The memory of that overwhelming stench still lingers in her mind.

When Anna Velez Negrón first visited her uncle’s nursing home in Sussex County, she was immediately confronted by the horrendous smell of human waste. The facility, situated along a quiet rural road, was a shocking sight that would stay with her forever.

“Entering through those double doors was like walking into a wall of odor,” she recounted. “It was so overpowering that it felt like it could burn our eyelashes. The staff were standing around, joking among themselves, while the residents were left unattended in their own filth.”

The living quarters were cramped, with residents packed closely together, and the showers were filthy, reeking of urine and feces. Every time Anna traveled from her home in Florida to visit her uncle, she was alarmed to see his health decline rapidly, as though no one was providing him with the care he desperately needed.

“It was filthy and disgusting,” Negrón described her experience at the Woodland Behavioral and Nursing Center located in Andover Township. “From the moment I learned he was there, I made it my mission to get him out.”

It took a grueling three years before a suitable alternative could be found for her uncle, Efrain Ramos, 81, a retired hospital custodian from Newark who had been residing there after suffering a stroke.

Earlier this year, the New Jersey Department of Health imposed severe sanctions on Woodland, mandating the relocation of Ramos and hundreds of other residents to safer facilities, ultimately leading to the rare closure of one of the state’s most infamous and hazardous nursing homes.

Woodland has recorded the highest number of COVID-related deaths among all long-term care facilities in New Jersey. The U.S. Centers for Medicare & Medicaid Services imposed a staggering civil penalty of nearly $1 million in August, citing serious jeopardy to the health and safety of the residents, marking it as the first nursing home in New Jersey to be forcibly shut down since 2018, amid a history filled with complaints, lawsuits, and extensive reports of horrific living conditions.

Previously known as Andover Subacute and Rehabilitation Center II, Woodland gained public notoriety during the COVID-19 pandemic when, on Easter Sunday in 2020, authorities discovered 17 deceased individuals, some of whom were kept in temporary morgues, as COVID-19 fatalities surged uncontrollably. However, the deplorable conditions had existed long before the pandemic, raising questions among advocates about why these issues were allowed to persist for so long.

An in-depth investigation by NJ Advance Media, which included a thorough examination of hundreds of federal and state reports along with interviews of advocates, experts, and families, revealed a troubled management team on the brink of bankruptcy that had consistently cut corners, thereby compromising the safety and care of hundreds of elderly and vulnerable residents even prior to the pandemic.

These public records and interviews, along with lawsuits initiated by attorneys seeking accountability for Woodland’s alleged negligence, unveiled a long history of reported abuses that persisted for years. Complaints ranged from the use of substandard blankets providing minimal comfort to the lack of adequate medical care and insufficient nursing staff to address the medical necessities of fragile residents, alongside squalid living conditions resulting from management’s cuts to the housekeeping staff.

At times, residents even went without access to television for extended periods.

While the ownership of Woodland faced severe criticism, advocates, families, and industry professionals argue that the state should have intervened much sooner, given that the facility receives millions in taxpayer funds annually from Medicaid. According to advocates, the Department of Health had been aware of the atrocious conditions for years yet hesitated to take decisive action to shut the facility down.

Staffing inadequacies were a recurring theme in both state and federal inspection reports. In 2019, a state investigation revealed that staff members failed to respond to a door alarm, allowing a 76-year-old resident, considered at high risk of elopement, to exit the building undetected in freezing temperatures. Shortly after the onset of COVID-19, a federal survey team concluded that the facility’s failures “caused or was likely to cause serious injury or death to residents.”

Indeed, the state’s inaction as conditions at Woodland continued to deteriorate raises troubling questions about how many other facilities in New Jersey might also be providing inadequate care to residents.

“New Jersey consistently ranks among the weakest states in the nation when it comes to holding nursing homes accountable for poor care and degrading conditions,” asserted watchdog Richard Mollot, an attorney and executive director of the Long Term Care Community Coalition, a non-profit organization advocating for nursing home residents.

The coalition has repeatedly analyzed data comparing how states enforce quality care and safety standards, consistently finding that New Jersey and New York rank among the weakest, year after year, according to Mollot, who is well-acquainted with the state.

He emphasized that the state Health Department’s surveyors lack the necessary personnel, skills, and leadership to hold nursing homes accountable. However, he noted that the federal government also shares blame for not increasing inspection funding in the past seven years.

“Surveyors often lack the training and support to effectively identify substandard care and enforce accountability, even when it leads to harm to residents,” he stated, labeling Woodland as “a prime example of this failure.”

Moreover, when the state imposes fines, they tend to be low and frequently appealed.

“It’s often cheaper for operators to contest or pay these fines than to hire qualified staff,” Mollot noted, adding that the number of fines imposed on Woodland before the state and CMS sought to shut it down speaks volumes about the systemic issues. “When will the state begin to take its responsibilities seriously?”

The conditions at Woodland were described as “abominable” by Rosemary Arnold, a lawyer from Fort Lee who has represented several clients with cases against the facility.

“Any competent inspection would have uncovered the dangers present,” she stated, asserting that either the state and federal regulators were aware and took no action, or they should have been aware but failed to act.

“Either way, it is disgraceful that it took such a long time to shut it down,” she said. “Any 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 inquiries regarding their inspections and oversight of Woodland, nor did they make any officials available for comment.

“The department has dedicated extensive time, effort, and resources to ensure the health and safety of Woodland residents,” stated the department, also mentioning that they “coordinated with other relevant state agencies, such as the Department of Human Services and the Long-Term Care Ombudsman.”

When asked specifically about any hesitation to take action, officials responded: “Like every facility, the state Health Department strives to bring facilities into compliance to ensure long-term care residents remain healthy and safe in their homes (which is the facility). The department will act decisively in the best interest of long-term care residents at risk of serious and imminent harm.”

It is not as if the state was oblivious, as advocates pointed out. Numerous reports documented warning signs that had been evident for years. Last February, the Office of the State Comptroller identified the 15 worst nursing homes in New Jersey, including Woodland, stating that these facilities had failed to improve over the years yet faced no real repercussions — despite costing the state’s Medicaid program upwards of $100 million annually.

Acting State Comptroller Kevin D. Walsh asserted that nursing homes repeatedly cited for serious health and safety violations should be expelled from the Medicaid program if they cannot rectify their issues and provide adequate care. Six months later, more than half of these facilities, including Woodland, which received $17 million in state Medicaid funding last year, had failed to do so.

Concerns regarding the state’s response to its nursing home crisis were highlighted by an outside consulting firm commissioned by the Murphy Administration in 2000, following the rising tide of deaths at Andover and other facilities.

Manatt Health concluded that the health department “lacked sufficient staff to conduct meaningful oversight of facilities prior to COVID-19.” New Jersey needed to utilize its authority more frequently and aggressively to demand improvements and enforce penalties, according to the consultants, who noted the high percentage of nursing homes facing infection control deficiencies and citations.

It wasn’t until a state report released this past February revealed alarming new failures in care at the understaffed facility — some of which posed immediate threats to residents’ lives and safety — that the state began to take significant action against Woodland.

The report uncovered that staff made no attempts to resuscitate a 55-year-old resident found in cardiac arrest on New Year’s Day. Another nursing aide reportedly left a resident soiled in feces for an entire ten-hour overnight shift. Regulators noted that there was not a single day in a two-week period where there were enough certified nurse aides on duty.

“Those residents were sitting ducks,” stated attorney Daniel Marchese from Newton, regarding the vulnerable individuals at Woodland. “These people didn’t have conditions that made them incapable of caring for themselves; they simply required assistance.”

Marchese now represents several families suing Woodland’s owners for the wrongful deaths of their loved ones.

Legal representatives for Alliance Healthcare Holdings of Lakewood, the operators of Woodland, stated that they were not authorized to comment and directed inquiries to the owners, who did not respond to any of the multiple requests for comment.

Alliance, however, did not seek an administrative hearing to contest the state’s subsequent revocation of its license, according to health department officials.

Meanwhile, despite the state’s continuous condemnation of Woodland through various enforcement actions, Alliance continues to operate. Led by CEO Chaim “Mutty” Scheinbaum, 40, and Louis Schwartz, 37, the limited liability company manages a second, smaller nursing home across the street from Woodland, Limecrest Subacute and Rehabilitation Center, which has not faced similar issues. According to CMS reports, Scheinbaum and Schwartz also operate two nursing homes in Pennsylvania that have received ratings of “below average” and “much below average” from federal regulators.

Woodland faced unique challenges; being located in Sussex County, advocates note, made it consistently difficult to find qualified staff willing to work there. Additionally, the facility served a resident population that required extensive direct care, with some individuals being unpredictably combative, while others suffered from severe mental illnesses such as advanced dementia and schizophrenia. Many residents had no family to advocate for them, with legal representatives for Alliance indicating that numerous residents were wards of the state.

“Caring for this unique population presents its own challenges, beyond those typically faced in more conventional long-term care facilities,” stated Woodland attorney Peter Slocum in court documents.

However, even those within the long-term care industry are perplexed as to why Woodland was permitted to operate for so long.

“It was evident to industry leaders early on that the facility was troubled and on a downward trajectory,” noted Andrew Aronson, CEO of the Health Care Association of New Jersey. “State officials opted for a strategy aimed at reversing the situation and ultimately sought to find a new operator to take over. It is unsurprising that no experienced nursing home operator was willing to step into such a challenging environment during the pandemic.”

Aronson raised questions regarding why a shutdown was not enforced sooner.

“I am surprised it took the state so long to take that course of action,” he remarked.

Experience of a Survivor

Tom Henderson, a 58-year-old survivor of cancer and stroke, arrived at Woodland in October 2021, hoping to initiate physical therapy to regain strength after suffering partial paralysis on his left side.

What he encountered was a nightmare.

“The place was horrendously filthy. During my last week there, I had to keep the lights on at night because of a cockroach infestation,” he stated in a phone interview. “I had four opportunities to leave but they concocted lies to keep me there. It felt 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, reported that for ten months, Henderson was forced to share cramped and unsanitary rooms with one or two other residents. He lost many of his belongings, including clothes. Physical therapy amounted to a rare supervised walk down the hallway. When he voiced concerns about medication delays or neglectful treatment, she stated that he was repeatedly threatened with