5,368 dead and counting: An investigation of state failures as crisis rampaged through N.J. nursing homes

The last time Claire Collins saw her family through the glass door of the nursing home in Bergen County, the 87-year-old woman looked weak but happy. As relatives huddled under an umbrella to stay dry, she sang “Singin’ in the Rain.”

Three days later, on April 6, she was dead.

Her daughter now agonizes over what she said she has learned from emails and other families since her mother died. Eighty percent of the residents of Atrium Post Acute Care at Park Ridge had coronavirus symptoms in mid-April, but only about a dozen had been tested because there were no supplies, Catherine Collins-Mullen said.

With numerous employees becoming ill, the facility, like so many other long-term nursing homes across New Jersey, fell desperately short of staff, supplies and outside assistance, turning many into “death traps,” as one national expert called them.

“I don’t understand the state’s lack of urgency in responding for calls to help the nursing homes,” Collins-Mullen said. “Did my mom die scared, neglected and alone?”

More than 40% of the coronavirus deaths in the state have been tied to long-term care settings — a staggering toll that includes the elderly, decorated soldiers, patients with dementia. Based on the state’s own numbers, that means roughly 1 in 13 people who were in long-term care when the pandemic started in New Jersey are now dead — 5,368 to date. Scores of nursing home employees died as well.

Gov. Phil Murphy’s administration largely has blamed nursing home owners.

“The performance by the operators has been extremely disappointing — not in every case, but in too many cases,” Murphy said at his daily briefing in Trenton earlier this month. “Uneven. Disappointing. Lacking in communication, lacking in basic blocking and tackling.”

But, an investigation by NJ Advance Media for NJ.com based on internal department records and statements by officials, as well as interviews with players behind the scenes, points to major missteps and negligence by the state.

Facing the biggest public health crisis in more than a century, New Jersey failed to react fast enough or take forceful, aggressive actions to slow the rampage in nursing homes as the virus preyed on the state’s most vulnerable patients, according to more than a dozen public health experts, industry officials, family members and advocates.

Consider:

• Knowing nursing home residents were at grave risk, state inspectors did not begin making on-site inspections until April 16, according to officials — 36 days after New Jersey reported its first death and not until reports surfaced that one nursing facility was storing 17 bodies in a makeshift morgue. Asked why teams were not sent earlier, state Health Commissioner Judith Persichilli said in mid-April they did not have proper-fitting masks. She later said the state gave hospitals first dibs on protective equipment, leaving a short supply of ill-fitting masks for nursing home inspectors.
• Nursing homes were short-changed for weeks on deliveries of protective masks and other equipment, known as PPE, which state and nursing home officials concede remains in critically short supply at dozens of facilities — increasing the chances of viral spread from resident to resident, according to nursing home operators and industry officials. “We were told flat-out, ‘No PPE for you, just hospitals,’” said the president of the state’s long-term care industry association.
• When nursing home operators urgently called for staffing help, they said they received little assistance. Unlike other states, the Murphy administration did not move to deploy the National Guard into nursing homes until early May, and Guard members did not arrive until May 7 — weeks after at least six other states and more than two months after the first death in New Jersey.
• The state Health Department did not announce until earlier this month it would conduct widespread testing of nursing home residents, even as an increasing share of the coronavirus deaths were coming from long-term care facilities. Nursing home operators said they desperately needed test kits, but said the state failed to respond to repeated requests.
• The Health Department refused to publish a list of positive COVID-19 cases and deaths by facility until three weeks after families — prevented from visiting their loved ones since March 14 — pleaded with officials to force operators to let them know what was going on inside the nursing homes. Families desperate for information claimed in many cases, the first word they got was after a loved one was already critically ill.
• A startling number of nursing home workers have succumbed to the virus. State data compiled by the Department of Health provided to NJ Advance Media show as of May 11 at least 89 nursing home employees have died from the coronavirus. Nearly 9,000 have tested positive for COVID-19.

Even now, conditions remain dire in many facilities. According to additional Health Department data obtained by NJ Advance Media, some nursing facilities have less than a week’s supply — or no supply at all — of surgical masks, N95 respirators, gloves or face shields, desperately needed to protect workers and residents.

Despite the governor’s criticism of nursing home operators, the long-term care facility in New Jersey with the most deaths is the state-run Veterans Memorial Home in Paramus, which as of Monday reported 79 dead and 283 residents testing positive for COVID-19.

Meanwhile, eight weeks after the first cases were reported out of nursing homes in the northern part of the state, death tolls continue to rise in South Jersey.

In wake of the mounting toll and increasing complaints, Department of Health officials and the governor assert they all took decisive action in responding to a tragic crisis as it rapidly unfolded.

“This is a tragedy. The numbers don’t lie,” said Persichilli, at the governor’s daily briefing on May 14. “We were able to do as best we could.”

Throughout the reporting of this story over the past three weeks, the administration repeatedly defended its performance. Department of Health officials on Tuesday reiterated that since March 3 — the day before New Jersey’s first confirmed case — they took “aggressive measures to protect residents and staff, issuing 18 guidance documents to facilities restricting visitors, requiring face masks, delivering more than 10.7 million in PPE, inspecting 83 facilities, hosting conference calls to emphasize guidance and prohibiting nursing homes from admitting or re-admitting residents unless they had sufficient staff, PPE and were able to cohort residents.”

On Wednesday, the health department claimed an additional 13 million pieces of PPE has been distributed to nursing homes in the last two weeks.

They added that the department worked with the facilities since early March on outbreak response plans, testing, grouping patients infected with COVID, and infection control.

Still, those and other measures came up short, as the death toll spun out of control with small clusters exploding into full-blown outbreaks in a matter of days, according to the administration’s own data.

The state missteps aside, there is no question the nursing home industry itself also failed its residents in the life-and-death battle against the coronavirus, according to industry experts, families and advocates.

Absurdly low pay led to staffing shortages long before the virus struck. Late last year, a powerful lobbying effort by the industry help kill legislation that would have mandated minimum staffing levels at nursing homes in New Jersey, ranked as one of the worst in the country for the number of hours staff spent with residents, according to advocates. The industry complained the measure would be too costly.

As the coronavirus outbreak worsened, administrators were also far too slow in recognizing the need to lock down facilities to visitors, advocates said. Many facilities did not initially inform patients and families of residents testing positive for COVID-19, family members complained, even though required to do so by law.

Still, nursing homes are licensed by the state Department of Health, and responsibility rests with the department and its inspectors to make certain that standards and protocols are followed.

New Jersey health officials say the circumstances they were forced to confront were unprecedented.

“Situations like this show pretty clearly the vulnerability of our systems of care and this is one of them,” Health Department spokeswoman Donna Leusner said.

At his daily press briefing on Tuesday, Murphy mourned the loss of life, but praised his administration’s efforts. “The rate of new cases has decreased from its peak and we continue to throw everything but the kitchen sink, and maybe including that, at long-term care facilities to push this curve even lower,” he said.

But a member of New Jersey’s pandemic response team, involved in the day-to-day discussions and strategy sessions among multiple departments and the governor’s office, disagreed with the governor, charging that the state presided over a total “public health failure” that contributed to tragedy.

As early as mid-March the department already knew “a substantial percentage of the fatalities in the state,” were coming out of New Jersey long-term care facilities, according to the individual. Of the first nine people who died in New Jersey from COVID-19, three involved residents in long-term care facilities.

Those nursing homes deaths did not get much attention at first, said the insider, noting there was no urgency to put a plan on the table.

“Long-term care was left out of the equation,” the individual told NJ Advance Media. Speaking on condition of anonymity and asking not to be identified over fear of retaliation, the official — who shared internal staff reports and data analysis not subject to public disclosure — said everyone knew the nursing homes were vulnerable, but the administration took too long to respond.

“We need to have leadership that leans in and responds quickly, and that is what we don’t have,” the member of the pandemic response team said.

In fact, the administration looked to outside expertise for assistance. Eight weeks after the crisis took hold, Murphy unexpectedly announced plans on May 6 to engage outside consultants, Manatt Health, a national health advisory practice, to conduct an immediate, short-term review.

The team’s mission is “to mitigate the impact of COVID-19 and reduce impacts of future outbreaks” in the state’s long-term care facilities.

The state confirmed to NJ Advance Media it has retained management consultants McKinsey & Company, though officials would not disclose how much they are paying McKinsey or Manatt.

The member of the pandemic response team said unnecessary delays and inexplicable decisions by the state already carried an unacceptably high cost.

“We could have prevented deaths,” the official asserted.

Early Warning Signs

The stories out of the nursing homes have been wrenching.

They include harrowing accounts of body bags being ordered on Easter Sunday, as the dead began piling up like cordwood in one nursing facility. In Elizabeth, 22 residents died, yet nursing home administrators never alerted the mayor or any official. The mayor said he learned what had happened only after the local health officer got a call from a hospital.

Less than 30 miles away, Dolores White, an 87-year-old retired embroidery worker from Cliffside Park, moved into a New Milford nursing home in February. “On March 1, we were there for her birthday. Nobody had masks on. None of the staff. None of the visitors,” said her daughter, Lynn Cohen.

Later that month, her mother was diagnosed with the virus. By April 1, she was gone.

“I don’t know if they were overwhelmed,” said Cohen.

A spokesman for CareOne at New Milford, where White died, noted that World Health Organization had not declared the virus a global pandemic until March 11, nearly two weeks after the first case in a nursing home was reported in Seattle on Feb. 28, and that New Jersey reported its first COVID-19 positive case after March 1. At the same time, universal masking guidelines were not issued by federal health officials until April.

Workers on the front lines in a number of nursing homes, though, said they were indeed overwhelmed from the beginning.

“It moved really, really fast. We weren’t prepared. We weren’t educated on nothing,” said Jennifer Silvestro, who left her job as director of housekeeping at the Atrium Post Acute Care of Woodbury over fears she would bring home the virus. Her father, who has COPD, lives with her. “Everyone was hit in the face with this thing. Everyone is running around scared.”

Two pregnant women quit, she said.

“I saw people crying,” Silvestro said. “They were afraid of going home to their families.”

Christina O’Leary, a spokeswoman for the Spring Hills Communities — Atrium’s parent company — disputed Silvestro’s assertion that Woodbury had not been prepared for the pandemic.

“The facility was well supplied with PPE and we began staff training on infectious disease control as early as February 2020 in preparation for high-risk care,” O’Leary said.

There were early warning signs pointing to the coming storm.

Before the current crisis, New Jersey had seen what could happen when a virus invades a nursing facility. More than a year before COVID-19 hit, an outbreak of a different lethal virus struck the Wanaque Center for Nursing and Rehabilitation in northern New Jersey, offering a harsh lesson and a blueprint on how quickly people can die in a nursing home environment.

The weeks-long outbreak of adenovirus killed 11 children, many with compromised immune systems and on ventilators. A follow-up investigation by the U.S. Centers for Medicare and Medicaid Services, or CMS, revealed that Wanaque — and the state — did not respond quickly enough.

The facility, according to the investigation, lacked strong infection control procedures, and had practically no emergency plan.

If that weren’t enough, in early March just as New Jersey was announcing its earliest cases of the coronavirus, there was the disturbing news out of Washington state, where 35 people died at a highly regarded nursing home. At the time, those deaths represented the single deadliest outbreak of the coronavirus, and showed how easily and fast the novel virus could spread without aggressive intervention.

An investigation led by the U.S. Centers for Disease Control and Prevention reported by mid-March that staff members at the Life Care Center of Kirkland inadvertently spread the coronavirus. The CDC said they brought it in from other facilities because many worked multiple jobs.

The belief that New Jersey officials should have learned from their own and others’ mistakes came up again and again in interviews with nursing home administrators, family members and health experts.

That outbreak in the Washington nursing home should have shown the Murphy administration “that frail and elderly residents in nursing homes were most at risk,” said Sidney Greenberger, CEO of AristaCare Health Services, which operates six long-term care facilities in central and south New Jersey and Pennsylvania.

Instead, he said the state directed much of its early attention on hospitals, based on predictions that they could be slammed with more than 100,000 patients at once.

Under Persichilli’s orders, hospitals doubled the number of intensive care and critical care beds from nearly 2,000 to 4,000 and expanded the number of hospital beds by 60%. The expansion enabled the state to handle the surge of hospital patients in April, including nursing home patients.

But the state also issued an order that health experts and nursing home administrators believe contributed to the spread of the disease. Beginning March 31, nursing homes were required to accept non-critically ill residents who had been discharged from the hospital, but who were still recovering from the coronavirus.

The rule was designed to help hospitals, seeking to make room for a surge of critically ill patients. The decision compounded problems inside nursing facilities, which lacked protective equipment and ample staff, operators said.

“Those officials ordered COVID-positive patients into those long-term care facilities without providing necessary support,” Greenberger said.

Paradoxically, he and other nursing industry officials said the order only created more hospitalizations, as more elderly and vulnerable residents fell ill.

In response to those criticisms Persichilli said on Monday that while the state did advise long-term care facilities to readmit their own residents following hospitalizations, it was conditioned on their having appropriate PPE, adequate staffing and the ability to isolate COVID-positive patients.

“If the long-term care facility was not able to do that, they should not have readmitted,” the health commissioner said.

Leusner, Persichilli’s spokeswoman, disputed the claim that the state failed to learn from the experience in Washington state.

The commissioner held a March 25 call “to hear their lessons learned from the outbreak,” Leusner said, and “the steps they reviewed with us aligned with the efforts we had underway.” This included implementing “infection control strategies” of segregating infected patients and the employees who took care of them, she said.

‘Death Traps’

Arthur Caplan, professor of Bioethics at NYU Langone Health, said the scenario that played out in New Jersey occurred in every state devastated by the virus.

“That’s because nursing homes are forgotten institutions in good times and their reputation is horrible in good times,” he said. “They have turned into death traps with inadequate staff and equipment and very little medical attention.” (Since his interview, Caplan’s own mother died of the coronavirus in a nursing home in Massachusetts.)

As the tsunami approached, there should have been a basic game plan, said Caplan, a prominent national voice on medical ethics: “Get there and inspect what is going on. Every nursing home should get a visit and see what is happening. Get them equipment and make sure they know how to use it.”

He said immediate steps also were needed to isolate the infected, “which meant testing, testing, testing,” a refrain that has become almost cliché now. Finally, there was the need for mental and emotional support for those in their final hours.

Much of that didn’t appear to happen in New Jersey.

The Society of Licensed Nursing Home Administrators of New Jersey in a recent op-ed said its members “were an afterthought” when it came to receiving testing supplies and protective equipment.

“As was screamed from the rooftops to deaf ears, without effective testing kits for staff and residents, it’s all but impossible to keep the virus out of the facility or contained in the facility,” the group wrote.

The shortage of testing supplies was not unique to New Jersey. But the state prioritized testing kits for hospitals and the drive-thru sites in Bergen and Monmouth counties run by the Federal Emergency Management Agency, according to nursing home officials, and corroborated by the insider on the state’s pandemic response team.

“The unavailability of testing put us in a very difficult position,” said Benjamin F. Miller, senior management representative for Hamilton Continuing Care Center, a nonprofit that operates a 180-bed facility in Hamilton Square.

He accused the state of letting nursing homes down by not acting on what was clear weeks into the pandemic.

“During the height of the outbreak in New Jersey, the guidance from the CDC, CMS and the Department of Health was to separate patients with symptoms from those who did not. We now know that COVID-19 is not just spread by those with symptoms,” Miller said. “Many COVID-positive patients and staff without symptoms spread the disease to other patients and staff.”

The response, he said, should have been to test staff and residents to determine who was spreading the illness.

Murphy announced on May 12 that all long-term care facility residents and staff would be tested for the coronavirus. Eight states moved faster than New Jersey: Delaware (May 5), Maryland (April 29), New York (May 4), Oklahoma (April 28), South Carolina (May 6), West Virginia (April 20), Wisconsin (May 4) and Tennessee (April 29). Pennsylvania announced its decision on May 13, the day after New Jersey; Connecticut declared its intention on the same day as the Garden State, May 12.

Asked why testing was not made more available in nursing homes, Leusner said testing resources had been in short supply. “We needed and we continue to need test kits, reagents, swabs and PPE — especially gowns,” she said.

Delaying action

One of the most troubling questions in New Jersey remains why it took state officials more than a month after the first nursing home fatalities to inspect facilities and see first-hand how critical the situation was inside.

Indeed, state inspectors didn’t start going to nursing homes until the horrifying discovery of the makeshift morgue with 17 bodies at the Andover Subacute and Rehab Center in Andover Township, which led to national headlines and immediate calls for an investigation.

A scathing federal inspection report released last week revealed that sick residents awaiting the results of coronavirus tests were put in rooms with healthy residents. One patient who had fallen on a wet floor and suffered from a high fever was found dead in bed, 12 hours later. A doctor was never told. Another resident had a temperature of 104.9 on April 6. The following day, the resident’s temperature was not documented at all. The next day, the resident was found unresponsive and pronounced dead.

The Centers for Medicare and Medicaid Services report also found multiple instances of insufficient PPE usage and protection for staff in the facility.

Asked why the state had not been on the scene earlier, Persichilli said the N95 masks available to Health Department surveyors came in too large. “But then we got the right fit tests, and more went out into the field,” she said at the governor’s daily coronavirus briefing on April 20. “They are more anxious to get out in the field and to see as many organizations as possible, particularly in the northern part of the state.”

Leusner, the Health Department spokeswoman, said that the national PPE supply chain “was in short supply. We were prioritizing available PPE for health care providers doing direct care in long-term care facilities and hospitals,” she added.

In a span of four days through April 20, the Health Department said 33 facilities were reviewed, or about 5% in the state. By then, however, 1,779 nursing home residents had died at 450 long-term care facilities.

A Health Department spokeswoman said there are approximately 70,000 nursing home residents at 678 assisted living centers, nursing homes and other long-term care facilities licensed by the state.

To date, the state has inspected 83 nursing homes, according to Leusner. She declined to release inspection reports, saying they would be made available only through an Open Public Records Act request. NJ Advance Media filed the request on April 16 and has yet to receive any documents, despite the mandates of the disclosure law.

Not only were no state inspectors on scene, a federally mandated lockdown of the facilities to all visitors resulted in nobody else watching. For safety reasons, family visits were suspended in mid-March. That move also eliminated the watchful eyes of family and friends who could no longer check on their loved ones and be their advocates.

Laurie Facciarossa Brewer, the director of the Office of Long-term Care Ombudsman, said by the last week in March, her office was inundated with calls from frantic families frustrated they were not getting information from nursing homes about how many residents were sick, had tested positive or who had succumbed to the illness.

“The issue is communication. Families are on the outside looking in, and they do not like what they see, to the extent they see anything,” Facciarossa Brewer said. “If they can’t keep the lines of communications open, that is a facility in absolute crisis.”

Persichilli and Murphy have refused requests to identify the nursing homes that were not returning calls to frantic families. Persichilli said she was assured those calls were happening.

The other big unanswered question is why the state was slow to send the National Guard to long-term care facilities, despite a growing shortage of nursing home staff, to help feed and care for residents.

Maryland Gov. Larry Hogan sent in the Guard the week of April 6 to join “strike teams” to help overwhelmed nursing homes. Georgia tapped National Guard members in early April to help disinfect nursing homes. On April 15, Gov. Ron DeSantis announced the Florida National Guard would help with testing at long-term care facilities, and the California National Guard was stationed inside nursing homes to boost staffing levels the week of April 20. A week later, Gov. Ned Lamont ordered Connecticut National Guard to help perform inspections in nursing homes, where 43% of the state’s deaths from COVID-19 are nursing home patients.

Despite frantic pleas from families and horror stories from nursing home workers, the state initially used the National Guard to help assemble field hospitals in March. It wasn’t until Thursday, April 9, that 75 medics were sent to two of the state veterans homes in Edison and Paramus in response to the growing number of employees calling out sick.

One of the first to publicly call for the National Guard to be used to long-term care employees was David Barile, director of geriatric medicine at UPenn Hospital of Princeton. Visiting patients at assisted living centers and nursing homes, he witnessed how people were not regularly eating or getting their medicine on time.

As the pandemic raged, “state government has made no provision to assist with staffing,” Barile wrote in an open letter to the governor on May 1. “This desperate situation needs to be addressed immediately. How could a government and its health department allow a health care business to operate knowing that deaths will increase without staffing support?”

Asked that same day when the state might see a more widespread deployment of the National Guard to privately run nursing homes, the governor said it was under consideration, but there were concerns medically qualified members of the Guard already were battling the coronavirus in their “day job somewhere.”

Persichilli said during a daily briefing the department had tried to bring in the Guard, but they were “diverted.” A Health Department spokeswoman clarified that the commissioner had also contacted the federal office of the National Guard, which did not respond to requests from NJ Advance Media for comment.

A National Guard public affairs officer, in response to questions about the deployment, said official notification for the New Jersey National Guard to support long-term care facilities “was on or about May 3, 2020. The Governor’s Office, the Department of Health, and the Department of Military and Veterans Affairs were in discussions prior to this date to plan the rollout of National Guard members to LTCs.”

On May 7, the state finally announced it was sending 120 National Guard soldiers to long-term care facilities besieged by the coronavirus outbreak. The governor said they would be used to help supplement the staff as much-needed “backup."

“We don’t take this step lightly,” Murphy said that day. “But we take it knowing that the crisis in our long-term care facilities requires us to take it.”

By May 7, state officials said there had been 4,556 deaths and just under 25,000 infections attributed to long-term care facilities.

The soldiers who eventually deployed were not medical professionals, and were intended to help with testing, janitorial services, cooking and serving meals and performing administrative or logistical tasks.

The first round of 22 troops began arriving at Andover, the largest and one of the most decimated nursing homes by the virus, on May 8, nearly a month after the 17 bodies were discovered there.

“They’ve been more than wanting to help out,” Persichilli said. “It’s just to make sure that we put them in the right spots.”

Asked whether the Murphy administration regretted not using the National Guard sooner, Leusner said, “As Gov. Murphy has said, the state will conduct a postmortem to determine the strengths and weaknesses of the Department’s response.”

Separately, other states also took a more aggressive role in financially assisting nursing homes overwhelmed by the pandemic, say nursing home operators. Last month, for example, Connecticut and Massachusetts also temporarily raised Medicaid reimbursement rates for nursing homes by 15% and 10%, respectively, to reflect the demands of taking care of COVID-19 patients, according to published reports and announcements from the governors’ offices.

“Connecticut nursing home operators and their employees provide an incredible service to the people of our state, including for the 22,000 residents that receive direct care in nursing homes on a daily basis,” Lamont said in his announcement.

New Jersey Medicaid rates — notoriously the lowest in the country — rose in last year’s budget but they have not been adjusted since the pandemic, state Human Services spokesman Tom Hester said.

Sam Stein of Complete Care Management, which operates 15 nursing homes in New Jersey, took note of how other states collaborated with nursing homes.

“Some of our neighboring states immediately prioritized support for nursing homes by creating funds for additional staffing and the PPE that we all desperately needed. New Jersey did not,” Stein said. “Maryland also recognized the need to assist overburdened nursing homes and established strike teams to provide emergency care, supplies and equipment.

“I wish we had followed that model,” he added.

‘If you get a mask, you’re lucky’

From Day One of the crisis, there was a dire shortage of masks, gloves and gowns throughout the entire healthcare system.

The shortage was catastrophic in nursing homes.

In early March, then with just a single COVID-19 death in the state, nurses and aides in hospitals and nursing homes sounded the alarm, saying they had “shocking concerns” about the lack of medical armor needed to fight the war.

Representatives from six labor unions called on the Murphy administration to “ensure all healthcare facilities have the supplies, training materials and staffing support they need to reduce everyone’s risk of exposure.”

But as the outbreak spread through the state’s nursing homes, operators say most PPE supplies were diverted to critical care hospitals.

As nursing homes appealed to county emergency management officials for PPE supplies, “we were told flat-out, ‘no PPE for you, just hospitals,’” said Jon Dolan, president of the Health Care Association of New Jersey, the trade group that lobbies for the state long-term care providers.

He declined to identify which county official made the comment.

While national shortages existed, he said providers repeatedly were rebuffed by county and state Office of Emergency Management coordinators, who told them that long-term care facilities were not a Level One priority, and would likely not see deliveries.

“And we did not, until later,” Dolan said.

Reports obtained by NJ Advance Media show that situation still has not substantially changed.

A survey of facilities conducted for the Department of Health earlier this month showed more than 15% of 358 long-term care facilities had less than a week’s supply of N95 respirators — or no inventory at all. One in 10 facilities had the same kind of shortages of gowns, and about the same number were short on gloves.

Judy Fullman, a certified nurse aide who works at a North Jersey nursing home that she asked not to be named, said the facility is always short of protective equipment.

“We are suffering for PPE,” she said. “If you get a mask, you’re lucky. Sometimes you get nothing.”

The facility where she works has had five COVID-19 deaths and more than 30 of its residents have tested positive for the virus.

Administrators tell her there are no supplies, she said, and her facility is always short-staffed. Asked if she had a message for the state, her plea was simple: “Get us more PPE and more workers.”

Jennifer Silvestro, who said she was forced to leave her housekeeping job at Atrium, claimed she was given an ultimatum to work in the COVID-19 unit or quit. Silvestro said they were not getting supplies.

“Everything was on back order, like sanitizer,” she said. “They have known for a couple of weeks they were going to accept COVID patients. There should have been enough supplies.”

Health officials said they are making sure nursing homes get the protective gear needed.

“The department continues to work with long-term care facilities to deliver infection control education to facilities with outbreaks, which includes instruction on donning and doffing (gowns and masks), and is working to get them the supplies they need,” said Leusner, the Health Department spokeswoman.

Caregivers needing care

The casualties in the COVID-19 war are not just nursing home residents. Thousands of workers who take care of them are getting sick as well and dozens are dying.

Data compiled by the state’s pandemic response team obtained by NJ Advance Media showed that through May 11, 6,140 nursing home and other long-term care facility workers have tested positive for COVID-19, or were symptomatic.

According to the data, 4,708 recovered and returned to work. But at least 89 have died, including the top administrator at Family of Caring nursing home in Montclair. It was not until Tuesday, after NJ Advance Media asked specifically about the data it had, that the state included updated numbers of nursing home staff who tested positive — now more than 8,000.

Gabby Niziolek, a certified nurse aide who asked that the nursing home where she works not be named, became sick, but has recovered.

She said she was provided with a single N95 mask and has been told to reuse it. She gets an isolation gown to wear throughout the day, which she cannot change between patients. At the end of the day, the gown is washed and reused.

“It’s like a necessity. You need to protect it and others after leaving the room,” she said, recalling that for a time, the masks, gloves and gowns were kept under lock and key, and unavailable if the nursing home’s administrator was not there.

“How can anyone not understand you need this?”

The nursing home where she works so far has reported 17 deaths. More than 40 residents there have tested positive for the coronavirus, records show.

“We always had a staffing crisis,” said Barile. “Now it’s much worse.”

It was well known that even before the COVID crisis, 1 in 4 of the state’s nursing homes had long-standing staffing issues, according to CMS reports. The COVID-19 pandemic only made it more difficult to find people.

For certified nursing assistants, or CNAs, the situation has been even more dire. The job of a CNA is tough, and the pay very low — about $10.50 to $12 an hour to start.

“If one facility pays a few bucks more an hour, (the employee) will call out and go work there,” he said.

And while there had been talk of volunteers, nursing industry officials say their facilities have yet to receive any guidance from the state on whom they can hire, or participate in any planning meetings to get medical or nonmedical help.

Of greater concern to many health experts is that the role of workers themselves spreading the virus has not been addressed by New Jersey.

One of the CDC findings from the outbreak at Life Care Center of Kirkland in Washington state was that front-line nursing home workers — juggling multiple jobs at several nursing homes — were inadvertently spreading the coronavirus. Those lessons were not lost on Judith Lightfoot, chief of infectious disease at Rowan University.

“I questioned right away about how many places these workers work,” Lightfoot said. “The patients go nowhere really. At that time, when it wasn’t quite clear who was carrying the virus, it had to be the workers. Many of them work two jobs.”

State officials, however, repeatedly pushed back on any consideration of limiting staffs to one facility, even as they failed to make sure enough masks, gowns and gloves were available to limit the spread of infections by nursing home workers.

At a press briefing in April, the governor acknowledged “the reality of asymptomatic workers in these long-term facilities” who unwittingly may pass on the virus, which he called “unfortunately not just the New Jersey story,” but a national one.

Persichilli rejected the suggestion of limiting where nurse aides may work.

“We don’t anticipate telling CNAs particularly that they can’t work, and they must work in only one organization,” the health commissioner said. “There’s a reason why they’re working in several places. It’s because the wages are not enough to support what they need to do to support their families, put food on the table, and they’re working their little hearts to the bone here, just trying to survive.”

Will the waters recede?

New Jersey officials continue to insist that they met the challenges of COVID-19 from the beginning.

Administration officials point to a list of 18 “guidance” letters since early March and nearly a half-dozen conference calls that made the state’s expectations clear. Nursing homes have been told they must communicate with families about their loved ones, make room to segregate infected or recovering patients and report data about staffing and equipment needs to the Health Department.

To address the problem of where nursing home patients would go after leaving the hospital, Persichilli announced the state had found 100 nursing home beds each in north and central Jersey.

Persichilli also said wider testing is also targeting South Jersey, with the help of partners that include a number of other hospitals and nursing homes.

Most people tested in the South Jersey nursing homes were asymptomatic, the commissioner said.

However, the state official who spoke to NJ Advance Media on condition of anonymity said a second-round of testing in late April unexpectedly found new infections among 10% of those tested. People are still spreading the virus.

Data obtained by NJ Advance Media shows the number of those testing positive for COVID-19 in nursing homes to the south, which initially escaped the first wave of the pandemic, are now rising faster than elsewhere in New Jersey.

Statewide, there are now 528 long-term care facilities with COVID-19 outbreaks. According to the latest Health Department accounting, 19,454 residents and 8,858 staff of those facilities have tested positive for the coronavirus. While not all deaths have been confirmed, the nursing home death toll in New Jersey is now at 5,368 people.

(That number would suggest that more than half of all COVID-19-related deaths in New Jersey were nursing home-related. However, while the deaths in nursing homes include both lab-confirmed and suspected cases of the coronavirus, the overall state totals include only lab-confirmed deaths from the virus, according to health department data. When accounting for only the 4,295 lab-confirmed COVID deaths in long-term care facilities, the toll is 40.6% of the 10,586 statewide overall lab-confirmed deaths — or about 4 in 10 of all New Jersey deaths.)

The Murphy administration on Tuesday also began counting nursing home fatalities confirmed by lab tests separately from those whose deaths were suspected of being COVID-related. It was a move that offended Catherine Collins-Mullen, whose mother, Claire died last month.

“This (new) number does not reflect those, like my mom, who were denied testing because we were told not enough tests were available,” Collins-Mullen said.

“This is salt in our wounds. My mother has been denied, again. The first time was when we asked to have her tested, but we were told that they did not have enough tests. Now they are trying to use their lack of tests to close the door and deny my mother’s death was related to COVID,” she said.

When the outbreak finally subsides, many say there will need to be a deep look at what went wrong and why. The state’s Democratically controlled Senate already plans a series of public hearings to investigate New Jersey’s response to the COVID-19 pandemic in what legislative leaders called “devastated populations.”

All 15 Republican members of the state Senate separately sent a letter to Senate President Stephen Sweeney, D-Gloucester, calling for an investigation into the Murphy administration’s handling of the pandemic in long-term care facilities.

“It’s increasingly apparent that the tragedy that occurred in Andover and at nursing and veterans homes across New Jersey didn’t need to happen,” said Sen. Steven Oroho, R-Sussex. “Staff at many facilities warned that they were ill-prepared for an outbreak, lacking the personal protective equipment, tests and ability to segregate sick residents necessary to keep their vulnerable populations safe.”

Ann Kohler, New Jersey’s former Medicaid director and a retired national health care consultant, said there may need to be tougher controls, like an immediate admissions ban and stronger fines or penalties.

“Unfortunately, this terrible situation will continue for a while,” she said.

Yet options can be limited. She said many facilities historically cited for bad practices are not easily shut down.

She does not blame the state for the growing death toll in long-term care facilities.

“I don’t think the Department of Health dropped the ball. Remember we did not know about the virus initially,” Kohler said. “It has a long incubation period which resulted in a significant spread both in nursing homes as well as the community.”

State officials have themselves announced a broadening of an ongoing investigation by the Attorney General’s Office into long-term care facilities that have experienced a “disproportionate number of deaths.” An online link, covid19.nj.gov/ltc, was set up allow anyone to alert the state to problems anonymously.

“When we do our own postmortem in New Jersey, a huge focus will be on long-term care,” the governor said.

During the May 14 daily briefing, Persichilli expressed remorse for the “tragic” loss of life.

“The tragedy of long-term care will haunt us for a long time,” Persichilli said. “But we will definitely put things in place that will prevent them from happening again. … I’ll reach out to anyone that will help us determine what we should be doing going forward so that this never happens again.”

For the industry, there is widespread acknowledgement of the difficulties they have faced while trying to provide care and services.

“As you look back, everyone is going to find things they might have done different, or how they will act different in the future,” said Jim McCracken, who heads LeadingAge New Jersey, the statewide association of not-for-profit senior care organizations.

He wonders if there will ever be a return to normalcy.

“In the past, the waters receded,” McCracken said. “Now people are tired and there is no end in sight.”

Judy Fullman, the nurse aide at a North Jersey nursing home, said she still loves what she does.

“It’s my passion,” she said. “I love taking care of people who cannot help themselves.”

Still, she continues to wonder who is helping her.

In interview last month, she said her nursing facility never has enough personal protective equipment for staff. They sometimes hand out “cheap, flimsy” surgical masks, but they are also not always available. She purchased her own N95 respirator mask and has taken to wearing a bandana at times.

Gowns remain in short supply. When there are no gowns, she said she is forced to improvise.

She wears a plastic garbage bag.

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Susan K. Livio may be reached at slivio@njadvancemedia.com. Follow her on Twitter @SusanKLivio.

Ted Sherman may be reached at tsherman@njadvancemedia.com.