For Dante Maglioli, a box of photographs is a time capsule. They show moments spent with his father during his childhood -- something he holds most sacred.
“I remember being a kid and saying, ‘Santa, you smell so much like my dad … and you have the same exact shoes,’” Maglioli told ABC News. “Literally today, to this day, [I] hear his voice resonate, laughing and crying at the same time because he recognized that I know it was him.”
His father, Joseph Maglioli, was often looking to laugh and he was a man who always put his family first, Dante Maglioli said as he wiped away tears.
“My father definitely did as much as he could … to make me have a good life when I was a child,” he said.
Years later, Dante Maglioli and his siblings wanted to make sure their father was well cared for as he aged.
He said the decision to check Joseph Maglioli into a nursing home was a difficult one. But they had settled on the Andover Subacute and Rehabilitation Center in Andover, New Jersey, because Dante Maglioli’s brother lived close by.
“The Andover place was supposed to be kind of temporary until we were able to get him somewhere else,” Dante Maglioli said. “My brother was working on trying to get him somewhere else and obviously that didn't work out in due time.”
The decision to admit their father into the home is now one that continues to haunt Dante Maglioli to this day. His father died of COVID-19 on April 9, becoming one of the more than 36,000 nursing home residents that have died from the coronavirus in the U.S.
Those who’ve died in nursing homes account for 27% of the total COVID-19 deaths in the country, although the number is likely higher.
Joseph Maglioli’s family believes he was one of the 13 bodies authorities discovered in April at Andover Subacute Rehabilitation Center One and Two -- the two facilities run by the center. Police said they found the bodies after receiving a large request for body bags from the nursing home.
Eighty residents and two employees at the Andover have died from COVID-19. Now the two centers are facing a state investigation and two lawsuits.
“I was told by several of the staff members that this morgue, as one of them had called it, was full,” said Jennifer Jean Miller, who covered the Andover incident as a reporter for The New Jersey Herald.
The incident has raised numerous questions about how the facility was preparing for the pandemic and whether more oversight by the state was necessary.
“That's the thing that's really bothers me is they knew what was going on,” said Michael Lensak, mayor of Andover Township. “It was obvious. Like I said, I'm not a medical professional. But it doesn't take a rocket scientist. When bodies are piling up, there's something wrong.”
Meanwhile, families that have lost their loved ones are caught in the middle.
“It baffles me... So many people die at the hands of a place like Andover,” Dante Maglioli said. “And they're still open and there are still people there, living there.”
In some ways, the disaster at Andover may have begun long before COVID-19 entered its halls. The facility, which consists of two buildings, is the largest long-term care facility in New Jersey with a total of 702 beds.
“The common perception has been, for years, that it's never been a great facility. That it's really-- it's always been loaded with problems,” Miller said. “There was already trouble in that facility in that they already had citations ... and they just really started to snowball as the pandemic got worse.”
Just a month before the virus swept through the facility, a routine inspection by the Center for Medicare and Medicaid Services (CMS) found several cases of substandard infection control practices, including cases where the facility staff failed to wash their hands and failed to use required personal protective equipment (PPE).
Attorney Daniel Marchese is representing multiple families -- including Dante Magioli’s -- in two lawsuits against the facility and its owners, which allege they did not have adequate infection control and staffing in place and didn’t protect the residents adequately during the pandemic.
“They should've had these protocols in place ... and they weren't, so they only have themselves to blame,” Marchese said.
He pointed to a recent audit by federal inspectors that shows a breakdown in protocols when the first case of the virus appeared in March.
“There were basic things that these facilities didn't do to prevent the spread. There were breakdowns in protocol of how to properly equip the employees,” Marchese said.
These breakdowns may have allowed the virus to sweep through the facilities at an alarming rate, the lawsuits allege, even as the staff tried to get the outbreak under control.
“They didn't protect the patients,” Marchese alleged. “The facilities had COVID patients in with other non-COVID patients… The employees weren't wearing protective equipment in the rooms with COVID patients and then went to rooms with patients without COVID.”
As the pandemic continued, Dante Maglioli said his family received very little information from the facility about how it was caring for residents. He said the residents themselves were being kept in the dark as well.
Maglioli said the first time he heard about a COVID-19 case at Andover was from his father.
“[He] literally said to my sister on the phone ... ‘Hey, I found out that someone's got this COVID-19… Someone died. I'm really scared. What do we do?’” Maglioli said. “And my sister called up Andover, addressed it with the nurse, and the nurse said, ‘I don't know what you're talking about. No one's sick. ... There's no COVID-19. No one's died.’”
As more residents became sick with COVID-19, Miller said staffing became an issue.
“I can speak for staff members that I have gotten to know through my reporting, and they're very caring people. ... But there aren't enough of them, really, to take care of the needs of the residents,” she said.
By Easter weekend, the outbreak had taken hold of the facility. More residents were dying, forcing the facility to request help.
“I remember a Saturday mid-afternoon, getting a phone call that they needed 20 body bags,” said Sussex County Sheriff Michael Strada, one of the local officials who responded to the call.
“Some individuals were being placed outside because there was no room in the facility to keep the bodies,” he added.
By this point, some families say they still weren’t alerted about the dire situation at the facility. Francesca Veen, whose grandmother lived at the facility, said she became worried when she heard about the COVID-19 deaths at the home.
“I wanted to know,” Veen said. “Anybody would want to know… Is she one of those bodies?”
Desperate for answers after she says her numerous calls to the facility went unanswered, Veen posted a video to Facebook in April. The post went viral.
“I am sick and tired of being told that I cannot talk to her,” Veen said in the video. “That I cannot see her [on video]. We have not heard from her. We are told when we do get someone [that] she is sleeping and that she is OK. I want to talk to her.”
Veen said she just wanted to bring awareness to the situation and express how angry and sad she was over it.
Many are now questioning how the situation at Andover escalated so quickly. Miller said the state should have been well aware of Andover’s poor inspection record and that the state should have stepped in earlier.
“The state had access to this information back in early March. So they knew about this,” she said.
Lensak agrees that the state should have stepped in sooner.
“The fact of the matter is, yes, I do think the state dropped the ball in a huge way,” he said. “They were directing the hospitals to not keep the patients there, to bring them back to the nursing home… Thus bringing back possible COVID [patients] and putting them back into the most vulnerable people that we have in our town.”
Since the start of the pandemic, Sheriff Strada’s team has provided local nursing homes with protective equipment. He said that in the beginning, most of the PPE donations were from local residents.
After the deaths at Andover, county officials requested that the state activate the National Guard to help the facility with operations, which the state eventually did in May. Strada says that his team is now receiving an adequate amount of PPE to distribute from the state Department of Health.
The New Jersey Department of Health told ABC News that in addition to providing directives to nursing home facilities, once ”the outbreak was reported to them," the health department started monitoring Andover, responding to complaints, and providing PPE and staffing support as needed.
But for families like the Magliolis, it’s too little too late. Dante Maglioli still doesn’t have confirmation that his father is among the bodies that were being held at the facility during Easter weekend. He also says his family still has not been contacted from Andover to offer condolences.
“I wish that we were able to have gotten him into a safer place that was a better place,” he said. “There's a lot of things I wish I could do over. I wish I literally could have just taken him out myself.”
Veen says she also still hasn’t been able to reach her grandmother who is still inside the facility.
“I haven't talked to her. I miss her. This is when she first met my son,” she said. “She was so happy that I was a mom.”
Andover Subacute and Rehabilitation Center denied all allegations contained in the lawsuits and issued a statement saying its health care professionals worked around the clock and took proactive steps to prepare and handle the crisis internally, including separating sick patients and following guidelines from the Centers for Disease Control and Prevention. It says it also reached out to government agencies for help dozens of times.
The center said that it has made significant progress since the height of the pandemic, taking extra steps to ensure patient and staff safety, and that it has not had a single COVID-19 symptomatic resident since May 12.
To date, both buildings at the Andover facility remain operational and are now, along with several other nursing homes, part of a statewide investigation by the attorney general.
New Jersey now says they’re implementing reforms based on an independent review of long-term care facilities in the state, which the Andover facility plans on cooperating with.