, with at least 375 residents and 454 beds total, plus nearly 400 staff members. Brewster notes that by virtue of its size alone, it had a greater likelihood of a large outbreak. Its numbers also meant it had more than a few residents going to and from hospitals and doctors’ appointments for treatment. Many of its staff members also worked at multiple facilities to make ends meet. “It’s a small community, as nurses are in limited supply. Other staff are in limited supply,” Brewster says. “Staff take shifts at different facilities.” The more staff and residents moved about in the community and in and out of other facilities, the more likely it was that the virus would be transferred between locations.

On March 11, 2020, according to an internal memo, Charlotte Hall suspended visitation, except in end-of-life cases. But even as the home barred loved ones and nonessential visitors, residents in its assisted-living program - who live more independently than its nursing home residents - were allowed to come and go from the campus, creating another point of entry for the virus.

Two weeks after Charlotte Hall restricted visitation, on March 26, the facility had its first two residents who tested positive for the coronavirus. Both were from assisted living. On March 28, Brewster issued a short-term quarantine order for the assisted-living residents, discouraging them from traveling off campus. “We recognized that the mobility of the residents interfacing with their community was contributing to the spread of COVID within that whole facility,” Brewster says, “including impacting the [nursing home side].” HMR then requested that its staff no longer work at multiple facilities; they had to choose one site.

By March 23, the state of Maryland was encouraging nursing homes to “cohort” COVID patients and, if possible, to create a separate unit for them. Charlotte Hall had an empty unit, 1A, ready for residents with COVID who needed skilled nursing care. The home, under the direction of the county health department, initially decided to keep the sick assisted-living residents isolated on their regular unit - a pattern that continued across the facility as the outbreak grew larger. In a statement, HMR said that unit 1A opened on April 8, when a COVID-positive resident returned from the hospital. It also said temporary walls separated residents “when available space prohibited isolation on a dedicated COVID unit.” This infection control strategy depended on sick residents remaining in their rooms, as the home mandated, but family members and nurses say it was nearly impossible to keep some residents from leaving their rooms and mingling.

It’s a key part of infection control to move sick residents into a separate wing, according to Charlene Harrington, a nursing-home expert and professor emerita at the University of California at San Francisco’s nursing school. “That’s common sense.” A delay can be “the kiss of death,” she says. “Once you have one patient, it can just spread.”

‘The numbers speak for themselves’

Thousands of pages of emails from state officials and HMR employees — obtained through a public records request — detail how the virus moved through the facility. At first, they were buoyed by the low case counts. Maryland Secretary of Veterans Affairs George Owings III bragged in an email about the “outstanding” work of the staff, writing, “The numbers speak for themselves.” By April 20, Charlotte Hall had at least six confirmed COVID cases among residents - five of them in assisted living. Two and a half weeks later, it had 49 resident cases and three COVID deaths.

A Maryland Department of Veterans Affairs spokesperson declined interview requests on behalf of Owings and Sharon Murphy, who was the home’s director until she retired this year. Russell Keogler, the home’s administrator until last year and an HMR employee, also declined an interview, but he contributed to written statements provided by HMR.

Like in most facilities early in the pandemic, personal protective equipment (PPE) was in short supply, though Brewster says the veterans home never ran out. Gowns were particularly scarce. Ad hoc supply chains sprung up. Volunteers delivered face shields to the facility. HMR contracted a hockey-jersey manufacturer to make reusable gowns.

Coronavirus testing was also limited. It took days to get results. “Sometimes it was longer than a week,” Brewster says. On April 29, a month into the outbreak, Gov. Larry Hogan announced that Maryland nursing homes should test both the symptomatic and the asymptomatic. In May, a National Guard team arrived to assist with testing and moving positive patients into COVID units. “They were swamped,” says Col. Eric Allely, the Maryland Army National Guard state surgeon. “They didn’t have enough people to do everything they wanted to do as quickly as they would have liked to have done it.”

After that round of universal testing, the home reported that 92 residents and 43 staff members had tested positive, and nine people had died of COVID. Charlotte Hall was well managed with good procedures in place, Allely says, but “they were overwhelmed by the speed with which the disease moved through the community.”

Caring for residents with dementia became a particular challenge. “You can’t really train them to wash their hands or use hand sanitizer,” says Heyward Hilliard, HMR’s executive vice president of operations. It is doubly hard to have them mask or social distance. Dementia patients are prone to wandering, which is why they often reside in locked units specializing in memory care to keep them safe and limit their mobility. The website of the Centers for Disease Control and Prevention has stipulated that long-term-care facilities should weigh the pros and cons of keeping dementia residents with COVID in their locked units, instead of moving them to COVID units that aren’t set up for memory care. A loved one emailed Keogler on May 5 with a “plea to quarantine positive residents” who were still living on one of Charlotte Hall’s locked memory-care units, where there were then seven cases: “To hear from you tonight that it is difficult and that there are no current plans to quarantine ... the positive cases on 1C from the twenty-five or so other residents is not only disappointing but quite frankly, negligent.” Keogler replied that they were very firm in following infection-control protocols set by multiple agencies.

Alex Kavounis’s father, Al, lived on a dementia unit. The 92-year-old was confined to his room after the outbreak. According to Kavounis, the World War II vet, a rule-follower to the end, would yell out his door if he could see fellow residents wandering in the hallway, telling them to stay in their rooms. On May 13, he died of COVID.

Outside the home, loved ones waited for information. They could call a hotline and hear the number of cases that day. “The person who was doing the updates had just the kindest voice,” one family member says. The numbers kept going up. For some, it was hard to reach nurses on the units by phone.

For weeks, Bill’s unit had been spared from the virus. The building’s main dining room was closed, but Bill says his unit, 3C, had its own dining area, where the staff still served residents communal meals. He chose to stay in his room. Bill said he spoke to a supervisor about residents who weren’t social distancing. “Well, we can’t make them stay in their room” was the reply. Bill told me, “I mean, I get it, there were guys here that were really hard to keep in their room. OK, but you know, letting them wander in and out of everybody else’s room was not helping anything.” According to his notes, the first COVID case showed up on his unit on May 14.

Staffing shortages

Employees were also falling ill in large numbers. A staff member died of COVID. At one point, the home’s assistant administrator had a symptomatic case of COVID and was trying to telework, according to an account in Provider, a trade magazine. Keogler, the home’s then-administrator, told Provider that he slept on an air mattress in his office and that 24-hour shifts for him were common.

Without adequate staffing, it becomes more difficult to practice good infection control. Hilliard of HMR says, “You lose some of your tools and controls because you’re not just battling the virus with those you’re taking care of, you’re battling it with those who are doing the caring.” On May 24, a volunteer who had a loved one at Charlotte Hall emailed the state secretary of health to complain about the staffing shortages. “Nurses and aides are working the COVID wings and crossing over to the healthy units to fill in the shortages,” she wrote. “One night shift over Memorial Day weekend had only one nurse, one aide for 40 residents. This is unacceptable.”

In May, nearly two months into the outbreak, Charlotte Hall and the state alerted the regional Veterans Health Administration that help was needed. Murphy emailed that “staffing is at a critical low.” By late May, the home had recorded 15 deaths and 162 total cases, including 48 among the staff. While VA is clear that it doesn’t run the state veterans homes, it can provide extra health care and resources in times of crisis.

The federal agency deployed 38 volunteer nurses within five days from D.C., Maryland and West Virginia. They arrived at a local hotel with go-bags of PPE and extra supplies for the facility. VA personnel also provided training to the Charlotte Hall staff in infection control, patient safety and PPE use, according to a Veterans Health Administration report. VA nurses staffed most of the night shift at Charlotte Hall and later helped on the day shift. They helped create three additional COVID units to house the growing number of positive residents, according to the same VHA report. “The last three days have been incredibly challenging,” Keogler wrote to senior staff just before midnight on May 25.

Deadliest weeks of the outbreak

On unit 3C, Bill heard his roommate coughing. Not long after the VA reinforcements arrived, his roommate tested positive and was moved to a COVID unit downstairs. Within two days, Bill also had a positive test and was moved to another COVID wing. VA’s arrival couldn’t stop what was already in motion: Their mission coincided with the deadliest weeks of the outbreak.

One of those losses was Cy “Tike” Butler, an 81-year-old Navy veteran with Alzheimer’s. In late May, his family got a call that someone he shared a bathroom with had COVID, and then a few days later, he had it. He was eventually sent to the hospital, where his daughter Sandi Junge held the phone so her high-risk mother could talk to him before he died. “They just had the love story,” she told me later. Married 55 years and still holding hands. Her mother had polycystic kidney disease and died nine months later. “If you can die from a broken heart,” says Junge, “I think she did.”

At one point, more than half the residents were testing positive. By mid-June, more VA staff had been deployed to the home from across the country.

Bill was among the lucky ones. He never had any symptoms after testing positive. Still, he waited in his private room on one of the COVID units. It was lonely and tedious. When he arrived, he hadn’t bothered to have his things unpacked because he expected to be there for only two weeks. Instead, the weeks turned into two months.

He grew depressed. During phone calls, it was the saddest and most frustrated that Patty had ever heard him, and that included when he found out he would never walk again. “I was actually scared that he would just die of sadness, and that’s the truth,” Patty says. Bill didn’t know how many people had succumbed to the virus around him or who was gone, aside from snippets he heard from his nurses. One kindly let him know that his former roommate had died.

Other residents also struggled. Retired Army Sgt. 1st Class Harvey Greene, a longtime assisted-living resident, would dress every day, only to sit and stare at the television. He avoided the virus, but two close friends died of COVID. “It was very difficult,” he recalls. He knew that a lot of people had gotten sick, but he wasn’t sure how many were gone. What haunts him the most is that his mother died while the home was locked down. Because he was under quarantine orders, he says, he couldn’t attend her funeral. “It still hurts me today.”

Retired Marine Lt. Col. Philip Forbes, who served in Vietnam, says the staff has “taken real good care of me,” but it didn’t make the isolation easier. “You get very frustrated,” he says. He missed dinners with his wife, smelling the grass outside, getting to Mass on Sundays. “Thank God for news channels,” he says, “or we could be on the moon when they lock you down.”

In isolation, Bill began writing an essay. The work was painstaking. He has some movement in his arm, so he used those muscles to propel his hand toward the keyboard. He hit each keystroke with the side of his thumb. One letter at a time, for 1,145 words, he worked out his thoughts, spending two days on his draft.

Inspections and more infections

Sen. Chris Van Hollen’s office flagged Bill’s essay for the Maryland Department of Health, which then reached out to Bill. It would take almost 10 months before anyone investigated his concerns. Inspectors arrived at Charlotte Hall on April 5, 2021, to investigate 26 complaints, according to records from the Centers for Medicare & Medicaid Services (CMS), which is part of the Department of Health and Human Services. Bill soon received a letter from the Maryland Office of Health Care Quality stating that inspectors “were not able to find that a specific regulation was not being met” in reference to his complaint.

The complaint inspection reports from April 2021 did not detail incidents related to COVID-19 and infection control. Many inspections were suspended early in the pandemic, and a CMS spokesperson confirmed that no CMS inspector went into Charlotte Hall in April or May 2020, when the facility was most overwhelmed by the virus. An “off-site” review was done instead. No regular VA inspections happened at the home at all in 2020, according to the agency. A CMS inspection focused on infection control was completed on June 11, 2020, only after VA had provided extra staff and resources and the home was starting to get a handle on the outbreak. That inspection found no deficiencies.

In August, there was another outbreak at Charlotte Hall. Two more residents died of COVID, according to HMR and Maryland COVID data. Between the weeks of Aug. 18 and Oct. 20, Maryland reported that 15 residents and 17 staff members tested positive. Bill Meck didn’t know how the outbreak started. He suspected that vaccinated residents had breakthrough cases and were too vulnerable to withstand the virus. “It still makes me mad,” he says. “They were at the end of their lives, but you don’t need to shove them out the damn door.”

Ninety-six percent of the home’s residents had gotten a vaccine, but by Sept. 5, not long after the governor mandated that Charlotte Hall employees get vaccinated, only 58% of the facility’s staff had been, according to CMS. “You have to have a 90 or 100% vaccination rate to be safe,” Harrington told me. In September and October, news releases from the Maryland Department of Health ranked Charlotte Hall among the 10 facilities with the lowest staff vaccination rates in the state.

With the outbreak came another lockdown and a cessation of visitation. For Bill, the resumption of normal life had been short-lived anyway. Starting last fall, he had been able to visit with his family outside, and he looked forward to more activities after his vaccination in February. But in the spring, a nurse noticed that his knee was red and swollen. It turned out to be a spiral fracture in his femur. Though he couldn’t feel it, the break made for a long recovery. It wasn’t prudent to ride far in his wheelchair, or around the grounds or trails, lest he bump his injured leg and make the problem worse.

By September, he had spent the better part of five months back in his room, and mostly in bed, waiting to heal. Bill didn’t blame the staff. Forty years of immobility and these things happen. Patty thought someone had turned him wrong, but she didn’t suspect abuse. Her brother, after all, was not afraid to call 911 if he suspected anything. “He has done it before.”

There was nothing Bill could do about the leg, so he tried not to let it “p--- him off.” He could feel himself taking it out on the employees sometimes, which he didn’t want to do. “It’s not y’all’s fault,” he’d tell them. It was the isolation that got to him. After his leg fracture, his sister had received special permission to see him indoors occasionally, but with the second outbreak, even that was put on hold for two months.

Bill still saw his care team, of course, and he appreciated that they were no longer decked out in full PPE, like they were entering a lab, when they came into his room. A staff member had asked him recently if he would help with a resident council meeting. He was thinking about saying yes and getting involved again. But he also debated whether it was time to take a step back from nursing-home advocacy. “How do you stop caring?” he wondered. “How do you get to that point?” He didn’t know yet. He was still looking for answers.