The people in the yellow hazmat suits arrived at St. Joseph's Senior Home in Woodbridge, N.J., on a crisp morning in late March, emerging from blue and white ambulance buses all suited up, like astronauts descending from a lunar rover.

For the 78 residents whom they had come to evacuate on March 25th, however, this all felt more like an alien abduction. As the hazmats approached, some residents shouted and furiously clawed at the air; others begged not to be taken away, clutching the nuns' sleeves, dissolving into tears.

The sisters who ran St. Joseph's told the residents' families later that they'd never seen anything like it. "People were loaded up like cattle," said one person who saw the events unfold. "It was horrible... When I close my eyes, even today, I still see it."

That day St. Joseph's — most people call it "St. Joe's" — became the only long-term care facility in New Jersey to be entirely evacuated during the pandemic, and no other long-term facilities in the state have been cleared out in the same way since.

A months-long NPR Investigation involving three dozen interviews with former and current New Jersey Department of Health officials, family members, experts on the elderly, and people who witnessed the events as they unfolded found that the State's decision to evacuate St. Joe's was both rushed and flawed.

The reporting makes clear that the state failed to sufficiently take into account the fragility of the evacuees, possible alternatives to the move, and how complicated it would be to transfer 78 older adults to a facility 45 minutes away. The consequences of the decision are stark: nearly half the people loaded on the ambulance buses that morning died a short time later, some within days. Experts on aging say the stress of the evacuation was undoubtedly a contributing factor.

According to people close to St. Joe's and families who were monitoring the facility at the time, when the evacuation order came, the nuns who ran St. Joe's were not presiding over an uncontrollable outbreak.

NPR saw contemporaneous emails that indicated that fewer than a dozen of the residents had confirmed positive for the virus shortly before the state decided to evacuate. The New Jersey Department of Health, through a spokesperson, claimed there were twice that many.

In a written statement, the department said residents in the facility were showing signs of illness, but they stopped short of saying they had tested positive for the virus. "The impact of COVID-19 on St. Joseph's was severe," a spokesperson wrote.

It appears that the real problem at St. Joe's was not so much a coronavirus outbreak among residents as it was an acute shortage of staff — something at least half the states in the U.S. are struggling with now in this latest winter surge.

Nurses, certified nursing assistants, and caregivers at St. Joe's who had contact with residents who had tested positive for COVID-19 had to be quarantined to make sure they wouldn't contribute to the spread. Some of the facility's outside staff — concerned they would catch the mysterious virus that few understood at the time — stopped showing up for work. So St. Joe's needed help.

Before the coronavirus, a typical shift at St. Joe's included some 50 people with direct access to the patients. In the days just before the evacuation, that number had fallen to about twenty.

That's why the nuns at St. Joe's started calling around for reinforcements. A DOH spokesperson said the agency spent two days looking for temporary staff for St. Joe's. They sent over some people from New Jersey's largest nursing home chain, CareOne. A handful of their nurses and managers covered three shifts.

Annette Kociolek, 93, a bubbly, devout Catholic who was known in her family for her love of broaches, beads and barrettes, had been sitting up in bed, watching TV, and talking on the phone with her daughters just days before the evacuation.

So she was surprised to find herself strapped to a gurney and loaded onto an ambulance bus the morning of March 25th. Her daughters say she was one of St. Joe's reluctant evacuees, fighting off the hazmat suits when they came for her, asking the nuns to tell them she wanted to stay.

"When I try to imagine what that would have felt like, seeing people in hazmat suits, me being wheeled out of the place that I know is my home, away from the caretakers, having no family around to comfort or explain what was going on," her daughter Angie Kociolek told me. "It had to be traumatic."

Christopher Neuwirth was part of the New Jersey Health Department's Emergency Preparedness and Response at the time. As an Assistant Commissioner he had helped with floods and fires and yet, when it came to the evacuation of St. Joe's, he'd never seen the state weigh in like this.

"It was obvious from the get-go that everything that happened with St. Joe's was odd," he told NPR. "The State doesn't get involved with local evacuations. Even at the time everyone in my office was saying, wait, why are we in the middle of this?"

Neuwirth no longer works for the state. He said he was fired earlier this year because he filed an ethics complaint against a high ranking official. He has since filed a whistleblower complaint and the suit is pending. The State has denied his allegations.

Little Servant Sisters

St. Joseph's Senior Home is a four-star, 101-bed facility run by The Little Servant Sisters to the Immaculate Conception, a Polish order established in the 1850s with the mission to "nurture the mind, body, and soul... by serving the residents with the same love as if serving Christ Himself." The nuns have been operating schools, health care facilities, and senior homes in New Jersey since 1926.

For 93-year-old Annette Kociolek — her friends called her "Toni" — the family atmosphere and the religiosity of the place appealed.

"My mom was Polish Catholic and St. Joe's was run by Polish sisters," the eldest of her three daughters, Bernadette Sohler explained. "They had masses daily and the nuns spoke Polish to her," which Annette Kociolek loved.

It is important to remember that in early March, the mere idea of a pandemic seemed a distant threat, like a light on a far off field. The first big coronavirus outbreak on the east coast, in New Rochelle, N.Y., had yet to make the headlines and family members were still allowed to visit nursing homes and bring in food.

Ten days before the evacuation, on March 15, Kociolek was in her room at St. Joe's eating Polish donuts with her daughter and Sohler said visits to her mother were riotous affairs. "She'd always say, 'Bernie!' And make a big deal, and 'this is my daughter' to all the workers there," her daughter recalled. "Little did we know, you know, less than two weeks later, everything would change."

The first inkling that something was wrong came on March 16th, when the nuns called Sohler to report that a couple of the residents "had the sniffles." Just to be safe, the nuns told her, they had confined everyone to their rooms.

St. Joe's phoned Sohler again the next day to say that the facility appeared to have its first positive COVID case. A day after that, Sohler found out that the St. Joe resident who had tested positive was her mother's roommate.

"I remember calling my sister saying, you know, hopefully we have nothing to worry about," Sohler said. "My mother is very, very resilient. She had been hospitalized three times last year, she bounces back all the time. I talked to her that day and I asked her how she was doing, and she goes, 'I got these little sniffles.' She was more concerned about what they were giving her for lunch than about any virus."

After that, however, everything seemed to pick up speed.

The staff at St. Joe's began quarantining; caregivers weren't showing up to work. The COVID numbers inside the facility began ticking up. By March 21st, seven residents had tested positive for the virus and Toni Kociolek was among them.

"It happened so, so very fast from when there were sniffles to when you know, one person had it, then seven people had it," Sohler said. "They had suspended social activity for the residents, and Sister Monika told me they had contacted the state for additional nursing support."

Sohler found out four days later that the state had ordered that all the residents be transferred to another facility. The decision came so fast, Sohler said later, the nuns didn't have time to inform all the families.

A bus ride with the virus

Viral outbreaks have rocked New Jersey long-term care facilities before. In 2018, in what had become an infamous case, a strain of adenovirus raged through a pediatric ward of medically frail children in northern New Jersey.

The virus, common in communal living facilities, rarely results in serious illness, but it can be fatal to those with compromised immune systems, which is exactly what these children had. Dozens fell ill, 11 died.

In response, New Jersey Gov. Phil Murphy signed a law requiring that nearly all of the state's more than 840 long-term care facilities draw up outbreak response plans. Among other things, facilities needed to work out how they would isolate and separate the sick from at-risk residents who are healthy.

The homes had 180 days to come up with a list of protocols and many had to submit their plans to the state by February 11, 2020 — just weeks before the coronavirus arrived in earnest in New Jersey. St. Joe's does not appear to have created a plan, but they weren't alone.

As COVID raged, the uneven, panicked responses made plain that many had not, according to Laurie Facciarossa Brewer, an ombudsman for New Jersey's Long-term Care system. "It's pretty clear that most long-term care facilities did not have those plans in place when they were required to be done by the second week of February," she said.

One way to minimize outbreaks in communal living situations is something called cohorting — essentially it involves isolating those who have the disease or virus from those who don't. St Joe's began doing that when its residents first began to "have the sniffles." That may be why the nuns seemed to be able to keep the total number of positive cases among the residents so low.

The evacuation team, when it first arrived the morning of March 25th, attempted to keep all of St. Joe's COVID positive patients together, relegating them to their own buses.

But by the end of a long day, with nearly everyone loaded and ready, the team started to put the remaining residents wherever they could find room, according to medical officials who received the patients and family members who heard about the evacuation later.

A DOH official said later that they just assumed everyone at St. Joe's had been exposed to the virus.

"Well, that's kind of crazy," said Melissa O'Connor, an expert in nursing care for older adults at Villanova University's M. Louise Fitzpatrick College of Nursing in Pennsylvania. "Buses don't have filtration systems like airplanes, they were all breathing the same air" and probably contracting the virus in the process.

O'Connor and others said that given what we now know about the community spread of the coronavirus, those residents who didn't have COVID when they left St. Joe's on March 25th, may well have caught it during their transfer. Even if they were masked, the danger was there as they waited in the buses for the other residents to load and then drove, all together, the 45 minutes to the new facility.

Dr. Pamela Cacchione, who studies older adult care at University of Pennsylvania School of Nursing, said she doesn't understand why the state didn't just designate St. Joe's a COVID facility and leave all the residents there — isolating the sick — instead of transferring them somewhere else.

That would have been easier on everyone involved, particularly given that CareOne in Hanover didn't actually have vacant beds waiting for the residents of St. Joe's. To accommodate them, CareOne had to move dozens of their own residents to three other CareOne homes in the area.

CareOne declined to comment for this story.

Neuwirth, the former DOH assistant commissioner for emergency preparedness, told NPR that, among other things, New Jersey officials seemed to have fixed on the wrong protocol when they decided to empty out St. Joe's.

"This wasn't a flood or a fire but they responded like this was a natural disaster and they needed to rush to higher ground," he said. "That doesn't work when you're dealing with a pandemic disease. It follows you, wherever you go."

Behind the scenes

Around the same time the nuns were having their staffing problems at St. Joe's, there was a much worse coronavirus outbreak at the New Jersey Veterans Home at Paramus, a state-run facility for former military veterans about 40 minutes from St. Joe's in Woodbridge.

By late March, almost every resident at the Paramus facility — 98 percent — had contracted the coronavirus. Some 60 percent of their staff was out sick in what quickly evolved into one of the biggest coronavirus outbreaks in the country.

U.S. Rep. Josh Gottheimer, who has Paramus in his district, weighed in and arranged for nurses and the National Guard to help.

No one seems to have an answer as to why the same wasn't done for St. Joe's, though officials who were there at the time, and spoke on the condition of anonymity out of concern they would lose their jobs, said it seemed once Health Department officials decided to evacuate, momentum to finish the job continued to build.

Donna Leusner, director of communications for the New Jersey Department of Health, denied this in response to questions from NPR.

She said the state tried to help the sisters find staff and, she said, DOH spent two days looking for reinforcements.

At some point, a nun named Sister Patricia Codey began talking to state officials about the staffing issues at St. Joe's. "Sister Pat," as she's called, is president of The Catholic HealthCare Partnership of New Jersey, and few people in the state's health care circles are as connected as she. Her brother, Richard, used to be governor.

Codey declined to be interviewed for this story. But three officials familiar with the discussions, whom NPR agreed not to name because they fear retaliation for revealing internal deliberations, said she brought the problems at St. Joe's to the attention of health department officials, and to one in particular, Deputy Commissioner of Health Systems, Marcela Maziarz, who oversees nursing homes in the state.

A focus on evacuation

"Maziarz was quite open about asking people in meetings to help her find a place to put people from St. Joe's," said one Department of Health official, who was part of the discussions in mid-March and still works there. "She wanted them to be first in line for a move."

According to three officials who attended meetings with Maziarz in March and April, the deputy commissioner told colleagues in meetings that she thought the best thing to do would be move them to CareOne Hanover. As the largest nursing home chain in the state, CareOne had the beds, the ability to isolate COVID-19 patients, and a willingness to help.

Maziarz had been working with people at CareOne on various licensing agreements for months so the transfer was relatively simple to arrange.

Three DOH officials close to the discussions say it started as a verbal agreement — CareOne would take St. Joe's residents — and the precise terms, everyone agreed, would be worked out later.

DOH's Leusner told NPR "emergent discussions came before executing" the agreement because it was "very time sensitive."

NPR filed an Open Public Records Act request to look at any contracts and agreements between CareOne and DOH, and the request was denied.

DOH declined to make Maziarz available for comment. Care One declined to comment as well.

"I'm not surprised that a company like CareOne would be a place where you would look to try to do something quickly," said Brewer, the long-term care ombudsman. "A lot of other long-term care facilities were really struggling at that point and would not have been able to do it."

Brewer said she couldn't say why state officials didn't just supplement St. Joe's staff instead. "I think the model is to move people out when there's a crisis," she said. "Historically that has been the way to solve a problem in a facility, usually it is a physical plant problem" like a flood, not a virus.

Two DOH officials confirmed that someone in the deputy commissioner's office, it is unclear if it was Maziarz herself, asked CareOne to send people over to St. Joe's to assess the situation. They were nurses and managers from various CareOne facilities and, according to DOH, they reported what they saw at St. Joe's to state officials the same day.

"Because CareOne had sent staff into the facility to assist, they were able to provide the Department with information to determine the best way to provide care" for the residents of St. Joe's, Leusner said in a written statement.

Their recommendation was to move them all to CareOne. There was never an independent assessment before the evacuation. University of Pennsylvania's Cacchione, the elder care specialist, said having CareOne do that assessment was "very concerning" because of the obvious conflict of interest. "It's like the fox guarding the henhouse," she said.

NPR filed numerous Open Public Records Act requests to DOH asking for a copy of that assessment of St. Joe's. Several DOH divisions said they had no documents that would be responsive to the request. One division said it would keep looking.

The report CareOne sent to the state, according to two officials familiar with it, characterized the situation inside St. Joe's as chaotic. CareOne officials claimed there were only a handful of nuns taking care of the residents there.

Officials close to St. Joe's say that when the CareOne officials showed up on March 22nd — three days before everyone at St. Joe's was evacuated — there were nearly two dozen caregivers, nurses, nurses assistants and visiting nuns in the facility caring for the residents. Little Servant Sisters' other locations in New Jersey had pitched in to help.

Shortly after CareOne provided its report to the State, New Jersey Department of Health Commissioner Judy Persichilli told reporters, at a March 24 press conference, that DOH was working with St. Joe's on an evacuation.

"This may result, unfortunately and ultimately, in the closure of that facility," she said, "a facility that has cared for the most vulnerable population in Woodbridge and the surrounding area for decades."

Twelve hours later, the ambulance buses arrived.

Care transition

Standard operating procedure when moving older patients is to look for available beds close by, where people can live temporarily and their families can still have some sort of access. Typically, there are a couple beds here, and a few others there. Last March, as the pandemic was starting to rage, the state's long-term care ombudsman Brewer said, those spare beds were hard to find.

"To me, the part of the St. Joe's evacuation that was really unusual was that they all went from one place to another place," she said. "But then, everything was unprecedented at that time. The rules that we had all abided by all these years seem to be falling by the wayside."

One of those rules is that moving the elderly is a last resort.

When University of Pennsylvania's Cacchione was doing her research on long-term care, she had worked with the elderly during a natural disaster. A mini tornado had knocked out the power to a long-term care facility that she was studying. Everyone had to be evacuated for five days. She said the move traumatized those who were evacuated.

"Over 50 percent of the participants in the study became delirious or developed acute confusion, which is potentially fatal in itself," she said. "To think that [St. Joe's] had to transition 78 older adults from one facility to another is hard to fathom. The literature shows that these acute evacuations are very dangerous for older adults."

Even if older evacuees weather the physical transfer, Cacchione said, under the best of circumstances they have to endure mix-ups at the receiving facility. Just think how complicated it is to check someone into the hospital, she said, now multiply that by 78 all arriving at once.

"Just the medication errors that would occur from a transition like that are just tremendous," she said. "Getting the appropriate diet, preparing them for appropriate roommate situations, when they often had their own rooms prior to this. That's a real significant challenge to an older adult."

A FaceTime goodbye

It appeared to be a challenge for Annette Kociolek.

"My gut reaction was that [my mom] was going to get lost in the mix," Kociolek's middle daughter, Dorothy Cassaro told me, as she tracked her mother's progress from St. Joe's to CareOne. "Up until the time of the evacuation my mother was still sitting up, watching TV, and she was still verbal" but the new facility wouldn't know that, she said. She was sure her mother would seem weaker than she was.

"She was going to be presented on a stretcher, she's going to look weak and feeble, and I guess I felt that would impact judgments," she said.

Cassaro's inclination proved to be prescient. When her mother arrived at CareOne, the doctor there immediately recommended that she be put into hospice, a kind of compassionate care for people in the last stages of life.

"We were a little stubborn about signing the papers," said Cassaro, saying they were trying to slow walk the decision, hoping her mother would rally. "She was admitted on a Wednesday or Thursday and I believe it was Saturday that she went into hospice."

Cassaro kept calling, asking for updates. The nurse offered to set up a FaceTime call as soon as her mother arrived on her floor. Nine thirty came and went without a call. Ten thirty came and went. "You're in a weird situation, right, because you're a family member, but you don't want to be that family member." The kind of family member whose calls nurses try to avoid.

Finally at noon Cassaro called back. The nurse told her to stay on the line while she went to her mother's floor. The call dropped in the elevator.

Cassaro called back and she and the nurse began talking about end-of-life visits. "I was asking her if she can give me my mother's vital signs only because I felt like if I heard the vital signs, I would know how close she was," Cassaro said.

But doing something as simple as checking her vitals seemed like more than the nursing station could handle at the time. "They seemed really busy," Cassaro said, so she told the nurse that a FaceTime call with her mom would do and the nurse could "catch me up on the vitals afterwards."

Cassaro listened as the nurse walked into the hospice room and started talking to Cassaro's mother, telling her her daughter was on the line. "I'm like, Hey, Ma, how are you doing?" Cassaro said. "I said you don't look any worse for wear today, or something to her."

Cassaro could only see her mother from the nose up. She asked the nurse to move the camera down and then she gasped. What Cassaro saw was what she called a "death gape."

"I was kind of taken aback," she said, "and I take a screenshot and another nurse walks in off camera and she goes, oh, your mother has passed." Then, Cassaro said, the nurse turned the camera on herself and told her, "I'm sorry for your loss."

Then the line went dead.

CareOne told NPR that it "unequivocally denies the allegation. The family didn't FaceTime immediately in advance of their loved one's passing." Cassaro shared that last screenshot with NPR, which had a timestamp coinciding with Cassaro's version of events.

The list

Annette Kociolek, 93, who loved broaches, beads and barrettes, died March 30, 2020, five days after the buses came to take her away from St. Joe's. The cause, according to her death certificate: complications from COVID-19.

But there is an odd thing about that, too. The New Jersey Department of Health Long-Term Care Facility list of recorded COVID-19 deaths indicated that Annette Kociolek and the 35 other St. Joe's evacuees who died days after the move didn't die at CareOne.

Instead the list suggests they died at St. Joe's. Annette Kociolek's family found that galling. Their mother was moved against her will, and now it appeared that the nuns at St. Joe's had presided over her death when they hadn't. "No one she knew was holding her hand," said Cassaro. "My mom died among strangers."

The keeper of the COVID-19 list, Dr. Tina Tan, who is the state's epidemiologist at the Department of Health, declined NPR's repeated requests for an interview.

But DOH said in a statement that during outbreaks "deaths are counted based on the association with an outbreak facility, not the actual location of the individual's death."

DOH said there were 36 confirmed COVID-19 deaths among the residents of St. Joe's, and three or four additional deaths that were thought to be COVID-19 related but weren't confirmed — the patients hadn't been tested.

But that's odd too. St. Joe's claims it only had about a dozen confirmed COVID-19 cases among the residents before the evacuation. The state maintains it was twice that many, but again, it has not produced any documents corroborating that figure.

Yet all 36 of the evacuees who died at CareOne in the ensuing weeks showed up as part of the tally of dead associated with St. Joe's.

Kociolek's youngest daughter, Angie Krza-Kociolek, has been trying to get that changed for months. She needs that, she said, for closure. "Even though my mother had already died, I felt like the least we could do is honor the deaths that occurred by reporting the deaths accurately," she said.

Since July, the New Jersey DOH has changed the way it compiles the list, reporting only active outbreaks in long-term care facilities, telling NPR it made the change "to more accurately represent the current situation in facilities. Cases or deaths from an outbreak that ended are not included in the list."

An outbreak is considered over in a facility if there hasn't been a new case in 28 days.

Of the 320,000 deaths attributed to the coronavirus in the United States, some 116,000 of them are linked to long-term care facilities — almost 40 percent of the nation's COVID-19 deaths.

At St. Joes, the numbers are equally stark — 78 people evacuated, 36 of whom died.

There's little question that New Jersey officials would handle St. Joe's differently if the outbreak happened today, if only because no outbreak has been handled like it since. St. Joe's is still the only long-term care facility in the state to have been emptied out in that way.

Shortly after it took in the residents of St. Joe's, CareOne was given a license agreement to provide more than 700 beds at five of its facilities to care for COVID-19 patients being discharged from hospitals, according to DOH.

According to an investigation by ProPublica published in August, in the early days of the pandemic CareOne would go on to have the highest rate of COVID-19-related deaths among large long-term care companies in New Jersey.

As for St. Joe's? Three weeks after the evacuation, the state of New Jersey moved 38 surviving evacuees back. As of December 21st, records show that St. Joe's had one resident and four staff testing positive for COVID-19.

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