At one point, Bell's infection got so bad that the hospital used maggots to try to eat away the decay. That's not unusual treatment, but what happened afterward was.
"The dressing that they had on there was real poorly done," said Bell's granddaughter, Chesney Shirmer. "Some of the maggots got out and they were in the bed with him, you know? He could feel them in the bed."
Ed Bell died of gangrene in the VA hospital in 2002.
One More Problem
When confronted with these details, Perlin said he shared the outrage and promised to look into fixing these things.
But there is one more problem. Many whistle-blowers and critics say if you try to expose the truth, VA managers don't want to hear it.
Charles Steinert, who worked for Billik in Charleston, says he felt pressure to leave after he complained about some of the building projects and how he was being treated by supervisors.
Nurse Melissa Craven, who also worked at the Charleston VA, says she suffered retribution for two years after she spoke out about some of her supervisors.
Perlin said it is easy for patients and their loved ones to lodge complaints about VA care. "That's important to us, because if there are concerns, we want to address them," he said.
But many patients and their loved ones told ABCNEWS that wasn't their experience — and even worse, many of the families are afraid to speak out.
"They're afraid to say what really goes on, because they're afraid any little benefits that they have are going to be taken away from them," said Denise Soles.
The day after Primetime presented its findings to the VA's Perlin, he ordered inspections of the facilities Primetime investigated.
They found a number of problems at the Temple, Texas, VA, including poor hygiene, insufficient staffing and low satisfaction among patients and their families.
The VA announced it would bring in new supervisors, reassign some personnel, train others, and begin recruiting additional staff.
Inspectors who went to the VA in Cleveland said it was in good condition. However, after their visit, Primetime received phone calls from several sources saying that the hospital had advance warning of the so-called surprise inspection.
And to those patients who accuse the VA of assembly-line care — that patients go through a succession of doctors — a public relations officer for the VA said it tries to ensure continuity of care, but that may not always be possible.
As for Dean Billik, he has now retired. In a phone conversation on Wednesday, he said he disagreed with the VA inspectors, saying their report was "an opinion."
Billik said he relied on his staff to supervise nursing and recommend budgets, and if he had renovated some buildings that then were closed it was because he didn't possess 20/20 hindsight and made the best decisions at the time.
Rep. Ted Strickland, a member of the House Veterans Affairs Committee, called for the White House and Congress to approve enough money to ensure that veterans get the care they deserve.
It's a "situation that's crying out for change," the Ohio Democrat said after viewing Primetime's tapes.
Veterans and their families agree they deserve better. "They were good enough to go fight for their country," said Melba Bell. "They deserve to have the best treatment that they could get."
Denise Soles says that before her husband died he asked just one thing of her: to speak out.
She said Terry Soles told her, "If we can help one other veteran from going through the hell … That's what we have to do."
Some Internet resources for veterans: GIreports, http://www.gireports.com; Iraq War Veterans Organization, http://www.iraqwarveterans.org; American Legion, http://www.legion.org; National Gulf War Resource Center, http://www.ngwrc.org