Over the years, Elmhurst residents have learned to mostly ignore the bedraggled and destitute residents who quarrel over cigarettes and beg for change outside the Queens Adult Care Center.

But now, inside the worn brick building, are all the elements of an epidemiologist’s nightmare.

On March 22 came proof that the deadly coronavirus had made its way into the home when one of its residents, an 82-year-old former nurse, succumbed to COVID-19. Now, staffers say, another may have died and as many as a dozen more residents have been sent to the hospital for treatment. At least 20 are in some form of isolation within the center. Up to a dozen of its 100 or more workers are out sick with coronavirus symptoms, workers say, and the numbers seem to be changing all the time.

Since the coronavirus hit the U.S., most of the attention has been on nursing homes. But there are hundreds of adult homes like the one in Queens across the state. Many pack in a combustible mix of the sick, elderly patients alongside those with mental illness. They are free to come and go, with little understanding of the risks of infectious disease.

Now that the virus is inside the Queens home, it may be impossible to stop.

First there is the center’s location, just one block from the now-notorious Elmhurst Hospital, where 13 patients died from the coronavirus in a single day last week and dozens more wear masks and cough as they wait for hours in a line that trails down the sidewalk. The surrounding neighborhood has one of the highest rates of infection in New York City, according to data released by the city this week.

Then there are the residents. As many as 352 mentally ill or aging New Yorkers live in the home. Their ailments and age put them in the crosshairs of the coronavirus. Chronic obstructive pulmonary disease, which constricts airflow to the lungs, is rampant. So are diabetes and heart disease.

Inside there’s no escape from the roommate with a cough or fever. The residents, mostly poor with nowhere else to go, live side-by-side, cramped two to a bedroom — the sick, old and bedridden next to the mentally ill. Bathrooms are shared by groups of four. Every day there are at least three more opportunities for community spread, the center’s staffers say. Residents say they only began to eat their meals in their own rooms on Wednesday. Before that they were gathering to eat in groups of 50 or even 100 or more.

Many residents have cognitive limitations, making it difficult for them to absorb the severity of the coronavirus and the importance of staying indoors. Some residents, who staffers suspect are infected, wander freely through the center’s three floors and recreational rooms. They congregate in communal rooms thick with cigarette smoke. Others can be seen in the surrounding neighborhood, panhandling and picking through the trash. They can ask for masks at the front desk, but few bother.

Leon Hofman, the owner of the Queens Adult Care Center, and his lawyer said the center is following all guidelines from the New York Department of Health, which oversees the home, and they are “working tirelessly to address this challenging situation.”

One longtime resident, Robert Schettino, 70, said he tested positive for the disease this week. He said he self-quarantined in his room, just down the hall from the former nurse who died.

He said keeping the infection from spreading among his fellow residents may be impossible. “They don’t even wear shoes and socks, let alone gloves and masks,” he said.

Roughly half of the residents routinely shuffle down the street for appointments at a mental health clinic, potentially bringing or leaving with the virus.

“It’s an incubator,” said Jill Twohig, a mental health counselor who works with center residents at the clinic. “I don’t feel that the home is doing a good job controlling the residents, and I am terrified.”

Some frightened workers, dependent on the job and critical for the residents, said in interviews that they are flying blind. The home’s administration, the workers said, either doesn’t know or won’t tell them which residents are sick and which are not. Janitors and home health aides take a gamble each time they enter a room. Then they take that risk home to their families on public transportation or bring it back with them when they return.

“I think it’s out of everyone’s hands already,” said one worker, who now worries she has symptoms of the disease and has shared it with her family.

Denis Nash, a professor of epidemiology at the CUNY Graduate School of Public Health and Health Policy, called the circumstances at the home “really horrifying.”

The risk of viral conflagration at the Queens center, he said, “is likely no longer containable.”

Richard Mollot, the executive director of the Long Term Care Community Coalition, a New York-based elder care watchdog, was equally alarmed: “That is really, strikingly, frightening. I don’t know how else to put it. It’s hard to find a way to articulate how vulnerable residents are in this situation.”

One of the earliest outbreaks started at a nursing home in Kirkland, Washington, and spread in the community. But Mollot said adult homes like the Queens center are probably at more risk. They house people who are often medically frail enough to live in a nursing home, but with more freedom, less government oversight and, typically, less qualified staff.

“These homes can be very dangerous on a good day,” Mollot said. “And the good days are behind us for the time being. If I was a resident, I would be very concerned. If I were a family member, I would be very concerned. And if I were a member of that community, I would be very concerned.”

“The risk,” he said, “is enormous.”

In recent years, ProPublica has written extensively about conditions inside adult homes and their alternatives, including the Queens Adult Care Center. So when the pandemic arrived in New York, and Elmhurst became its epicenter, we began to call people who live and work in or near the facility.

When first contacted on March 25, Hofman said none of his workers were sick and only one resident was being treated for the virus at Elmhurst Hospital. At that point, ProPublica later learned, the first resident had already died.

Hofman then stopped returning calls, instead responding through emails sent by his lawyer, Kurt Bratten. The pair have defended the center’s response to the virus and suggested that the workers are exaggerating the danger.

On March 31, they said that only six residents, but no workers, had tested positive for COVID-19.

When ProPublica reminded Hofman and Bratten that many sick people can’t get tested, they said they did not have time to respond to additional questions.

In an email, they said the information gathered by ProPublica was “categorically false” and an article that contains it “will perpetuate fear and panic.”

At this point it may be impossible to capture current reality at the home, or at similar facilities across the country. Information that seems reliable and up-to-date one minute changes the next, usually for the worse.

In the last week, ProPublica interviewed three residents, four of Hofman’s employees and three current and former workers from a nearby mental health clinic.

Last Friday, workers said, five of their colleagues were out sick. By this Wednesday, they put that number at 12, though they acknowledged that some might just be steering clear of the home for their own safety. More show symptoms by the day, but none has been immediately tested, the workers said.

In wrenching terms, the workers discussed mounting fear and shame that they may have already infected their families with the virus. They said the home’s administration is not doing enough to protect them from infection and has been dishonest about the severity of the problem.

“These people don’t give a shit about us,” said one worker, who like all quoted in this story asked for their names not to be used for fear of losing their jobs.

Jonah Bruno, a spokesman for the New York Department of Health, which regulates the group home, would not say how many residents or workers are sick at the home or how many have died, citing patient privacy restrictions.

Perhaps even more chilling, Nash, the CUNY epidemiologist, said the crisis in Queens could easily unfold elsewhere. There are more than 500 adult care facilities scattered throughout New York state. In New York City alone, there are nearly two dozen, tucked away in low-rent neighborhoods that each house some 200 mentally ill and elderly residents. An infection in any one of them would be equally difficult to contain, Nash said.

Bruno said that across the state there are currently 399 COVID-19 positive cases in 106 facilities and 71 “associated deaths.”

On Monday, The Wall Street Journal reported that 15% of coronavirus deaths in New York state had occurred inside nursing homes. On Saturday, a neighborhood blog reported that an Upper West Side residence for seniors was being evacuated.

“These percolating situations are nightmare scenarios,” Nash said.

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At the New York Psychotherapy and Counseling Center down the street from the group home, Twohig, 47, can trace the arc of her fear.

For nearly three years, she has worked in a windowless office inside the rundown clinic, where she helps 56 residents of the center. But over the past two weeks, she said her job has shifted from therapist to public health educator.

Usually she counsels patients on their troubles — helping them cope with medication side effects, disputes with roommates, loneliness and depression. But as concerns over the virus mounted, she began teaching them how to properly wash their hands, sneeze and cough into their elbows, stay away from others and use hand sanitizer.

On March 18, she said, it became clear her efforts were not enough. That afternoon, her supervisor, Kam Ng, gathered the staff to deliver some grim news.

The roommate of one of the clinic’s clients had tested positive for the coronavirus and was in the hospital. Twohig and her co-workers sat with their mouths agape. “It’s here,” she remembered thinking. After a pause, the group let loose a flurry of questions: Had the roommate been tested? Would they have to continue to come to work? The residents are supposed to come in for one session per week. What if the staff already had it?

Ng, Twohig said, didn’t have many answers.

She said Ng told them that his superiors said there would be no immediate changes to their policy: Residents would continue to come in for their regularly scheduled therapy sessions. They would use hand sanitizer before they entered the office and would keep the sessions short.

“We were in disbelief,” Twohig said. She went back into her office, shut the door and began to panic. “What the hell is going on?” she thought. “What are they not telling us?”

When she walked past the home that evening on her way back to the subway, several of the residents were still sitting outside, sitting next to each other, smoking cigarettes. None wore masks or gloves.

“The concept of the virus seems beyond the realm of their comprehension,” she said. “It’s just something they see on TV.”

On the train, its cars nearly empty, her heart rate quickened and reality sank in: She was now considered an “essential worker” in the middle of a pandemic.

Twohig avoided the clinic for the next three days, handling her sessions by phone. She spent the weekend inside her East Village apartment, watching cat videos and talking to friends on FaceTime.

The following Monday morning, she said Ng called to say that his bosses would allow her and the staff to work two days a week from home, but they’d need to come in for the other three.

Confoundingly, she said he reassured her that she would still do her sessions by phone, even from inside the clinic. The patients would come in, enter a separate room, and speak to her over a speaker phone.

Why, Twohig asked, couldn’t she just call her patients from home and avoid the risk of exposure on her 45-minute train commute?

She said Ng said his bosses believed her patients would be more likely to engage in the sessions knowing she was in the building. If the patients didn’t show, he said she could go into the group home and physically find them — a prospect she refuses to entertain.

Neither Ng nor Elliott Klein, the chief executive officer of New York Psychotherapy and Counseling Center, responded to calls and emails for this story.

In response to questions on Twohig’s situation, the New York Office of Mental Health, which regulates the clinic, said in a statement that “it had waived some regulations to make it easier for providers to serve their clients by phone.”

On her way to work Friday morning, Twohig said she saw one of her patients wandering to a bodega with a surgical mask dangling from his wrist. She called out to him, “Show me how you put it on.” He fumbled with a demonstration, then ambled off toward Broadway, the thoroughfare that cuts through Queens.

Later that day, Ng told her and the other staff that the patient in the hospital had died and that his roommate, their client, was still refusing medical attention because he insisted he had no symptoms.

Twohig could feel a pit form in her stomach. She asked if their client was being quarantined. Ng said no, and the pit in her stomach rose to her throat.

ProPublica separately learned that Shamshudin Karmali, an 82-year-old resident of the home, died on March 22. A relative confirmed the cause was the coronavirus. A worker at the home said Karmali had scarcely left the facility in the months before his death.

Reached by phone, Karmali’s former roommate, a 61-year-old man with paranoid schizophrenia, said he’d been told Karmali died because of the virus.

The man said he hadn’t changed his behavior after the coronavirus had hit the facility and killed his roommate. He said he’d watched the film “Son of Kong” that day with 15 other patients inside a TV room.

“They take my temperature,” he said of the staff. “I’m not worried.”

But just down the hall on the same floor, Schettino is. Five days after Karmali’s death, he spiked a fever that scared him into braving Elmhurst Hospital. A doctor there, he said, jammed a swab so far up his nose he started bleeding. “It’s like they hit your brain,” he said. Two days later, he said he learned he was positive for the coronavirus. Now isolated in his room, he said he is mostly worried about the workers.

He and one other resident said that the staff only recently started delivering meals directly to the residents’ rooms. Before that, every meal was a jostling opportunity to spread COVID-19.

“They stand outside the dining room within inches of each other like they never got fed before,” he said. “They tell them, ‘When you get in line, stay 6 feet apart.’ But I don’t know if they know what 6 feet means.’”

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Crowded with people in poor health who receive scant services, adult homes have long been prime targets for highly infectious disease.

The Queens Adult Care Center is one of nearly two dozen homes with a long and troubled history in New York City. It is also one of the biggest.

In the 1970s, the homes were envisioned as a more humane alternative to the state’s notoriously abusive state psychiatric hospitals. But in the ensuing decades, they, too, devolved into centers of misery and neglect.

In 2002, The New York Times found that more than 1,000 people died inside the homes over a six-year period. Some threw themselves from rooftops. Others died of heat exposure in rooms with no air conditioning. Residents were warehoused and exploited for profit. The Queens Adult Care Center, then called Leben Home, was singled out as one of the worst.

The stories prompted a class-action lawsuit. After 10 years of litigation, a federal judge ordered the state to give adult home residents with mental illness a chance to live independently in their own apartments. But as ProPublica reported last year, the state also brokered a quiet deal with the adult homes. It gave them a second chance with a new, more lucrative population in the form of the elderly and infirm. The Queens Adult Care Center was one of more than a dozen facilities that took advantage of the offer. Now the two vulnerable groups live together in the facility.

Along the way, Hofman, the owner and operator of the center, positioned himself as a kind of adult home reformer. He took over the facility following the Times investigation, having earned praise from the state for improving other homes. He renamed it, made renovations, added rehabilitation rooms and increased staffing.

But now, some workers complain that the coronavirus is exposing gaps in the home’s care for patients, protections for workers and consideration for the surrounding community.

In interviews this week, four workers, who help feed, medicate and oversee the residents, said that the home’s managers appear primarily concerned with protecting themselves. Since the virus began to take hold in New York, the administrators have sequestered themselves in their offices, the workers said. They also use the more expensive and increasingly rare N95 masks, which offer more protection than the disposable, loose-fitting surgical masks distributed to staff.

Home health aides and cleaning staff only get one surgical mask per day, according to the workers. The workers have gloves but not protective gowns. Only residents who ask for masks receive them, and one worker estimated that maybe 2% bother to do so.

Hofman and his lawyer said the home has plenty of masks and everyone can get as many as they need. They said some staffers prefer the surgical masks over the N95s.

The workers said reliable information on who might be infected is difficult to come by, but last week they noted that kitchen workers were preparing separate meals for roughly 20 people who are not allowed to dine with the rest of the residents in the communal dining room

One worker believes that number should have been larger.

Early last week, one resident was coughing so heavily in a dining hall that he was struggling to breathe, according to a worker watching him. The worker tried to alert a supervisor repeatedly, but the supervisor ignored the man.

“I said this guy is sick, please remove him from the dining room. I have seen him here three times. He is coughing and sneezing in everyone’s face. He can’t even breathe,” the worker said. “And they just said, ‘OK, thank you for letting us know.’”

The worker said the man continued to show up in the dining hall afterward. And now several residents and workers are sick.

“There are no precautions in the building,” the worker said. “It’s going to spread throughout the whole building.”

Last week, two workers estimated that as many as eight residents were admitted to a hospital for coronavirus symptoms and five workers have stayed home with symptoms. Now one of those workers puts that estimate at a dozen each, though they note that historically residents are often sent to the hospital for a variety of reasons.

ProPublica spoke to one of the sick workers Saturday.

The worker had been home for nearly a week with a fever that rose to 101 degrees and throat pain that made it impossible to swallow. The worker relies on a wage of roughly $17 an hour but said the company was not paying for sick leave. In an email, the center’s lawyer said it was paying for sick time.

“The company treats us like we are nothing,” the worker said. “Like we are not even human beings.”

One worker has allegedly quit because she did not want to get her elderly parents sick. Another said that more workers might have the coronavirus but do not want to disclose their symptoms, because they are worried they won’t get their jobs back if they take time off.

“We are poor people,” the worker said. “We live on a salary of $15 or $16 an hour. We can’t afford to lose our jobs.”

All of them worry for the surrounding community.

“Why isn’t this door shut?” said one worker. “Why are these residents still able to go out into the community?”

The staff is also concerned that they are becoming vectors for the virus themselves. One clinic worker said she has to take two buses and two trains to get to work each day. She then goes home to her husband, children and mother.

“There is a risk for us and our families,” she said. “We don’t know exactly what to do. … Can you help us?”

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Nash, the CUNY epidemiologist, grew increasingly concerned about the conditions at the Queens center as ProPublica shared the deteriorating conditions with him.

“The risk that there could be a substantial amount of serious illness, hospitalization and deaths due to COVID among the residents in this setting seems very high, given the age profile and what could be a high prevalence of underlying health conditions and smoking,” he said.

“We have seen a few very sad examples of what this could look like in New York state and around the country.”

Initially, he recommended ways to contain the virus: Quarantine anyone with a confirmed case or anyone who had close contact with a confirmed case. Communicate regularly with the Department of Health. Give residents and staff regular health checks and protective equipment. Limit movement between floors and rooms.

But by Sunday, Nash urged ProPublica to report the situation to the state and city departments of health. He said the government should intervene as soon as possible.

ProPublica forwarded Nash’s concerns to the state Health Department. In a statement, spokesman Bruno said, “All New Yorkers, including those who live in Adult Homes, should follow the state directions to limit exposure to COVID-19 by avoiding contact with others.”

The department, the statement said, was working with homes to make sure residents understood social distancing and the need to stay indoors, but it acknowledged that “Adult Home residents maintain a level of independence and are free to come and go like anyone else in the community.” Those who test positive or exposed to COVID-19 “must follow all state-issued quarantine guidance.”

In his sole conversation with ProPublica on March 25, Hofman, the center’s owner, gave a much different impression of his facility’s preparedness and conditions than those who work for him.

Hofman said he “got lucky’’ and he bought personal protective equipment for his staff before the crisis hit, and that “knock on wood” none of his workers were sick. He said many of his workers live in the neighborhood and didn’t have to rely on public transportation.

Hofman said he is following guidelines from the state Health Department, which recommend that in “areas of high concentrations of positive coronavirus cases, residents should be encouraged to remain at home” and that the home “must have staff available to screen residents for symptoms or potential exposure to someone with COVID-19.”

According to Bratten’s emails, only one resident was currently receiving medical treatment for COVID-19 at Elmhurst Hospital and no workers had tested positive. They would not say how many workers had called out sick with symptoms, nor how many residents had already received treatment at Elmhurst and come back or were sent to any other hospital.

A staff member, they wrote, takes the temperatures of workers before they start their shifts and residents who appear symptomatic. But Hofman said that he can’t prevent residents from leaving the facility if they want to.

“The home,” they wrote, “is doing an excellent job of maintaining a healthy and safe environment for its residents and staff.”

Katie Zavadski contributed reporting.

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