She still remembers the smell.

The first time Anna Velez Negrn came to visit her uncle, she was all but assaulted by the vile odor of excrement when she entered the nursing home off a rural, two-lane road in Sussex County.

As soon as we walked in the double doors, the stench that came from there literally burned our eyelashes off, it was so bad, she recalled. The nurses were just standing around and joking, not doing anything. The patients were there in their own feces.

Rooms were crowded with residents living tightly together. The showers were moldy and stunk of poop and urine. And each time she came up north from her home in Florida to see him, she would find the mans condition had deteriorated, almost shockingly, as if no one had been taking care of him.

It was just dirty and nasty, Negrn said of the Woodland Behavioral and Nursing Center in Andover Township. I tried to get him out of there from the day I found out he was there.

It would take another three years before a different place could be found for her uncle, Efrain Ramos, 81, a retired hospital custodial worker from Newark who had been there since suffering a stroke.

Earlier this year, the state Department of Health slammed Woodland with tough enforcement sanctions that would permanently move Ramos and hundreds of others out to new places to live and would ultimately lead to the almost unheard-of closure of one of the largest, most notorious, and arguably most dangerous nursing homes in New Jersey.

More people have died from COVID at Woodland than at any other long-term care facility in the state. It was slapped in August with a nearly $1 million civil penalty by the U.S. Centers for Medicare & Medicaid Services for placing the health and lives of residents in jeopardy, while its demise marked the first nursing home in New Jersey to be forcibly shut down since 2018, following years of complaints, lawsuits, fines and reports of horrendous conditions

Once known as Andover Subacute and Rehabilitation Center II, Woodland came dramatically into the public eye at the height of the pandemic on Easter Sunday in 2020, following the discovery of 17 bodies, some being stored in a makeshift morgue, as COVID deaths there spiraled out of control. But wretched conditions existed long before the pandemic. So why, advocates ask, was it allowed to go on for so long?

An investigation by NJ Advance Media of hundreds of pages of federal and state reports, and interviews with advocates, experts, and family members who believe the care of their loved ones was deficient, painted a picture of a long-troubled operator teetering on the edge of bankruptcy who cut corners at every single turn, at the expense of hundreds of elderly and vulnerable residents, even before COVID hit.

Those public reports and interviews as well as lawsuits brought by attorneys who sought to make Woodland accountable for its alleged sins described a litany of reported abuses that played out for years. Complaints spanned from the purchase of the most threadbare blankets that provided sparse comfort, to the absence of proper medical care and far from enough nurses and aides to tend to medical needs of fragile and vulnerable residents, to filthy living conditions as management allegedly slashed the housekeeping staff to save money.

At one point, residents were even without TV for weeks.Efrain Ramos, 81, a retired hospital custodial worker from Newark, who was a resident at Woodland Behavioral and Nursing Center.Photo courtesy of Anna Velez Negrn

While Woodlands ownership has come under fire, advocates, families and industry officials say the state should have acted sooner, given that the facility receives tens of millions of taxpayer dollars each year from Medicaid. The Department of Health was well aware of the deplorable conditions for years, advocates argue, yet delayed taking action to shut it down.

Staffing issues repeatedly surfaced in state and federal inspection reports. In 2019, a state investigation found staff members failed to respond to a door alarm after a 76-year-old resident deemed at risk of leaving the building walked out undetected in minus 4-degree temperatures. And soon after COVID hit, a federal survey team concluded that the facilitys failures caused or was likely to cause serious injury or death to residents in the facility.

Indeed, the states inability to react as the conditions at Woodland became ever more horrific, call into question how many other facilities in the state might also be providing substandard care to residents, some say.

New Jersey is one of the weakest states in the country in respect to holding nursing homes accountable for poor care and degrading conditions, claimed watchdog Richard Mollot, an attorney and for the past 20 years the executive director of Long Term Care Community Coalition, a non-profit group that advocates for nursing home residents.

The coalition has analyzed data repeatedly comparing states enforcement of quality care and safety standards and New Jersey and New York are consistently the weakest, year after year, said Mollot, who lives in Weehawken and knows the state well.

He said the state Health Departments surveyors lack the personnel, the skill and leadership to hold nursing homes to account, although the blame must be shared with the federal government, which has not increased the amount of money spent on inspections in seven years.

Surveyors tend not to be equipped and supported in properly identifying substandard care and holding providers accountable even when it results in resident harm, he said, calling Woodland a poster child for that.

And when the state levies fines, he said they tend to be low and are often appealed.

Its a lot cheaper to fight or pay some of these fines than to hire an experienced nurse, Mollot said, adding that the fact that so many fines were imposed on Woodland before the state and CMS sought to turn off the lights was telling. When is the state going to take its job seriously?

The conditions at Woodland were abominable, said Rosemary Arnold, a Fort Lee lawyer who has had several clients contact her office regarding cases against the facility.

Any reasonably competent inspection would have revealed the dangers, she declared, adding that either the state and federal regulators knew and took no action, or they should have known but didnt.

Either way, its a disgrace it took them so long to close it down, she said. Any reasonably competent inspection would have revealed the dangers.The Easter 2020 incident at what was then called Andover Subacute II first cast a national spotlight on the problems at one of the state's largest nursing homes.Ed Murray | NJ Advance Media for NJ.com

The state Department of Health declined to comment on specific questions regarding the inspections and oversight of Woodland, nor would they make anyone within the department who is responsible for managing nursing homes available for comment.

The department devoted significant time, effort and resources to best ensuring the health and safety of the Woodland residents, the department said in statement, noting as well that it coordinated with other relevant state entities, such as Department of Human Services and the Long-Term Care Ombudsman.

Asked specifically if there had been any reluctance to act, officials said: As with every facility, the state Health Department makes every attempt to bring facilities into compliance so long-term care residents can be healthy and safe, remaining in their homes (which is the facility). The department will not hesitate to act in the best interests of long-term care residents who are at risk of serious and imminent harm.

Its not as if the state was unaware, advocates noted. Several reports documented the warning signs that have been out there for years. Last February, the Office of the State Comptroller identified the 15 worst nursing homes in New Jersey, which included Woodland, saying all had failed to improve for years, yet had not faced any real consequences despite costing the states Medicaid program mre than $100 million a year.

Acting State Comptroller Kevin D. Walsh said the nursing homes, repeatedly cited for serious health and safety issues should be kicked out of the Medicaid program if they could not fix what was wrong and provide better care. Six months later, more than half including Woodland, which last year received $17 million in state Medicaid funding had failed to do so.

Questions over states response to the crisis in its nursing homes were raised by an outside consulting firm brought in by the Murphy Administration in 2000, in the wake of the rising tide of deaths at Andover and elsewhere.

Manatt Health concluded that the health department did not have sufficient staff to deploy to facilities and conduct meaningful oversight prior to COVID-19. New Jersey needed to more frequently and aggressively use its authority to demand improvements and levy fines, the consultants said in a report, noting the large percentage of nursing homes with infection control deficiencies and citations.

It would not be until a state report this past February revealed alarming new failures in care at the still short-staffed facility some threatening the very lives and safety of residents that the state would begin taking significant action at Woodland.

That report found its staff made absolutely no effort to resuscitate a 55-year-old resident found in cardiac arrest on New Years Day. Another nursing aide reportedly left another resident soiled in feces for ten hours overnight. Underscoring the continued lack of help, regulators said not a day went by when there were enough certified nurse aides on duty during a two-week period.

Those people were sitting ducks, attorney Daniel Marchese of Newton said of the residents at Woodland. They didnt have diseases that would make them handicapped. They just needed help.

Marchese now represents several families suing Woodlands owners over the deaths of their loved ones.Those people were sitting ducks…Attorney Daniel Marchese

Lawyers for Alliance Healthcare Holdings of Lakewood, the operators of Woodland, said they were not authorized to comment and passed along requests for comment to the owners, who did not respond to multiple efforts to contact them.

Alliance, though, never sought an administrative hearing to challenge the states later revocation of its license, health department officials said.

In the meantime, despite the states repeated condemnation in a series of enforcement actions, Alliance remains in business. Headed by CEO Chaim Mutty Scheinbaum, 40, and Louis Schwartz, 37, the limited liability company operates a second and smaller nursing home across the road from Woodland, called Limecrest Subacute and Rehabilitation Center, which has not had the problems of its sister facility. According to CMS reports, Scheinbaum and Schwartz also run two nursing homes in Pennsylvania that have both garnered below average and much below average ratings from federal regulators.

To be sure, Woodland faced unique obstacles. The nursing home itself was in Sussex County, as advocates consistently note, making it always difficult to find anyone willing to work there. It also served a resident population requiring a great deal of direct care, some uncontrollably combative; others suffering from advanced dementia, schizophrenia, or other severe mental illnesses. Few had loved ones watching out for them, with lawyers for Alliance noting that many of Woodlands residents had no relatives. Some were wards of the state.

Caring for this unique population presents its own challenges, above and beyond those that present themselves in more traditional long-term care facilities, wrote Woodland attorney Peter Slocum in court filings.

But even those in the long-term care industry wonder why Woodland was able to hang on for so long.

Early on, it was obvious to industry leaders that the facility was troubled and heading in the wrong direction, observed Andrew Aronson, CEO of the Health Care Association of New Jersey. State officials chose to take actions that they hoped would reverse the situation and then ultimately tried to find a new operator to step in. It is not surprising that no experienced nursing home operator wanted to step in to such a difficult situation in the midst of the pandemic.

Aronson questioned why a shutdown had not been ordered sooner.

I am surprised that it took the state so long to choose that course of action, he said.A tough cookie

Tom Henderson, a 58-year-old cancer and stroke survivor, arrived at Woodland in October 2021, expecting to begin physical therapy to help recover from the partial paralysis on his left side.

When he got there, he encountered a nightmare

It was horrendously filthy. The last week I was there I had to sleep with the lights on, it was so overrun with cockroaches, he said in a telephone interview. I had a chance to get out four times. They made up lies to keep me there. They wanted to keep collecting the money. It was like a prison.Tom Henderson, a 58-year-old cancer and stroke survivor, who arrived at Woodland in October 2021.Photo courtesy of Janet Menge

His long-time girlfriend, Janet Menge, said for 10 months, Henderson shared cramped, filthy bedrooms with one or two other residents. Most of his clothes and other belongings went missing. Physical therapy was an occasional supervised walk up and down the hallway. When he complained about medication delays or neglectful conditions he and other residents endured, she said he was repeatedly threatened with banishment to the third floor, a locked unit known all too well to Woodlands residents and staff as a place of punishment, populated by people with serious mental illness who advocates say were woefully neglected.

Hes a tough guy. A tough cookie, remarked Menge. But Woodland changed the 6-foot, 3-inch builder. It nearly broke him, she said.

After learning of the conditions at the facility, she immediately searched for another rehab and nearly succeeded weeks later finding him an open spot at an assisted living facility in New York. She believes the social workers at Woodland sabotaged his transfer, delaying the paperwork and misrepresenting his medical condition, so they could keep collecting state Medicaid reimbursement for his stay.

He was literally rolled in there and forgotten about, she said.

According to emails Menge shared with NJ Advance Media, a new resident assigned to share the room was admitted with COVID-19 and was given to coughing fits. Henderson finally wheeled himself outside the doorway because he was uncomfortable with how sick his roommate appeared.

A security person approached him and told him he couldnt sit in the doorway. That it was a red unit and he was to stay in his room with the door closed, she explained. Henderson adamantly questioned this and a little strong arming happened where the security person was grabbing the back of his wheelchair to forcibly pull him back into the room while he held onto the doorway, she noted in a Jan. 5, 2022, email sent to the director of social work at Woodland.

It was so frustrating. There were times I would burst into tears, I didnt know what to do, she said. I had to call the police several times. He was assaulted by another resident and they did nothing.

Henderson said he was able to endure it because he is tough.

But I feel bad, he said. My one friend in there was 84 years old. He was in the military. He worked his whole life. He said, I literally never thought I would end up like this.

The state needs to do much more, he said. Nursing home regulators are not doing enough to protect the residents, especially those who have no family or friends to look out for them, he noted, adding Sadly that is the case for many of them.

They need to send people from the state undercover and have people written up on violations, " he said.Fond memories

Efrain Ramos did not drive. He would walk to work each day to the now shuttered Columbus Hospital in Newarks North Ward, where he was employed as a janitor. When he wasnt working, he wouldfrequently walk to his sisters house, where Anna, his young niece, looked forward to seeing him.

My mom and he were very close. He was always at our house, Negrn said. He would have conversations with us. Bring us candy and lollypops and always would try to make us laugh. I have a lot of fond memories of my uncle.

A short man she described him as boxy like he was nevertheless very strong. He had insurmountable strength for a little guy, said Negrn.

But a stroke sometime around 2014 left him partially incapacitated. For a time, he was being cared for in a nursing home in Newark. A clash with a roommate would eventually lead to his being sent to Andover Subacute II in 2019.

By then married and living in Tampa, Negrn came to visit him before the pandemic, flying into Newark to see her family and then making the long drive to Sussex County to spend time with her uncle. She gasped at what she found.

Conditions were deplorable, she said, recounting the stench, the atmosphere and what she saw as the seeming indifference of staff. My uncle was lucid. He was eating with one hand because of the stroke.

She bought him new clothes, all tagged with his name. She sent food. And tried repeatedly to get him moved. When she returned months later, COVID had already taken hold and their visit had to be taken outside. Even today, Negrn could not believe the change that had come over her uncle.

He could barely talk. He was barely able to eat, she said. They never put him in therapy and at that point he couldnt move his limbs. He had lost weight and I dont know whose clothes he was wearing but they werent the clothes I had bought him.

On a later trip, it did not appear as if he had even been bathed. His uncut fingernails and toenails grew so long, they had curled around grotesquely. Negrns husband asked to see his room. At first, he was denied. When he insisted, a nursing aide told them: Ill be right back

Finally admitted into the room, they located his bed and saw it had freshly laundered sheets on it.

It looked like nobody had slept there, she said.Cutting costs

A sprawling facility licensed for 540 beds, Woodland a 40-mile drive northwest of Newark had been under the eye of state and federal regulators even before Alliance Healthcare acquired it.

In 2017 under the management of its previous owner, the nursing home then known as Andover Subacute agreed to pay the federal government $888,000 to resolve allegations it provided substandard or worthless nursing services to some patients. The U.S. Attorneys Office charged that the nursing home allegedly billed New York Medicaid for materially substandard or worthless nursing services provided to certain patients that failed to meet federal standards of care.

The problems of Andover Subacute, though, did not go away.

Clearly, the new owners were not up to the task of operating such a huge, complicated facility, said Aronson, whose trade association represents the states long-term care industry.

Shortages of health care workers, in fact, continued to threaten lives, officials charged. In one 2019 incident, a state investigation revealed that staff members preoccupied with an agitated resident failed to respond to a beeping door alarm after an elderly resident with dementia simply walked out undetected in sub-zero temperatures. She was later discovered seated on an ice-covered sidewalk wearing only a short-sleeved shirt and pants, without a coat, socks or shoes.

By January 2020, it had become clear that Andover II had embarked on significant payroll and other cuts as well, according to Jennifer McMahon, chief of advocacy services for the New Jersey Office of the State Long-Term Care Ombudsman, a state agency that advocates for nursing home residents and their families. Based on conversations with employees, she learned that the housekeeping staff had been reduced from 75 to 35 employees.

It was absolutely obvious, she said of the cutbacks in the operation. But it was a slow decline. It was not something that was glaring at you. They went to the threadbare white blankets that would not keep you warm on the coldest day. The equipment and wheelchairs were not being sanitized or washed.

When COVID struck and every nursing home in New Jersey was suddenly forced to go into lockdown for months, there was little her office, or for that matter the families of those who lived there, could find out about exactly what was going on inside. And while the pandemic was raging and hundreds of nursing home residents statewide were dying every week, the state admitted it did not send out inspectors in the first two months because they did not have the right masks.

Andover became a black hole for information.

A scandal over dead bodies stacked up like cordwood one Easter weekend changed all that.Not ready for the common cold

Death stalked the corridors of Andover when the pandemic hit, becoming a national story after a call to police on Easter Sunday in 2020 that led to the discovery of the unclaimed bodies of 17 residents. The facilitys morgue did not have space for them all.

With cameras outside and major news organizations covering the story of a nursing home that could not even take care of its residents after they were dead, the state ordered the nursing home to cease all new admissions as they investigated the loss of as many as 39 residents who had died.Andover Township Police Department Chief Eric Danielson briefs the media at Andover Subacute II in Andover in April 2020 after police responded to a call for body bags at the nursing home.AP Photo/Ted Shaffrey

Andover was later hit with $220,235 in federal fines and penalties, after CMS blamed operators for allowing COVID to spread unchecked through a facility chronically short of staff and seemingly oblivious to the critical need for infection controls.

This place wasnt ready for the common cold. They werent ready for anything, they cut corners so much, complained Marchese, the lawyer whose cases against Andover include that of a 63-year-old woman who died of COVID days after the bodies at the nursing home were discovered.

Marchese said every nursing home in the country had been put on notice after the first COVID deaths in the U.S. were reported at the Life Care Center in Kirkland, Wash., which served as a grim harbinger of the tragedy that was to come.

They had time, he said. They just chose not to do anything about it.

Lawyers for the nursing home, in later court filings, said the long-term care facility unjustly became the whipping boy of the press and politicians alike following the Easter incident.Woodland was left to fend for itself…Peter Slocum, an attorney for Woodland

In reality, Woodlands dedicated leadership and staff moved mountains to attempt to care for their residents, pleading with every available state and federal resource to provide them critical aid during the height of the pandemic only to be turned down because no one was in a position to assist, they wrote. Woodland was left to fend for itself, as the state knows extremely well.

Amid the public outrage over the bodies, the Department of Health ordered administrators to retain outside consultants to assume several key roles at the facility, including an infection prevention specialist, a director of nursing and an administrative manager.

The New Jersey National Guard deployed to the scene as well.

Our airmen went above and beyond at Andover Subacute II, said Col. Yvonne Mays of the New Jersey Air National Guard, who served as commander of the Long Term Care Facility Task Force in 2020. During their time at the facility in 2020, our airmen assisted facility staff in clearing a backlog of tasks, supported residents and helped them make video calls to loved ones during lockdown.

When the mission was extended into the summer at the request of the Department of Health, she said every single airman volunteered to stay.U.S. Air Force Staff Sgt. Robert Budhan of the 108th Force Support Squadron with his N95 mask on at Andover Subacute II, after the New Jersey National Gurd was called in to help in May 2020.U.S. Army National Guard photo by Spc. Michael Schwenk

McMahon, the advocate working with the states Long-Term Care Ombudsmans office, acknowledged that many of those airmen were reluctant to leave.

They felt like they needed to stay on to get the job done, she said.

A few months later in June 2020, the state allowed nursing homes to begin arranging for outside visits between residents and their families and McMahon who lives near the nursing home contacted a social worker there and asked him to give her a list of residents who didnt have families or other visitors. She would be their family. She would often come to discuss current events with them, talk, or just check in to see how they were.

The place, however, remained unsettling. On some of her visits, McMahon noticed residents going outside without shoes or socks. Their fingernails were overgrown. Oral care was not being taken care of. She said many felt simply trapped, filling up on junk food and given no meaningful activities to fill their days.

Every time she went there, she described the situation as more appalling. On a visit in June of 2021, a nurse led her to the third floor, a place conjuring flashbacks to the psychotic hell of the Jack Nicholson movie One Flew Over the Cuckoos Nest. It was hot, sticky and humid. Food waste and spills were everywhere. Residents with vacant eyes wandered aimlessly.

The third floor was almost like a punishment if you had a really bad behavior, she said, recalling how one resident fed himself with his hands, food falling into his lap.

A nurse took her into the shower room. It was bone dry.

That told her that no one had showered that day.

In the face of the heightened attention and unwelcome publicity that had come after the discovery of the unclaimed bodies, Andover Subacute II changed its name in June 2021 to Woodland Behavioral and Nursing Center. But the story of the makeshift morgue resonated powerfully with Gwen Orlowski, executive director for Disability Rights New Jersey, a federally funded legal group that advocates for the human, civil, and legal rights of those with disabilities.

She found the number of individuals with developmental disabilities, serious mental illness and traumatic brain injuries who were dying at Andover really staggering.Jill Hoegel, (l.), Director of Investigations and Monitoring and Gwen Orlowski, Executive Director of Disability Rights New Jersey.Phil McAuliffe | For NJ Advance Media

By the summer of 2021, Disability Rights New Jersey resumed making in-person visits to nursing homes, including the now renamed Woodland Behavioral and Nursing Center. Jill Hoegel, the groups director of investigations and monitoring, said on their first trip back, concerns were growing about the number of people there with disabilities the largest number ever with serious mental illness, intellectual disabilities, and traumatic brain injuries.

That was a red flag for us. They didnt appear taken care of, she said. People were dirty, disoriented and seemed over-medicated. They were not coherent and shuffling around. Nobody was going outside and nobody was able to leave. They had been imprisoned inside.

Staffers there told Hoegel that what she saw was not atypical. Its pretty clear they werent getting much in the way of care, she said. There were not enough social workers.

At almost every visit, someone from management would confront them.

What are you doing here? they would demand.Nobody called 911

The first Monday after New Years Day this year was a day that would mark the beginning of the end for Woodland. That morning, a team from the Department of Healths Health Facility and Field Operations showed up for what was supposed to be a routine annual inspection. What they reported would stun even those already well familiar with the nursing homes failures, with detailed findings of widespread abuse and neglect including the staffs failure to even attempt resuscitation of several residents in cardiac arrest.

Woodland was cited for immediate jeopardy, the most serious violation it could face, signifying a threat to the health, safety, and lives of its residents.State report on deficiencies at Woodland Behavioral and Nursing Center in Andover, citing neglect and abuse of a resident.NJ Department of Health

Within weeks, the wheels were set in motion to curtail all new admissions and begin depopulating Woodland, eventually moving out hundreds of residents. It was given until March 3 to correct what now was a critical situation, or face the termination of all its federal funding.

Those corrections did not appear to materialize. Even simple repairs seemed unable to be fixed. The facility in January lost its cable television access for about six weeks. Woodland administrators claimed it was a problem with the satellite dish.

Things had gone downhill, said Laurie Facciarossa Brewer, New Jerseys Long-Term Care Ombudsman. All of these facilities ebb and flow in terms of staffing levels and ability to maintain services. They didnt listen to anybody. They didnt right the ship.A lack of caregivers

Following the release of its scathing inspection report, the state health department demanded the Woodlands resident census be further reduced because there just werent enough employees to handle the number of people living there.

McMahon and Facciarossa Brewer spent the next four months in their own fight with Woodland administrators to let transfers happen, as the ombudsmans office staff would seek to identify those who could be transferred to other nursing homes.

Facciarossa Brewer said moving everyone out of Woodland took longer than necessary, but Disability Rights New Jersey and staff from the state Medicaid office and the Department of Health backed up the work of the ombudsmans office.Laurie Facciarossa Brewer (l.), the state's Long Term Care Ombudsman, and Jennifer McMahon, Chief of Advocacy Services for the ombudsman's office.Julian Leshay | For NJ Advance Media

Through sheer persistence, we would just keep pushing, the ombudsman said, adding that Woodland wanted everyone to believe these people were so difficult that they were to blame they had to live in these conditions.

And yet, there were still more violations. After the state Department of Health in March named Atlantic Health Systems to serve as a monitor at Woodland to conduct a complete review of Woodlands operations, doctors there quickly flagged the nursing homes failure in monitoring the gastric tube feeding of residents who developed bowel obstructions.

Woodland was also running out of money as well. In court filings, the state said Woodland appeared to be in acute financial distress or at risk of filing for bankruptcy protection, noting that the facility had a negative cash flow, limited borrowing capacity and they questioned its real estate leasing structure.

On May 24, the state announced it would seek a court order to have a receiver take full charge of the facility. Federal regulators sounded the final death knell the next day. The Centers for Medicare and Medicaid Services said repeated surveys documented Woodlands failure to comply with federal requirements.

Woodland had run out of time.Somebody should care

The hearing before Superior Court Judge Frank J. DeAngelis in Sussex County on May 27 was held on-line and did not last long.

New Jersey had already moved to revoke Woodlands license. It is rare for a nursing home operator to be stripped of their license. The last time it happened was in March 2018, when the state ordered the shutdown of a dementia care home suspending the license of the Selah Care Center in Belvidere in Warren County over abuse allegations that the Department of Health found posed a serious risk of harm to residents.

Addressing the issues at Woodland publicly for the first time, attorneys for the nursing home said New Jerseys efforts represented an obscene overreach that ignored significant facts demonstrating the complete impropriety of the states requests.

The stte pushed back. On the video feed, Andrew Sherman, an outside attorney representing the state in the case, told the judge it was time to think about the residents.

Somebody should care about these patients, your honor the residents of these facilities. We cant lose sight of that, he told the judge. People should be here trying to help these people. Care should be paramount. The interest of the residents should be paramount.

He said the facility would have to be depopulated, simply because there is not enough staff.

The judge appointed Allen Wilen, a top turnaround expert at Eisner Advisory Group in Iselin, to serve as temporary receiver with full power to operate Woodland.

With the notice of revocation and the clock now ticking down the final days of federal funding, transfers of residents began taking place quickly.

We were like pushing a boulder up a hill, trying to get people out, said Facciarossa Brewer. Now the obstruction was gone.

On any given day, there would be 30 to 40 people from Disability Rights New Jersey, the ombudsmans office and the Department of Human Services were on site, working together to try to move these residents to a safer place to live. The new nursing homes would send vans or buses to take people away.

Woodland provided no assistance, and even fought the moves, said McMahon. Noting a lot of people were without family to stand up for them, she said it became collaborative effort.

Everyone had such a heart for these people, trying to find good places for them, she said. As residents would board the buses, she said any one of these people would give them a donut and wish them well. We wanted to make this a good experience, she recounted.The aftermath

Today, Woodland is no more. The last resident left in August.

By the time it closed, 109 of its residents and one staff member would be dead from the pandemic, according to the state, more than any other nursing home in New Jersey.

With its closure, Woodland was slapped with a massive $948,670 civil penalty by CMS in August. In the wake of the shutdown, advocates have visited more than half of the more than 300 people removed from Woodland.

Its premature to say its been successful, said Orlowski, the Disability Rights New Jersey executive director. Weve come across some people who were really happy with their new situation. There are other individuals we have spoken to and who say this was not the right nursing home for them.

Some hope that the lessons of Woodland will prompt the state to be more aggressive.

This facility certainly was the epitome of a bad actor that needlessly endangered its residents, said attorney Paul da Costa of Roseland who represented families in lawsuits charging New Jersey with gross negligence and incompetence over its handling of the COVID outbreak in the states veterans homes. Hopefully, the state will learn that regulation and close oversight needs to be strengthened. The bad actors cannot simply operate without any fear that their bad acts will go unpunished, he said.

Tom Henderson was among the last residents to leave Woodland. With help from a state-contracted social worker and the Ombudsmans Office, he was transferred to a nursing and rehab facility in Far Rockaway, N.Y.

He is making progress physically.

The new facility is better than Woodland in every way imaginable, his girlfriend said. No security guards intimidating you. They are cleaner, newer. They let you see the doctor.

The shutdown of Woodland, meanwhile, has had an impact beyond its doors.

Andover Mayor Thomas Walsh said the nursing homes closing meant the township lost its biggest taxpayer. Woodland paid $1.4 million in property taxes a year, a vital chunk of the municipalitys $10 million budget.

How would you like to be the mayor of a town and told your largest taxpayer is gone? said Walsh, who learned Woodland was closing the same way everyone else did, through media reports in July.Only the sign remains now at Woodland Behavioral, after all of its residents were relocated to other nursing homes.Julian Leshay | For NJ Advance Media

The mayor would like to see the place turned into a 55-and-over community, with some affordable housing for lower-income residents. The Township Committee just moved some money around and cobbled together about $20,000 to pay for a redevelopment study.

The area is beautiful; bucolic, he said. We could put a memorial up for all the people who died.

Our journalism needs your support. Please subscribe today to NJ.com.

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

Ted Sherman may be reached at tsherman@njadvancemedia.com. Follow him on Twitter @TedShermanSL.