With one of the nation’s deadliest outbreaks of COVID-19, the Soldiers' Home in Holyoke now faces at least four state and federal investigations.

But for years, the nursing home for aging veterans has operated without a visit by a state inspector and has not faced penalties or other enforcement, despite costing Massachusetts taxpayers more than $24 million a year to operate.

Unlike hundreds of other nursing homes in Massachusetts, the 247-bed facility in western Massachusetts is not inspected by the Department of Public Health. And the state’s long-term care ombudsmen program — which fields complaints from residents and acts as a frontline watchdog for abuse or maltreatment — also doesn’t serve the veterans’ home.

The agency enforcing standards at the Holyoke facility is the U.S. Department of Veterans Affairs, whose inspectors have typically uncovered just a few or no serious problems at the home in their annual surveys. Documents obtained by WGBH News show one unmet standard repeatedly flagged by inspectors since 2016 was overcrowding of veterans living here — an issue that critics say likely contributed to more than 150 COVID-19 cases and 74 deaths since mid-March among about 210 residents.

The VA accepted the facility's promises each time to fix the crowding, according to the survey reports.

The state’s other Soldiers' Home in Chelsea is subject to inspections by the Centers for Medicare Services, whose annual surveys of the site have typically highlighted dozens of deficiencies. Last year, the CMS inspection in Chelsea highlighted deficiencies in 12 categories, including problems with treatment plans, pharmacy practices, dementia care and beds at risk of entrapping residents. The Soldier's Home in Chelsea has seen 31 veterans die of COVID-19, among a population of about 200 residents.

“There is a lot less oversight in Holyoke than in Chelsea or any other facility in Massachusetts,” said Steven Connor, who heads the Western Massachusetts Veterans’ Service Officers Association and works with veterans in Hampshire County.

Connor, who helps place veterans in the Holyoke home, wrote a seven-page memo to his state legislator in late 2017, complaining about the VA’s lax oversight of the Soldiers' Home in Holyoke and lower standards than those enforced at the Chelsea home.

The State Executive Office of Health and Human Services said the Soldiers' Home in Holyoke is not subject to CMS inspections because the facility does not accept Medicare payments. The agency did not provide answers to specific concerns about the care provided at the Holyoke home.

Connor said the difference in oversight between Chelsea and Holyoke has shortchanged veterans in western Massachusetts.

The veterans at the Holyoke Soldiers' Home also don’t have access to a state ombudsman, while veterans at the Chelsea site saw weekly visits from an ombudsman before the pandemic, when ombudsmen were banned along with all other visitors from all long-term care facilities. In January, VA inspectors flagged the lack of an ombudsman in Holyoke as a problem and learned that the home’s leadership had decided in 2011 not to participate in the ombudsman program.

Elba Pires-Morgado, the state’s long-term care ombudsman at West Mass Elder Care in Holyoke, said she gets many calls from families at the Soldiers Home in Holyoke and tells them she can’t help. She refers callers back to the main number for the home. When a WGBH News reporter called the Holyoke home asking how to reach an ombudsman, he was told to call an 800-number for the state, an elder abuse hotline.

But it’s not clear if the state’s elder affairs agency can investigative any complaints at the Holyoke home.

Connor and other critics said that even before the COVID-19 outbreak, the VA knew of serious problems with understaffing and overcrowding at the home, but there was never any action taken to fix the problems.

The last five inspections by the VA all cited bedrooms crowded with too many veterans that violated the agency’s standards for living space and made egress from the rooms dangerous. Some beds were placed only 20 inches from each other.

Year after year, officials at the Holyoke home said they would address issues of overcrowding but never did. Despite the documented crowding issues in Holyoke, state lawmakers two years ago appropriated $199 million for 154 new beds at the Soldiers' Home in Chelsea.

Families of veterans said they complained about the tight quarters at Holyoke.

“It was like a closet. You could barely walk to get to the bed,” said Karla Jean Delisle, of Granby, whose father, a World War II vet, lived and died at the Holyoke home in late 2014.

Connor, the veterans’ agent in Northampton, is convinced it’s a big reason why COVID-19 spread so quickly there.

“When we heard (about) the first case, I said I can't see how it's not going to spread because they're all on top of each other, too many in the rooms,” he said.

Last week, the interim superintendent of the Holyoke home called for reducing the capacity to allow fewer than 170 veterans to live there.

“Going forward, only 160 residents can be there to safely meet their needs? I've been saying that for years,” said Connor. “You had to have all these people die before somebody has to come out and say it.”

State-led studies in 2017 and 2019 raised concerns about understaffing and the use of overtime for nurses at the Soldiers' Home in Holyoke.

A report last year from Suffolk University's Moakley Center for Public Management, commissioned by the state, found a shortage of certified nursing assistants, high staff turnover and workers pressed into overtime shifts.

Kwesi Ablordeppey, a nursing assistant who heads the local labor union at the Soldiers' Home in Holyoke, said mandatory overtime and short-staffing of nurses are part of what led to the COVID-19 outbreak, which has also infected more than 80 staff at the home.

"I know what goes on on the ground," Ablordeppey said. "Veterans are supposed to get the best. Why can't we give them the best?”