Report of Investigation

January 11, 2021 Cell Extractions at the

Edna Mahan Correctional Facility for Women

Prepared by:

LOWENSTEIN SANDLER LLP

June 3, 2021
 TABLE OF CONTENTS

PAGE

I.  Introduction .............................................................................................................. 1 

II.  Methodology............................................................................................................. 2 

III.  Background............................................................................................................... 4 

A.  The Facility.................................................................................................... 4 

B.  A Troubled History ....................................................................................... 7 

C.  Remedial Efforts............................................................................................ 8 

D.  New Legislation .......................................................................................... 11 

IV.  Applicable Legal Standards and Directives on Use of Force................................. 14 

V.  NJDOC Policies and Typical Practice in Conducting Cell Extractions ................. 17 

A.  Authorizing Cell Extractions ....................................................................... 18 

B.  Procedure for Conducting Cell Extractions ................................................ 21 

C.  Related Physical Searches ........................................................................... 23 

VI.  Findings and Analysis ............................................................................................ 24 

A.  The Months Leading to the Cell Extractions .............................................. 24 

1.  Facility Oversight ............................................................................. 24 

2.  RHU Conditions and Occurrences ................................................... 26 
B.  Cell Extraction Incident .............................................................................. 28 

1.  Decision to Conduct Cell Extractions .............................................. 29 

2.  Contact with NJDOC Central Office ............................................... 32 
3.  The Cell Extractions ......................................................................... 33 
C.  Previous Conduct of Participating Custody Staff ....................................... 43 

D.  The Response to the Cell Extraction Incident ............................................. 45 

VII.  Conclusions and Recommendations ....................................................................... 50 

-i-
I. INTRODUCTION

On January 25, 2021, NJ Advance Media reported that approximately 30

correctional officers and supervisors at the Edna Mahan Correctional Facility for Women

(“EMCF”) had been put on administrative leave, and a criminal investigation was

underway, after officers at the facility had been accused of severely beating several inmates

earlier that month. Subsequent media accounts stated that the brutality had taken place

during the process of corrections officers forcibly removing multiple inmates from their

cells shortly before midnight on January 11, through a process referred to as “cell

extraction.” EMCF inmates alleged that during that process, officers used excessive force,

resulting in serious physical injuries to multiple inmates. Additionally, one inmate made

an allegation of sexual assault by an officer during the cell extractions.

These allegations were particularly striking as they came in the middle of an

ongoing investigation by the United States Department of Justice (“DOJ”) into sexual

abuse of inmates by EMCF officers. In April 2020, DOJ had issued a 29-page notice stating

that DOJ had reasonable cause to believe that the New Jersey Department of Corrections

(“NJDOC”) “fails to keep prisoners at Edna Mahan safe from sexual abuse by staff.”

On January 27, 2021, New Jersey Governor Phil Murphy announced that

Lowenstein Sandler LLP (“Lowenstein”) would undertake an investigation into the events

of January 11 “to determine how this happened and make recommendations to prevent

anything like it from ever happening again.”

This report sets forth the results of Lowenstein’s investigation. Part II of the report

details the methodology used to conduct the investigation. Parts III, IV, and V provide

-1-
background information, set forth applicable legal standards, and summarize relevant

NJDOC policies and procedures. Together, they provide historical and legal context for

our findings and recommendations. Part VI of the report sets forth our detailed findings

and analysis regarding the cell extractions and the response by State officials. Part VII

contains our conclusions and recommendations to address the issues identified in the

course of our investigation.

II. METHODOLOGY

Lowenstein’s investigation team was led by former New Jersey State Comptroller

and federal prosecutor Matthew Boxer, Esq. The other principal members of the

investigation team were Rachel Moseson Dikovics, Esq., Jamie Gottlieb Furia, Esq.,

Rasmeet K. Chahil, Esq. and Amanda K. Cipriano, Esq., who managed many of the

investigative steps.

Lowenstein attorneys independently developed the investigative work plan.

NJDOC fully and without exception cooperated with the investigation in making its

officials available for interviews and promptly supplying Lowenstein with all requested

information, documents and other materials.

Lowenstein reviewed more than 21,000 documents, emails and other

correspondence requested from NJDOC and the Office of the Corrections Ombudsperson,

an office housed outside of NJDOC that is charged with protecting against improper

treatment of inmates in NJDOC’s custody. The reviewed materials included, for example,

incident reports, records of disciplinary action related to the cell extractions, disciplinary

histories of officers and inmates, records of inmate complaints, NJDOC internal

-2-
management procedures, attendance records, NJDOC organizational data, and email

correspondence of numerous NJDOC administrators and staff. We also reviewed

documents, correspondence and other materials obtained from witnesses interviewed,

online sources, and other third-party sources, some of which was unsolicited, including

correspondence received from EMCF inmates.

The methodology for this report also included statutory research, review of

applicable legal standards and best practices, and review of legislative testimony and

related documents. In addition, Lowenstein reviewed all available video footage relating

to the January 11 cell extractions, totaling more than 20 hours of recordings. The contents

of those recordings are described in this report.

In the course of the investigation, Lowenstein conducted 24 interviews and

interviewed some of those individuals on multiple occasions. For example, we interviewed

NJDOC Commissioner Marcus Hicks, NJDOC Chief of Staff Victoria Kuhn, NJDOC’s

Special Investigations Division Chief Duane Grade, Corrections Ombudsperson Dan

DiBenedetti, Governor Phil Murphy and several senior officials in the Governor’s Office,

current EMCF Administrator Patricia McGill, EMCF Assistant Superintendent Robin

Keller, and other present and former NJDOC officials. Additionally, we interviewed

EMCF inmates, the President of the Policemen’s Benevolent Association Local Number

105, criminal justice consultants, and a human rights advocate on behalf of prisoners.

Interviews were conducted in person, by videoconference or by phone, as circumstances

such as Covid-19 restrictions would permit.

-3-
 In the course of our work, we were careful to avoid interference with the substantial,

ongoing criminal investigations being led by the Office of the New Jersey Attorney

General, Office of Public Integrity & Accountability. Specific non-interference requests

by law enforcement affected the timing of our investigation and significantly limited the

individuals we were permitted to interview. Nonetheless, we were able to obtain necessary

information regarding those individuals and their version of events from, for example,

narratives from officer disciplinary proceedings and inmate disciplinary proceedings, their

emails, written statements provided to other authorities, other written narratives and

reports, video evidence and other sources. The evidence we obtained provides an

appropriate basis for the findings of this report.

Lowenstein attorneys also visited EMCF to inspect the unit within South Hall on

the maximum security compound where the January 11 cell extractions were conducted.

During our visit, we questioned EMCF administrators and custody staff, examined

unoccupied inmate cells and met privately with EMCF inmates.

III. BACKGROUND

A. The Facility

EMCF is New Jersey’s only correctional facility with an all-female inmate

population. The facility opened more than 100 years ago, in 1913, as the “State

Reformatory for Women.” It is located in a rural setting in Hunterdon County.

Approximately 372 prisoners are currently incarcerated at EMCF, including 94 prisoners

in the minimum security complex and 278 in the maximum security complex.

-4-
 EMCF has a total staff of 462, including 361 custody staff and 101 civilian staff.

Of those, 166 custody staff are female (46 percent) and 51 civilian staff are female (50

percent). Among the civilian staff are various administrators and mid-level supervisors.

EMCF is run by an “Administrator,” which is the term used in New Jersey correctional

facilities for the person more commonly known as a “warden.” EMCF’s current

Administrator is Patricia McGill.

EMCF’s minimum security compound is entirely separate from the maximum

security area, and in some respects resembles a college campus more than a typical prison.

It includes five operating buildings. Minimum security prisoners have relative freedom of

movement within their housing units and, to some extent, within the compound. In

contrast, the maximum security compound is fully fenced and includes eight operating

housing units, including the South Hall compound, which contains seven individual sub-

units.

Within the South Hall compound is the Restorative Housing Unit (“RHU”), a close

custody unit separate and apart from the general prisoner population, where prisoners are

placed because of disciplinary infractions. See N.J.A.C. 10A:5-9.5. The RHU is intended

to “provide a structured, controlled environment where inmate behavior shall be closely

monitored and documented by a team of custody and civilian staff.” N.J.A.C. 10A:5-9.2.

EMCF’s RHU was established through NJDOC policy in August 2020, following the July

2019 passage of the Isolated Confinement Restriction Act, N.J.S.A. 30:4-82.5–82.11. The

RHU’s physical location existed before that time, having been referred to, for example, as

Administrative Segregation.

-5-
 As NJDOC Commissioner Marcus Hicks described in his investigative interview,

RHU is a housing unit for individuals adjudicated guilty of “medium” disciplinary

infractions. Prisoner activity within the unit is more restricted than in the general facility

population, but unit conditions are less restrictive than in what NJDOC policies refer to as

the “Adjustment Unit.” NJDOC policy states that inmates in RHU “shall not have their

activity, movement, and social interaction severely restricted.”

RHU inmates are entitled to similar privileges as general population inmates,

including recreational time, commissary access, “JPAY” access (an email and grievance

system used by New Jersey correctional facilities) and phone calls. See N.J.A.C. 10A:5-

9.2. EMCF’s RHU includes 20 maximum security cells, most of which have the capacity

to house two inmates.

Aside from custody and civilian staff, also working at EMCF are members of

NJDOC’s Special Investigations Division (“SID”). SID is tasked with conducting

administrative investigations at NJDOC facilities, and in circumstances where criminal

conduct is at issue, working with law enforcement to investigate. See N.J.A.C. 10A:1-2.2.

All NJDOC SID investigators are former custody staff. In addition to the standard 14-

week training course completed by New Jersey correctional officers at the NJDOC

Training Academy, SID investigators undertake an additional 21-week specialized training

course.

SID’s management is based in Trenton at NJDOC’s Central Office, and is headed

by Chief Duane Grade, who reports directly to Commissioner Hicks. Three Deputy Chiefs

report to Grade. Each correctional facility’s SID investigators report to an on-site principal

-6-
investigator who, in turn, reports to an SID Deputy Chief. EMCF’s SID team includes

three investigators and a principal investigator.

B. A Troubled History

In recent years, numerous EMCF custody and civilian staff members have been the

subject of allegations of officer-on-inmate sexual assaults. By law, prisoners cannot

consent to sexual activity with custody or civilian staff of correctional facilities. N.J.S.A.

2C:14-2(c)(2). Between 2016 and 2018, seven EMCF employees – correctional officers

Brian Ambroise, Ronald Coleman, Anhwar Dixon, Jason Mays, Joel Mercado and Thomas

Seguine, and civilian staff member Joel Herscap – were charged with crimes relating to

sexual abuse of EMCF prisoners, including sexual assault, conspiracy to commit sexual

assault, criminal sexual contact and official misconduct. All but Ambroise, who was found

not guilty at trial, and Coleman, who has not yet been tried, have pled guilty or have been

found guilty at trial, and have been sentenced. Mays was sentenced to sixteen years in

prison; Dixon was sentenced to five years in prison; and Herscap, Mercado and Seguine

each were sentenced to three years in prison. In 2019, another EMCF correctional officer,

Ciera Roddy, was charged with crimes including official misconduct and criminal sexual

contact, and Lieutenant Jose Martinez was charged with witness tampering. Roddy pled

guilty and was sentenced to 90 days in jail. Martinez has not yet been tried.

In response to the above, on April 26, 2018, DOJ initiated an investigation of EMCF

pursuant to the Civil Rights of Institutionalized Persons Act, 42 U.S.C. § 1997 et seq., to

determine whether conditions at EMCF violated prisoners’ constitutional rights and

whether EMCF was able to protect prisoners from sexual abuse. In July 2018, DOJ

-7-
attorneys and experts conducted a four-day on-site review of EMCF. In April 2020, DOJ

released a report of its findings. It concluded that there was:

reasonable cause to believe, based on the totality of the

conditions, practices, and incidents discovered that: (1)
conditions at [EMCF] violate the Eighth Amendment of the
United States Constitution due to the sexual abuse of prisoners
by the facility’s staff; and (2) these violations are pursuant to a
pattern or practice of resistance to the full enjoyment of rights
protected by the Eighth Amendment.

As noted by Commissioner Hicks in recent testimony before the New Jersey Senate Budget

Committee, the State has reached a tentative agreement with DOJ on the terms of a

settlement, which NJDOC anticipates will include oversight of EMCF by a federal monitor.

That agreement is pending final approval from DOJ.

The above conduct also has resulted in civil lawsuits, including against NJDOC

itself. In April 2021, NJDOC settled a class action lawsuit brought by more than 20 current

and former EMCF inmates, which alleged sexual abuse by correctional officers at the

facility dating back to 2014. The settlement’s publicly disclosed terms include a $20.8

million payment by NJDOC.

C. Remedial Efforts

In the time since the arrests described above, NJDOC has undertaken various efforts

at EMCF in attempts to improve the culture and conditions at the facility.

1. External Advice

In 2017, NJDOC began to use external experts to guide and assist its efforts to

improve policies, procedures and conditions at EMCF. For example, it engaged a team of

consultants from the National Institute of Corrections (“NIC”), which is an agency within

-8-
the Federal Bureau of Prisons, to conduct an assessment of EMCF and provide advice. The

team of four NIC consultants was led by a criminal justice expert who specializes in sexual

safety. NIC consultants made a series of recommendations to NJDOC, including that

NJDOC should institute gender-responsive training, which NIC consultants later provided

to EMCF supervisors.

2. Camera Expansion and Upgrade

Since 2016, NJDOC has been attempting to overhaul EMCF’s camera surveillance

system. Prior to these efforts, there were 45 federally funded cameras at the facility.

Between 2016 and 2019, 183 additional cameras were installed to reduce “blind spots”

believed to have contributed to instances of sexual abuse. These 183 cameras were

temporary measures, installed to provide adequate surveillance while the camera system

was fully redesigned.

An outside engineering firm was hired to redesign EMCF’s camera system, and the

firm held its final design meeting with NJDOC in March 2019. The expansion and upgrade

project is being rolled out in phases. According to NJDOC, once it is complete, there will

be a total of 634 cameras at the facility. As of January 11, 2021, 99 cameras had been

installed, and from January 11 to April 30, 2021, 153 additional cameras were installed,

bringing the total upgraded cameras at the facility to 252. The project is estimated to be

finished by September 2021; according to Commissioner Hicks, its completion was

delayed because of Covid-19. The delays in camera implementation and their impact are

discussed later in this report.

-9-
 3. Female Leadership and Staffing

Beginning in September 2017, NJDOC appointed women to fill three critical roles

at EMCF that previously were held by men: at that time, Sarah Davis was appointed

Administrator; in June 2018, Renee Carr-Foster was appointed SID Principal Investigator;

and in August 2018, Robin Keller was appointed as Compliance Coordinator to oversee

the facility’s compliance with the federal Prison Rape Elimination Act, 34 U.S.C. § 30301

(“PREA”). PREA is a 2003 federal law that resulted in a series of detailed federal

regulations designed to deter the sexual assault of prisoners.

The number of female officers at EMCF also has increased in recent years. In 2015,

EMCF employed 124 female custody staff. As of March 2021, the facility employed 166

female custody staff. The increase in female officers was accomplished, in part, through

“gender-restricting” certain custody posts at EMCF, meaning that they must be occupied

by female officers, or, in some cases, that a minimum number of female officers occupy a

particular post at all times. For example, roles requiring officers to conduct frequent inmate

strip searches are gender-restricted to female custody staff. In August 2018, EMCF

notified custody staff that 17 additional minimum-security posts would be gender-

restricted to female officers only. A total of 55 posts (split between three work shifts) are

currently gender-restricted at EMCF.

4. Training Efforts

NJDOC also enhanced the training it provides to custody staff as it relates to PREA

and the prevention of sexual assault. In 2018, the NJDOC Office of Training created a new

gender-responsive training module based on the NIC’s supervisor training, and all EMCF

-10-
custody and civilian staff, as well as NJDOC officials and transportation staff who interact

with EMCF inmates, received that training. Additionally, in May 2019, NJDOC’s

executive staff, along with a group of EMCF supervisors, attended a three-day NIC training

on gender-informed practices, which focused specifically on working with female inmates.

NJDOC also expanded and updated its training on undue familiarity between

officers and inmates. Additionally, NJDOC added a sexual assault prevention training,

which was developed in consultation with the CLEAR Law Institute, to its standard officer

training.

D. New Legislation

Attempted remedial steps at EMCF have included legislative efforts as well, which

followed multiple rounds of legislative hearings that included testimony from inmate

advocates and former EMCF inmates. For example, the Isolated Confinement Restriction

Act, which limits the use of solitary and isolated confinement in New Jersey’s correctional

facilities, was signed into law in July 2019. The law provides that “[i]solated confinement

should only be used when necessary, and should not be used against vulnerable

populations.” N.J.S.A. 30:4-82.6(b). It defines “isolated confinement” as “confinement of

an inmate in a correctional facility, pursuant to disciplinary, administrative, protective,

investigative, medical, or other classification, in a cell . . . for approximately 20 hours or

more per day . . . with severely restricted activity, movement, and social interaction.”

N.J.S.A. 30:4-82.7. The privileges and movements of inmates in EMCF’s RHU are not

“severely restricted,” so RHU avoids qualification as an “isolated confinement” unit.

-11-
 In January 2020, the Dignity for Incarcerated Primary Caretakers Act was signed

into law. It had two primary purposes: increasing services for inmates who are parents,

and significantly expanding the authority and responsibilities of the Office of the

Corrections Ombudsperson (“OCO”). Those responsibilities now include conducting

unscheduled tours and inspections of correctional facilities; independently investigating

inmate complaints, including the authority to subpoena witnesses; conducting public

hearings; and otherwise ensuring correctional facilities’ compliance with relevant laws,

regulations and policies related to the treatment of inmates. N.J.S.A. 52:27EE-26–28.6.

Despite these expanded powers, our investigation found that the OCO’s practices have not

significantly changed since the law was passed. For example, although OCO has subpoena

power, it has not yet been exercised, and unscheduled correctional facility inspections

began only recently. This may be at least partially due to staffing issues; until recently,

there were only two Assistant Ombudspersons who, together with Ombudsperson Dan

DiBenedetti, were responsible for independent oversight of all correctional facilities in the

state. In early March 2021, four additional Assistant Ombudspersons were hired. In our

interview with DiBenedetti, who has announced he will retire this August, he told us that

even with these additions, his office is understaffed relative to the scope of its

responsibilities. DiBenedetti described that his office will sometimes receive 60 to 80

contacts in one day, and he stated that OCO was not finding it possible to keep up with that

volume.

On January 21, 2020, three bills that pertain to correctional facility training

requirements, officer misconduct reporting requirements, and policies related to strip

-12-
searches were signed into law. The first, codified at N.J.S.A. 30:1B-6.13-14, mandates 20

hours of in-service training for every correctional officer in each facility, in addition to

already-required firearms qualification and use-of-force training. Of those 20 hours, at

least four must be comprised of training on “(1) sexual assault, sexual abuse, and sexual

harassment prevention as required pursuant to the provisions of [PREA]; (2) non-

fraternization and undue familiarity; and (3) conditioning and manipulation awareness.”

The second statute, codified at N.J.S.A. 30:1B-39-45, requires employees of State

correctional facilities to report inmate abuse and provides for the establishment of an abuse

reporting program for corrections employees. It mandates that all correctional facility

employees “shall” report “in a timely manner” any suspicion or belief “that an inmate is

being or has been abused by any other employee.” N.J.S.A. 30:1B-40(a). The statute

prevents disclosure of the identity of the reporter, unless disclosure is otherwise required

by law, and also immunizes from civil or criminal liability and protects from retaliation

any person who makes a report under the law and/or testifies in relation to the report.

N.J.S.A. 30:1B-42. It provides for a fine of up to $5,000 in addition to administrative

disciplinary action against anyone who fails to make a required report. N.J.S.A. 30:1B-43.

Lastly, the third statute, codified at N.J.S.A. 30:1B-46, requires establishment of a

policy “to limit cross gender searches and surveillance” in New Jersey correctional

facilities. The law mandates that only specially trained, same-gender officers may perform

inmate strip searches, outside of emergency or extraordinary circumstances. Correctional

officers are also prohibited from viewing different-gender inmates who are nude or using

the toilet except in emergency or extraordinary circumstances. This statute lines up with

-13-
PREA requirements, see 28 C.F.R. § 115.15, with which correctional facilities must also

abide.

Despite the above efforts, on the night of January 11, 2021, a series of cell

extractions were so mishandled as to result in the injury of multiple inmates and the

ultimate suspension of 34 EMCF supervisors and staff. The next few sections of this report

set forth the standards that apply to a forced cell extraction and line up those standards

against what actually happened.

IV. APPLICABLE LEGAL STANDARDS AND DIRECTIVES ON USE OF

FORCE

The parameters of permissible uses of force in correctional settings provide context

for our analysis and findings in this investigation.

Title 10A of the New Jersey Administrative Code governs the functions of

correctional facilities. It defines “non-deadly force” to include “physical force” and

“mechanical force.” N.J.A.C. 10A:3-3.3(b). “Physical force” may include, for example,

“wrestling a resisting individual to the ground, using wrist locks or arm locks, striking with

the hands or feet, or other similar methods of hand-to-hand confrontation.” N.J.A.C.

10A:3-3.3(b)(1). “Mechanical force” “means the use of some device or substance, other

than a firearm, to overcome an individual’s resistance,” such as the use of pepper spray.

N.J.A.C. 10A:3-3.3(b)(2).

“Cell extractions” are not defined in Title 10A, but generally entail the removal of

an inmate from her cell by an extraction team, the members of which typically wear

protective equipment and utilize body shields, and may employ chemical agents like pepper

-14-
spray. Cell extractions may be carried out without the use of force if an inmate is

compliant, but a forced cell extraction inherently involves “use of force” and is subject to

standards related to justification and reasonableness.

Title 10A provides that non-deadly force by custody staff may be justified by

objectives such as to “prevent or quell a riot or disturbance,” to “enforce correctional

facility regulations,” or “in situations where a custody staff member with the rank of

Sergeant or above believes that the inmate’s failure to comply constitutes an immediate

threat to correctional facility security or personal safety.” N.J.A.C. 10A:3-3.3(a)(5), (7);

10A:31-8.18(a)(5).

The regulations state that custody staff members are empowered to “use the amount

of force reasonably necessary to accomplish the law enforcement objective,” subject to the

following: (1) custody staff must use “the minimum force possible that is objectively

reasonable under the totality of the circumstances”; (2) “as soon as the individual submits,

the custody staff member shall reduce the degree of force used”; and (3) there are no

circumstances in which use of force is “justified as a means of punishment or discipline.”

N.J.A.C. 10A:31-8.17(d), (e), (g). Custody staff is “encouraged to interrupt the flow of

events to help ensure that a fellow custody staff member does not resort to employing an

inappropriate or excessive use of force.” N.J.A.C. 10A:3-3.1(b); 10A:31-8.17(c). Custody

staff involved in a use-of-force incident are required to write a report of the incident and

must “be prepared to justify the use of physical force.” N.J.A.C. 10A:31-8.17(f), (h).

Constitutional proscriptions overlay any use of force by a public correctional

officer. Force used must be “objectively reasonable” under the Fourth Amendment to the

-15-
Constitution, Graham v. Connor, 490 U.S. 386, 396–97 (1989), and must not constitute

cruel and unusual punishment under the Eighth Amendment. See, e.g., Brooks v. Kyler,

204 F.3d 102, 106 (3d Cir. 2000). The United States Supreme Court has set forth factors

to determine whether a correctional officer’s use of force was “excessive and unjustified.”

Id. Those factors include:

(1) “the need for the application of force”; (2) “the relationship
between the need and the amount of force that was used”; (3)
“the extent of injury inflicted”; (4) “the extent of the threat to
the safety of staff and inmates, as reasonably perceived by
responsible officials on the basis of the facts known to them”;
and (5) “any efforts made to temper the severity of a forceful
response.”

Id. (quoting Whitley v. Albers, 475 U.S. 312, 321 (1986)). The Supreme Court has

explained that “[w]here a prison security measure is undertaken to resolve a disturbance,”

courts must examine “whether force was applied in a good faith effort to maintain or restore

discipline or maliciously and sadistically for the very purpose of causing harm.” Whitley,

475 U.S. at 320–21 (internal quotation marks and citation omitted).

In December 2020, New Jersey Attorney General Gurbir Grewal issued a directive

(the “Directive”) to all New Jersey law enforcement agencies regarding their use-of-force

policies, based on several “core principles.” Three of those principles are especially

relevant to our inquiry: (1) the duty to de-escalate and use force as a “last resort”; (2) the

“duty to use only objectively reasonable, necessary, and proportional force”; and (3) the

“duty to intervene and report.” Whether NJDOC correctional facilities are technically

subject to law enforcement directives from the Attorney General is a subject of some

debate, but in any event the NJDOC officials we interviewed informed us that the Directive

-16-
has been adopted by NJDOC as a “best practice.” An explanation of the NJDOC and

EMCF policies and procedures that attempt to effectuate the above standards follows in

Part V.

V. NJDOC POLICIES AND TYPICAL PRACTICE IN CONDUCTING CELL

EXTRACTIONS

NJDOC policies recognize that “[t]here will be occasions when it will be necessary

to force an inmate to move from one cell and/or area to another cell and/or area.” However,

conducting multiple cell extractions at the same time, as occurred here, is rare. Now-retired

EMCF Administrator Sarah Davis told us that she could not recall an instance at EMCF

when more than one cell extraction was conducted at one time, let alone across an entire

unit as occurred here.

According to NJDOC records, there were 21 events at EMCF between May 2018

and April 2021 that NJDOC considers cell extractions. Seventeen of those involved the

use of force and four did not. In all NJDOC facilities, there were a total 275 cell extractions

during that period.

There is an NJDOC policy that specifically governs cell extraction procedures, titled

“Use of Force and Security Equipment: Forced Cell Extraction.” The policy states that

custody staff members may only use force that is “objectively reasonable and necessary”

and that “the utmost restraint should be exercised and the use of force [should] never [be]

considered routine.”

Along those lines, former EMCF Administrator Davis told us that a cell extraction

should occur only after de-escalation attempts fail. From her perspective, cell extractions

-17-
are an “absolute last resort.” She explained that she preferred to talk to the inmate so the

situation “would abate itself.” Davis stated that she would also try to find a staff member

who had a positive rapport with the inmate to intercede. Davis said that most cell

extractions were related to inmate mental health issues. She said that when there is a cell

extraction, the officers “suit up” in protective gear and once an inmate sees the team at her

door, the inmate often has a change of heart and complies with the order at issue.

Consistent with that approach, NJDOC policy states that as long as “there is no

immediate danger to the inmate’s safety, or serious damage to state property by the inmate,

a reasonable amount of time will be allowed for the inmate to comply.” The policy states

that “compliance” at this stage “means the inmate removes all clothing (strips) and places

his or her hands through the food port (if applicable) so that he or she can be handcuffed.”

(We were told in multiple investigative interviews, however, that at EMCF, inmates are

generally strip searched after being moved to another cell, as opposed to in their own cell

before moving. In any event, whenever the inmate is strip searched, she is permitted to re-

dress before leaving the cell.) Davis stated that after arriving at an inmate’s cell, the

officers should use “constructive force” to verbally coax the inmate by telling her that if

she does not come out of the cell, the officer will deploy pepper spray. Davis further stated

that when “constructive force” does not work, deployment of pepper spray is the next step,

followed by further force if necessary.

A. Authorizing Cell Extractions

One issue that arose with respect to the cell extractions that took place on January

11 is whether proper authorization protocols were followed. NJDOC policy itself is not

-18-
entirely clear as to the required approval of a cell extraction, particularly as to whether

NJDOC Central Office must be notified or provide approval.

While one senior NJDOC official we interviewed suggested that Central Office has

to approve all EMCF cell extractions, and there has been legislative testimony to that effect,

NJDOC policy states that a “senior custody supervisor in conjunction with the facility

Major and Administrator” has the authority to make a decision on the use of force in the

case of a cell extraction. Similarly, though not identically, State regulations indicate that

any sergeant or higher-ranking official may authorize non-deadly force, which would seem

to encompass a forcible cell extraction. N.J.A.C. 10A:3–3.3. No mention is made of

NJDOC Central Office in either the policy or the regulations. Along these lines, former

Administrator Davis stated to us that she did not typically seek approval from Central

Office to conduct cell extractions, because cell extractions are generally “urgent

situation[s].” The current Administrator at the facility, Patricia McGill, stated to us that

she personally prefers to “get clearance” if possible, but that seeking permission from

Central Office prior to conducting cell extractions is not required in emergencies.

Senior NJDOC officials uniformly reported to us that conducting a cell extraction

on “third shift,” which is the overnight shift between 10:00 p.m. and 6:00 a.m., is highly

disfavored. For example, EMCF Assistant Superintendent Robin Keller stated that she was

taught not to do cell extractions on the third shift unless “absolutely emergent,” such as if

an inmate has a weapon or is self-injurious. She explained this is because there is only a

“skeleton staff” at the facility on the overnight shift and if anything goes wrong, there is

not enough staff to respond. A former high-ranking NJDOC official we interviewed put it

-19-
more bluntly, stating that a cell extraction taking place at this time of night “is for one

reason: there are fewer people around and fewer eyes.” That official said to empty an entire

restrictive housing area in the middle of the night is “extremely unusual” and “outside of

normal practice.”

Commissioner Hicks stated to us that last year, NJDOC Central Office verbally

communicated a directive to all facility administrators that cell extractions should not be

conducted on third shift, and if an administrator felt a cell extraction was necessary on third

shift, they would need approval from Central Office. According to Commissioner Hicks,

as part of his reform efforts at EMCF, he had streamlined the NJDOC reporting line as it

pertains to that facility. Specifically, he instructed the EMCF Administrator to report

directly to NJDOC Deputy Commissioner Michelle Ricci, as opposed to someone at the

director level. As a result, according to Commissioner Hicks, for a third-shift extraction to

take place at EMCF, Deputy Commissioner Ricci would personally need to provide

approval.

This third-shift approval directive was not provided in writing or via email, and its

parameters are not entirely clear. Commissioner Hicks stated to us that his understanding

is that the approval or denial should happen verbally, through dialogue between the facility

and Deputy Commissioner Ricci.

Commissioner Hicks stated that when extraction approval is sought and provided,

the Deputy Commissioner usually will notify him, but cell extractions can take place

without him knowing. He stated that if a cell extraction happens with no issue or injury,

-20-
he probably would learn about it through reading reports or during staff meetings. If there

were an issue or injury, he said he would be notified more immediately.

NJDOC regulations do mention potentially applicable post-extraction notification

requirements. Specifically, in the case of a disturbance involving “a considerable number

of inmate(s),” or a “serious injury to an inmate,” SID is to be notified and make an

immediate preliminary inquiry, and if the event is determined to have disrupted or have the

potential to disrupt the “secure or orderly operation of the correctional facility,” the

Administrator or their designee is to contact the NJDOC Assistant Commissioner of

Operations by telephone and explain what happened and who was involved. N.J.A.C.

10A:21-5.1–5.2. However, SID Chief Grade reported to us that, in practice, SID generally

is not notified after a cell extraction takes place.

B. Procedure for Conducting Cell Extractions

NJDOC policy sets forth in detail how a cell extraction, once authorized, is to be

conducted. Significantly, the policy states that once an extraction has been approved, “all

custody activity regarding the move shall cease pending arrival of a custody supervisor

with a video camera.” Even if the inmate changes her mind and agrees to comply with the

move at this time, the move may not be made until it can be video recorded. The person

recording the cell extraction must be a supervisor at the level of sergeant or above. Once

the assigned supervisor handling the video recording arrives, he or she must turn the camera

on and verbally announce the date, location, inmate involved and nature of the incident to

be recorded. After receiving the supervisor’s briefing, the extraction team members are to

announce their names on camera. The camera must be used to record the entire incident.

-21-
The video recording should not stop “until the inmate(s) involved have been placed in

mechanical restraints, examined by the medical department and secured in a cell and/or, if

ordered, placed in a restraint chair.”

The extraction team is to consist of five officers, each of whom is assigned a specific

member-number and responsibilities. Each officer assigned to the team must wear

protective equipment, including a helmet with a face shield, riot jacket with groin protector,

and protective gloves. Team member assignments and duties include:

1. “Team Member #1 is responsible for pinning the inmate against the furthest
wall or floor if the inmate falls or lies down, using the shield as protection
from bodily fluids and/or weapons.”

2. “Team Member #2 is responsible for assisting Team Member #1 with

pulling the inmate to the floor, if necessary, and securing the inmate’s arm
on the right side (regardless of which direction the inmate is facing).”

3. “Team Member #3 is responsible for securing the inmate’s arm on the left
side . . . and applying the handcuffs.” Once the handcuffs have been secured,
Team Member #3 must loudly announce “Hands Secured.”

4. “Team Member #4 is responsible for securing the inmate’s leg on the right
side . . . and assisting with rolling the inmate over if necessary for the
application of mechanical restraints.”

5. “Team Member #5 is responsible for securing the inmate leg on the left
side” and is to place “the leg irons on the inmate with the assistance of Team
Member #4 and, after completing the application of the leg irons, announce
loudly ‘Legs Secured.’”

The policy specifies the role of each of the five team members for each subsequent

step in the extraction process as well. Each extraction is to be handled individually, and

each inmate is to be afforded an opportunity to change her position regarding compliance

with the order to move at each step of the process.

-22-
 Immediately following any instance of physical force being used, “each staff

member who participated in or witnessed the event” must submit a written report to the

shift commander. The report must contain, among other things: a description of the events

leading up to the use of force; the reason for employing force; and a description of the

injuries sustained, if any, and medical treatment provided.

C. Related Physical Searches

Cell extractions include a physical search of the inmate. As per NJDOC policy,

such searches “shall be conducted in a professional and dignified manner.” Except in

“exigent circumstances,” female staff shall conduct searches of female inmates.

Consistent with the comments above regarding conducting multiple cell extractions,

interviewees reported to us that a search of an entire housing unit at one time, as occurred

on January 11, is rare. Commissioner Hicks stated that searching an entire housing unit at

one time does not happen “unless we have evidence or intelligence that the entire unit has

contraband or something negative is going to happen. Typically, even if you’re going to

do an extraction, it’s one cell. Search is one cell. To do an entire housing unit is rare.”

NJDOC policy does provide for “mass search” events, which, as Commissioner Hicks

noted, may be predicated on “specific information” received from a third party or based on

correctional officers’ observations, experience or knowledge.

Searches conducted in conjunction with a cell extraction may result in the seizure

of contraband, which NJDOC policy defines, in part, as “[a]ny article, which may be

harmful or presents a threat to the security and orderly operation of the correctional

-23-
facility.” The policy states that “[w]henever an item, article or material is determined to

be contraband, it shall be immediately seized.”

VI. FINDINGS AND ANALYSIS

This section of the report provides our investigative findings and analysis related to

the January 11 cell extractions. Our overview of the facts proceeds chronologically and

focuses on three main subjects: conditions and oversight at EMCF in the months leading

to January 11; the cell extraction incident; and the response to the incident.

A. The Months Leading to the Cell Extractions

In the latter part of 2020, there were changes at EMCF that ultimately contributed

to the January 11 incident.

1. Facility Oversight

In late 2020, leadership at EMCF was in a state of transition. Earlier that year, the

on-site SID Principal Investigator had retired. Then, on August 26, 2020, Sarah Davis, the

facility Administrator, filed for retirement with the State’s Division of Pensions & Benefits,

to begin in early 2021. NJDOC informed us that they received notification of that filing in

October 2020. NJDOC records indicate that the last day Davis actually was present at

EMCF was October 29, 2020. After that date, she used accumulated leave time until her

retirement became effective on February 1, 2021.

In our interview with Commissioner Hicks, he characterized Davis’s exit from

EMCF as “abrupt.” He said that while NJDOC leadership knew she intended to retire, they

did not know exactly when her leave would begin, and he said that when she did ultimately

give notice, it was less than two weeks before she physically departed the facility. Davis

-24-
sees it differently, telling us that she provided notice in the beginning of October, which

Davis said was a typical amount of notice for a supervisor to provide. She stated that it

was “not a secret” that she planned to retire in early 2021.

In any event, NJDOC appears to have been caught flat-footed in response to the

departure of the lead official, and someone brought in as a key reformer several years prior,

at its most troubled facility. NJDOC publicly posted the available Administrator position

at EMCF on October 16, 2020. That position ultimately was filled by current

Administrator Patricia McGill, whose first day at EMCF was January 16, 2021.

Our investigation revealed that between Davis’s last day at EMCF on October 29

and McGill’s appointment after the January 11 cell extractions, there was no Acting

Administrator at EMCF. Multiple people we interviewed, including Commissioner Hicks,

told us that their understanding was that Erica Stem was the Acting Administrator at the

facility beginning in late November 2020. However, others, including Stem herself and

the NJDOC Chief of Staff, told us that Stem was transferred to EMCF as an Associate

Administrator and remained in that title, not Acting Administrator. State personnel records

reflecting Stem’s assignment to EMCF confirm that she was transferred as an Associate

Administrator and do not suggest that her title changed upon her transfer. In our

investigative interview, Stem told us that she was not given any specific reason for her

reassignment to EMCF, and confirmed that no one ever told her she would serve as Acting

Administrator, and that she did not, in fact, serve in that capacity.

Associate Administrators report to the facility Administrator. NJDOC records show

that Stem joined EMCF management as an Associate Administrator effective on either

-25-
November 24 or 25, 2020. Until that point, EMCF had one Associate Administrator, Sean

St. Paul. Commissioner Hicks told us that St. Paul would have reported to Stem upon her

arrival at EMCF, but our investigation determined that St. Paul and Stem operated with

equivalent authority following Stem’s reassignment.

Stem and St. Paul worked together to run EMCF from late November 2020 until

McGill’s appointment on January 16. However, Stem was on leave and away from the

facility from January 4 through January 12, 2021. Thus, on the night of January 11, St.

Paul had oversight of EMCF. Both Stem and Davis stated to us that no one at the facility

was reporting to them while they were on leave; any issues would have been reported to

St. Paul.

2. RHU Conditions and Occurrences

The leadership transitions described above came at a challenging time at EMCF,

especially in the RHU. At that time, the RHU housed a number of inmates described by

EMCF supervisors as particularly “difficult to manage.” Additionally, we were informed

that because of the Covid-19 pandemic, other units within the South Hall compound that

previously were allocated for disciplinary housing had been converted to isolation and

quarantine wings, so RHU was limited to a single long hallway of cells. That made it

difficult or impossible to separate inmates who do not get along well with each other,

increasing tensions in the unit.

During this time, incidents of “splashing” increased in the RHU. “Splashing” is a

term used to refer to an inmate squirting a correctional officer with liquid, often urine or

feces. Facility supervisors we interviewed indicated that splashing is not considered an

-26-
emergency from an operational perspective (i.e., it is not something that requires an

immediate security response), but it constitutes a health emergency for the officer who is

splashed, particularly in the context of the Covid-19 pandemic, and that it “needs to be

reported.” Splashing is a form of assault. Splashing incidents are reported to SID, then

referred to county prosecutors. However, they are rarely if ever criminally prosecuted,

according to NJDOC officials and others we interviewed. Instead, inmates may receive

administrative disciplinary charges, which frequently result in their RHU sanctions being

extended, such that they remain for a longer period in the location in which their

misconduct took place.

SID Chief Grade told us that “assaulting officers with liquids” is a common problem

in correctional facilities across the state, though some administrators and inmates we

interviewed indicated that splashing is relatively new at EMCF. They said that RHU

inmates have learned various splashing techniques from inmates recently transferred to

EMCF from other facilities, where splashing of officers is more common. EMCF

administrators we interviewed said that splashing was occurring three to four times per

week in the months leading up to the January 11 cell extractions.

The RHU cells have doors that are a few inches thick, and each door has a window

and a food “port” or opening. The doorways are narrow, but there is a gap where the door

meets the wall that is a few centimeters wide. As one method of splashing, inmates

allegedly began affixing part of a hollowed-out pen to an empty shampoo bottle filled with

fluids, then, using that converted bottle, squirted liquids at officers through the gap between

the cell door and the wall. In our interview with Administrator McGill, she said that during

-27-
staff tours of RHU, inmates would throw “feces, urine, water, milk – you name it” at staff,

and that because of the layout of the RHU hallway, staff might be splashed from multiple

angles at the same time. EMCF supervisors reported to us that in the days preceding

January 11, there was a coordinated effort by RHU inmates to splash officers.

All of this contributed to substantial frustration on the part of EMCF officers, who

were upset that, in addition to the fact that inmates were not being criminally charged for

splashing, the disciplinary charges they received were downgraded in some cases. We

were told that officers felt that inmates were not being held accountable for their actions

and that their supervisors were not protecting them. As the officers’ union president put it

to us, “things reached a boiling point.” Compounding all of that was the stress caused by

the Covid-19 pandemic. EMCF officials we interviewed stated that custody staff was

frustrated and exhausted, and felt unsupported, and that there was heightened emotion

among staff as a result. One supervisor summarized things by saying that the RHU was

“in a dire state” by early January.

NJDOC Central Office officials apparently were not made aware of any increase in

splashing incidents at EMCF. For example, Commissioner Hicks told us that he does not

recall receiving any reports of inmates splashing liquids at weekly briefings during that

time.

B. Cell Extraction Incident

Beginning on the night of January 11 and extending into the early morning hours of

January 12, 2021, a series of cell extractions were conducted in the RHU. Below, we detail

facts about the extractions chronologically, breaking the incident into three phrases: the

-28-
decision to conduct cell extractions; the extent to which authorization was sought; and the

extractions themselves.

1. Decision to Conduct Cell Extractions

NJDOC records reflect that on January 11 at approximately 4:40 p.m., a correctional

officer conducted a search of Inmate 4’s1 RHU cell while she was not inside it; at that time

she was in the “RHU module,” where RHU inmates can access JPAY tablets and have

recreational time. A “contraband seizure” form indicates that a conditioner bottle with an

“inmate pen” attached to it was seized from the cell. The form attached a photograph of

the converted conditioner bottle:

Three splashing incidents occurred shortly after the search of Inmate 4’s cell. First,

at approximately 5:39 p.m., during service of evening “mess” (dinner) in the RHU, Inmate

4 sprayed a correctional officer with an unidentified liquid through the gap between her

cell door and the wall. The officer sprayed was the same one who had just conducted the

1
Because of the sensitive nature of the facts at issue, we have used numbers as opposed to names of inmate/victims.

-29-
search of Inmate 4’s cell. According to the officer’s report, the liquid struck her in her

right eye, went down the right side of her face, onto her shoulder, and down her back. She

stopped the mess movement on the wing, notified the area sergeant and went to receive

medical attention. The sergeant’s incident log report states that Inmate 4 “still retains the

item used” to assault the officer.

NJDOC disciplinary records show that this was not the first time that Inmate 4 had

been accused of splashing officers. She had been disciplined for “throwing bodily fluids”

at least twice before, in November and December 2020.

Documents indicate that the evening mess in the RHU resumed at 7:37 p.m. During

this second attempt to serve the meal, Inmate 1 “began spraying an unknown liquid out the

side of her cell door attempting to hit” the officer serving mess and two other correctional

officers who accompanied her. Mess service was again halted at that time.

At approximately 8:30 p.m., the officers attempted to place a “rolling shield” in

front of Inmate 1’s cell to screen themselves from further splashing. Nonetheless,

according to the officers, Inmate 4 splashed an officer on the arm while he was in the

process of placing the shield. A second correctional officer reported that at the same time,

Inmate 1 splashed him with an “unknown clear liquid” while he was attempting to place

the shield. A third officer claims to have been hit on his face, including his eyes, with an

unknown substance. The officer who allegedly was hit in the eyes received outside medical

attention; the other two officers declined medical attention. Video footage we reviewed

from a fixed camera in the RHU confirmed that at approximately 8:30 p.m., liquids were

-30-
expelled from at least two cells while four correctional officers attempted to place rolling

shields on the unit.

During these events, on-site officers were providing updates to facility supervisors.

Associate Administrator St. Paul subsequently drafted an email summarizing that dialogue.

His narrative largely tracks those of other supervisory reports that were filed. It states that

a facility major contacted him and informed him that “approximately five officers were

assaulted.” The narrative states that St. Paul and another supervising officer decided they

needed to “take a ride to EMCF.” Upon their arrival, they were briefed and informed that

suited extraction teams were prepared “to remove each inmate from their respective cell,

to search, remove contraband[] and return each inmate to their cell.” NJDOC

documentation states that the Associate Administrator along with two majors at the facility

approved the cell extractions.

Thus, as an incident log report states, at approximately 9:40 p.m.:

multiple extraction and escort teams were assembled to search

all of RHU due to multiple staff assaults that occurred
throughout the day by way of splashing custody staff members
with potentially dangerous unknown liquids. The objective
was to secure every inmate from RHU, conduct a thorough
search of each cell to discard all contraband and any items
capable of projecting liquid through the cell food port or
through the side of the cell doors.

The third shift at EMCF began shortly thereafter, at 10:00 p.m.

-31-
 2. Contact with NJDOC Central Office

That same night, Associate Administrator St. Paul made contact with NJDOC

Central Office to report that an inmate disturbance had taken place on the RHU.

REDACTED

REDACTED

-32-
 REDACTED

Deputy Commissioner Ricci did not make contact with Commissioner Hicks that

night about her dialogue with St. Paul. The timing of Commissioner Hicks becoming

aware of the cell extractions and the content of what he was told are discussed later in this

report. EMCF’s SID unit was not notified that the cell extractions were to take place, nor

was the OCO notified. Ombudsman DiBenedetti stated to us that in the past “the DOC has

notified me occasionally of searches and I have staff and/or myself report to the facility to

observe the event and complete a report a containing our observations.” That notification

did not happen in this case.

3. The Cell Extractions

The January 11 cell extractions in the RHU (the “Cell Extractions”) began at

approximately 10:30 p.m., 30 minutes into EMCF’s third staffing shift. According to

NJDOC records, 22 inmates in total were taken out of their cells. Seventeen inmates left

their cells without incident, four inmates required a forced extraction, and one inmate

initially complied but later became non-compliant. Records further indicate that no

contraband was discovered during the course of the extractions and related searches.

Lowenstein reviewed the videos that officers recorded of the Cell Extractions, as

well as recordings from the cameras mounted on the walls in the RHU. The videos show

that the Cell Extractions were conducted by groups of five officers, each of which was led

-33-
by a sergeant (“Extraction Teams”). The officers wore riot gear and carried shields and

canisters of pepper spray. Both male and female officers were involved in the Cell

Extractions.

According to NJDOC records, there were two Extraction Teams. Two sergeants

were assigned to videotape the extractions, with one sergeant being assigned to each team.

Additional officers escorted the inmates once they were removed from their cells.

The Cell Extractions required a significant amount of overtime by custody staff.

According to NJDOC records, 37 officers put in overtime due to the Cell Extractions during

the third shift.

During each of the Cell Extractions, the five officers on the Extraction Team lined

up in the hallway outside the inmate’s cell while the sergeant asked the inmate to put her

hands out through the food port to be handcuffed. Some inmates complied, while others

did not. The five officers then rushed into the cell, handcuffed the inmate (if not already

cuffed), put leg irons on her, and brought the inmate out of the cell. The lead sergeant

typically entered the cell, as did the video recorder, meaning that there were a total of seven

custody staff in each cell during the extractions. After being removed from the cell, each

inmate was escorted to the Medical Office for assessment, to a shower if she had been

pepper sprayed, and then to another cell to be strip searched.

In many of the videos, it is difficult to see exactly what is happening at every

moment because the recording officer is standing behind other officers, frequently

recording the officers’ backs instead of recording the inmate and what is happening to her.

While the officers are supposed to be identified by name before cell extractions are

-34-
conducted, this did not occur on the videos described below. Additionally, certain events

were not recorded at all.

Below is a summary of each of the forced Cell Extractions based on the video

recordings. The videos are exceedingly violent and are alarming in a way that is difficult

to put into words. One senior NJDOC official we interviewed described the video footage

as “one of the most disturbing series of videos I have ever seen.”

i. Extraction 1

The video of Inmate 1’s cell extraction begins with a sergeant ordering her to put

her hands through the food port to be handcuffed. She complies with the order. Her

cellmate, Inmate 5, was removed from the cell (described in further detail below), and then

the camera returned to the cell, where officers tell Inmate 1 to “stop resisting,” but she is

not visible as officers are blocking the view into the cell. Inmate 1 is pushed out of the cell

by the Extraction Team, with one officer pulling her by her sweatshirt.

Inmate 1 is held against a wall in the hallway for several minutes. She protests,

“I’m somebody!” The Extraction Team then takes her into the Medical Office for an

assessment. She says she does not want any medicine. The sergeant deems Inmate 1 to be

refusing a medical assessment, though she says she is not. The Extraction Team takes her

out of that office and the sergeant says to take her to the “strip cell.”

Inmate 1 is then taken into an empty cell with tiled walls identified in reports as the

South Hall North Wing shower area or the South Hall North Wing strip room. There are

seven officers behind her, and they ask her to strip, which she refuses to do. The male

officers leave, and three female officers enter the cell. Inmate 1 says at one point, “It’s in

-35-
my pussy and y’all ain’t getting it.” The officers begin forcefully cutting her clothes off.

The officers pull at the clothes and use a hooked blade to attempt to cut through them. Her

sweatshirt is torn, but her clothes are not removed. During some of this period, the camera

is pointed up or towards the wall. Inmate 1 begins spitting at the officers. The camera is

then pointed towards the wall while there is some commotion so it is unclear what happens,

but Inmate 1 is then on the ground with officers surrounding her, including male officers.

She repeatedly says “get off of me” and at one point says “get off my titty.”

Inmate 1 is then carried out of the strip cell while the officers say they are going to

put her in another cell and strip her. She is put into a cell, but it is not possible to see her

on the video as there are four or five officers crowding around her, including male officers,

who remain in the cell during the forced strip search. Inmate 1 says that the officers are

mad they got “splashed.” She says that she is going to make the officers’ lives as difficult

as possible and that she is about to bite one of them. A male officer again tells her to “stop

resisting.” One of the officers hands a sharp object to another. Some type of struggle

seems to take place, but cannot be seen on the video as there are officers blocking the

camera view. Inmate 1 asks, “Why is it a man ripping my clothes off? Why is you grabbing

my titties?” Some of her clothes are then thrown out of the cell. She yells, “PREA!” The

officers leave the cell and Inmate 1 is naked, apparently left in the cell alone, and the video

ends.

According to Inmate 1’s subsequent written statement, she complied with the order

to be handcuffed, and the officers then entered her cell and “kicked, punched, slammed,

and grabbed [her] hair.” She stated that the officers bent her arm back, cracking it out of

-36-
place. She wrote that she was taken to the shower where the officers “began to rip [her]

clothes off” with a “sharp knife like object,” which was not working. She stated that the

officers then took her to cell number five, where both male and female officers assaulted

her. She wrote that her shirt was ripped off, and that one officer choked her, grabbed her

breast, and “put his hands in [her] vagina,” scratching it and causing it to bleed.

The reports filed by the sergeant who supervised the Extraction Team and the

sergeant who videotaped the extraction state that Inmate 1 refused orders to strip, became

aggressive and started spitting at the officers. The reports incorrectly state that female staff

entered the area to forcibly remove Inmate 1’s clothing, while she continued to be non-

compliant.

The reports describe that Inmate 1 was later found lying unresponsive on the floor,

about an hour after the extraction, so a team of suited officers entered the cell and placed

her in a wheelchair. When she regained consciousness, she allegedly became belligerent

and non-responsive, and began spitting at the officers. According to the reports, Inmate 1

refused a medical assessment and was taken to the infirmary. There is no evidence of these

events on video.

Reports filed by the two sergeants state that Inmate 1 sustained no injuries during

the Cell Extraction. However, a medical report from January 12 notes she had superficial

scratches and visible purple bruising on her hand. Notes from the nurse at EMCF state it

was later determined that she broke her arm and that she received a cast.

-37-
 ii. Extraction 2

The video of Inmate 2’s cell extraction begins with a sergeant ordering her to put

her hands through the food port to be handcuffed. She says, “I’m not going” and that she

needs to use the restroom. The sergeant sprays pepper spray through the food port and

immediately (contrary to NJDOC policy) opens the cell door. The Extraction Team rushes

into the cell. Inmate 2 is pushed against the wall and the officers repeatedly tell her to

“stop resisting.” An officer pulls her back by her braids while another officer punches her

numerous times on her face, chest and back. It is difficult to see what is happening due to

numerous officers being inside the cell, but the sound of punches landing is audible and

goes on uninterrupted for about a minute. Inmate 2 has her arms up, attempting to cover

her face, while she is pressed against a wall with her back to the officers. She says, “Stop

punching me in my face.” Charges subsequently filed by the New Jersey Attorney General

allege that one officer alone punched Inmate 2 in the head and neck 28 times.

Ultimately, the officers push Inmate 2 out of the cell and she has a visibly bloody

mouth and squinting eyes. Her shirt is open. The officers hold Inmate 2 against a door.

An officer tells her to listen to orders and stop resisting; she says she is listening to orders

and is not resisting. She asks to be covered up. The officers walk her through the hallway

and as they walk, an officer yells at her, “You’re going to listen to my orders, do you

understand? If you don’t listen to my orders, you will get sprayed again. Do you

understand?” She does not respond. As she is brought into the Medical Office, she says,

“Y’all got my chest out, in front of the audience.” Her shirt is still open.

-38-
 Inmate 2 tells the nurse that the officers punched her in her face and chest and that

she has a concussion. The officers tell her they are going to strip search her. Inmate 2 asks

if the nurse can wipe her face as it is burning. The nurse says she is not sure if she has any

bandages. The officers take her to a shower and tell her to put her face in the water. She

says that she does not want to get in the shower. An officer then says “strip cell” and points

to a cell. The officers walk her down the hallway, but then take her back to the shower to

strip. Inmate 2 faces the camera and says, “Y’all see my lip on this camera? I’m about to

kill one of these officers.”

The officers lock Inmate 2 in the shower for her to strip (the door is grated but has

a curtain in front of it). She says, “Y’all want to beat the life out of me.” A male officer

tells her to strip and put her pants through the porthole. She says, “Please back up, I don’t

have no clothes on. This is PREA.” She gives her pants and underwear to a female officer

through the porthole, but male officers remain present. The female officer tells her to turn

around, squat and cough. After some back and forth, Inmate 2 says she is not doing that.

An officer tells her she will be sprayed again if she does not comply. The female officer

attempts to talk to Inmate 2 again, but she still does not comply with the order. A male

officer says, “At this time [Inmate 2] is not complying,” and pepper sprays her through the

grated door. She turns on the shower, presumably to wash off the pepper spray. The officer

tells her to put her hands through the porthole to be handcuffed. Inmate 2 continues to

shower while he repeats his orders. Inmate 2 says that she will strip and turns around and

coughs. She asks for clothes, and the officers give her clothes through the porthole. They

-39-
then cuff her through the porthole and walk her down the hallway to the cafeteria where

they lock her in a holding cell.

The sergeant’s special custody report states that Inmate 2 refused his orders to be

placed in handcuffs and that he then deployed pepper spray. The report then incorrectly

states, “[Inmate 2] continued to refuse all orders to be handcuffed. [The sergeant] then

ordered his team to enter the cell.” The video footage, however, shows that Inmate 2 was

not given an opportunity to comply with the handcuff order after the pepper spray was

used; the Extraction Team immediately rushed into the cell.

Another officer’s report states that after entering Inmate 2’s cell, “she was throwing

punches towards [his] torso area” and that he “used physical force to gain compliance.”

The video recording does not show the inmate punching the officer.

The use-of-force reports from the on-site sergeants both state that Inmate 2 sustained

no injuries during the Cell Extraction. The on-site medical report from that night, however,

states that she had a bleeding lower lip, which is visible on the video footage. The next

day, she was assessed by a nurse at EMCF, who noted that she had a swollen red/purple

lower lip with a small cut inside, bruises on her eye, arm, and shoulder, and a cut on her

right hand. Inmate 2 was taken to a hospital that day and was found to have suffered a

concussion and a cervical sprain.

iii. Extraction 3

Contrary to NJDOC policy, Inmate 3’s cell extraction was not recorded at all. There

is video footage following her extraction, which shows her with a black eye and bloody

face. The officers walk her through the hallways to the Medical Office and she says, “They

-40-
punchin’ me all in my eye for no reason. . . . I ain’t even do nothing. Stop hurting me.

Why are they punching me in my eye.” She tells the nurse she has a bad headache and

cannot see. She starts crying and says she did not do anything wrong and is hurt. The

officers take her out of the office and she repeatedly says, “Stop hurting me,” while crying.

There is blood on her face, which seems to be coming from her eye. The officers walk her

down a hallway, outside and to another building where they bring her into a cell. Her black

eye and blood on her face are visible. Twice she says to the officers that they should be

more focused on the inmates who are actually squirting them, as opposed to her. A nurse

comes in to see her and says she is going to come back with a blood pressure monitor, but

does not return. The officers take Inmate 3 to a cell for a strip search and take off her

handcuffs. The officers all leave the cell, and she removes her clothes and gives them to

two female officers through the porthole (no male officers appear to be in the hallway).

She does not appear to be resisting at any time.

One sergeant’s report says that he filmed Inmate 3 and that she “became self-

injurious.” The Attorney General’s criminal charges state that this report was false.

Similarly, another officer’s report seems, falsely, to try to explain her injuries by saying

that she was “banging her head on the cell door.” The criminal charges state that video

shows Inmate 3 did appear to throw an unknown white liquid out of her cell into the

hallway, but further that during her cell extraction she immediately complied with an order

to be handcuffed before officers entered her cell. The related affidavits say that, according

to other inmates, Inmate 3 “begged officers not to harm her” and that she was “crying in

-41-
pain” as corrections offers struck her multiple times with their fists, despite her being

handcuffed and not resisting.

The medical reports from the night of the Cell Extractions state that Inmate 3’s right

eye was completely swollen shut and that her mouth was bloody. On January 12, she was

taken to a hospital and was found to have suffered an orbital wall fracture.

iv. Extraction 4

The video recording of Inmate 4’s cell extraction shows a sergeant ordering her to

“cuff up” through the food port. She does not comply with the order. The sergeant repeats

his order. After 30 seconds, the sergeant sprays pepper spray through the food port. He

again asks her to “cuff up” and tells her to “stop grabbing that, we’re coming in.” The

Extraction Team then rushes into the cell. Inmate 4 is not visible as the officers are in the

way of the camera and the lights in the cell appear to be off. The officers repeatedly tell

her to “stop resisting” and she seems to be on the floor. One of the officers says to “pull

her pants up.” As the Extraction Team then takes her out of her cell, her pants are falling

down her legs. The officers take her to the Medical Office, and she says she has no injuries

or bruises. She is put into a cell to strip, and the male officers leave while three female

officers remain outside and monitor the strip search, which takes place without incident.

The sergeant’s ensuing report states that Inmate 4 refused to report to the food port

to be handcuffed, so he deployed pepper spray. His report also claims that he “observed

her reaching under her bed for a possible weapon” prior to the Extraction Team entering

the cell. We were not able to substantiate that claim through the video evidence.

-42-
 v. Extraction 5

The video of Inmate 5’s cell extraction shows her complying with the sergeant’s

order to put her hands through the food port to be handcuffed. The Extraction Team then

rushes into her cell. She is not visible on the video at this point, but seems to be on her bed

with the officers crowded around her. The officers yell at her to “stop resisting,” and she

says she is not resisting. A struggle can be heard for about a minute. The Extraction Team

then drags her out of the cell, with officers holding her legs and another officer holding her

arms. The officers push her down the hallway. She is then laying on the floor with officers

surrounding her. The officers tell her to “stop resisting,” and she says she is not resisting.

She is then walked down the hallway.

There is no further video of Inmate 5. The camera then turns to Inmate 1 who is

extracted from the same cell, as detailed above.

C. Previous Conduct of Participating Custody Staff

NJDOC records reveal that some of the officers participating in the Cell Extractions

engaged in previous conduct predictive of the misconduct described above.

For example, disciplinary records indicate that one of the lieutenants suspended

following the Cell Extractions has been disciplined twice previously for failing to properly

record a cell extraction or escort. In 2013, the lieutenant received an official reprimand

after he “operated the camera in the still photo mode, rather than the video mode[,]

[t]hereby rendering the taping useless.” Then, in 2016, he was suspended after he was

shown on “surveillance video holding [his] assigned video camera down to [his] side while

[he] leaned against a doorway watching the altercation.”

-43-
 Similarly, NJDOC records indicate that another one of the officers involved in the

Cell Extractions had been disciplined previously for failing to conduct a cell search in a

professional manner. The file indicates he received a letter of counseling as a result.

Two supervisors involved in the Cell Extractions were alleged to have engaged in

violent conduct while off-duty during their employment with NJDOC. Senior NJDOC

officials we interviewed were largely unaware of these allegations.

According to NJDOC administrative records, one senior EMCF officer involved in

the Cell Extractions was arrested in 2017 for criminal mischief after he allegedly punched

a door during a domestic violence incident with the mother of his child, who also was an

EMCF correctional officer at the time. He was placed on a “no armed post” list, until the

criminal mischief charge was dismissed in 2018 and he underwent an evaluation that

deemed him fit to possess a weapon. He later became romantically involved with another

EMCF employee, allegedly leading to a “love triangle” that resulted in one of the women

having her car “keyed” by an unidentified person.

Records show that another senior EMCF official self-reported being involved in two

separate incidents in which he discharged his off-duty firearm while driving. In the second

incident, which was reported in 2003, he allegedly shot at another driver. The EMCF

official stated that the other driver had a gun pointed at him and refused to lower it, but

witnesses said the other driver was unarmed and that the official shot at him as he drove

away. This same EMCF official was one of the individuals who last year formally

reviewed and signed off on one of EMCF’s use-of-force policies.

-44-
 D. The Response to the Cell Extraction Incident

EMCF staff responded to the January 11 splashing incidents by filing disciplinary

charges against Inmate 4 for splashing officers with an unknown liquid and Inmates 1 and

3 for spraying unknown liquids and attempting to hit officers. As noted above, the physical

evidence against Inmate 4 included a bottle of hair conditioner “with an inmate pen

hollowed out attached to bottle.” The charge against Inmate 3 was later changed to “being

unsanitary.” Additionally, Inmates 2, 4 and 5 received disciplinary charges for refusing to

obey orders from the officers during the Cell Extractions.

Through the NJDOC adjudication process, all five inmates initially received

sanctions based on the above charges. Sanctions against Inmates 3 and 5 were upheld on

appeal, with the explanation for Inmate 5 stating, “Reports indicate you were non-

compliant throughout the search . . . . Start focusing on your actions since you will be held

accountable.” Sanctions against Inmates 1 and 2 were modified on appeal based on

“leniency.” Most of Inmate 4’s sanctions were suspended on appeal, but a 30-day loss of

phone privileges and 30-day loss of JPAY and email were upheld.

When Commissioner Hicks became aware of these charges, he directed that they be

suspended. All proceedings regarding them are currently on hold, and the discipline has

not been carried out. The process through which NJDOC Central Office learned of the

Cell Extractions is set forth below.

NJDOC senior officials were first notified of the Cell Extractions via an email from

the NJDOC Central Operations Desk (“COD”). At each NJDOC facility on each shift,

there is a shift commander responsible for reporting to COD any qualifying incident that

-45-
occurs during that shift. COD sends periodic emails to a large list of recipients, including

NJDOC officials and facility supervisors, which contain reports of major incidents across

NJDOC facilities.

On January 12, 2021, at 4:17 a.m., COD sent such an email, stating that at 11:30

p.m. on January 11, St. Paul and two others on site gave the order to have all RHU inmates

removed from their cells and strip searched, and for cell searches to be conducted as well.

The email stated that all but four inmates complied and that no injuries were reported.

Listed recipients of the email included Hicks, Ricci and Grade.

Later that morning, Inmate 2 called the OCO to lodge a complaint regarding the

Cell Extractions. The OCO’s notes of that call indicate that Inmate 2 alleged she was

punched in the face and suffered a concussion and an injured lip. Ombudsman DiBenedetti

emailed SID and EMCF staff regarding Inmate 2’s allegations. SID Chief Grade then

forwarded that email to the EMCF SID Principal Investigator for investigation, noting that

the COD report had stated that there were no injuries during the Cell Extractions. Grade

asked the investigator to ensure that Inmate 2 had been medically evaluated.

Around noon on January 12, Inmate 2’s aunt called NJDOC Central Office staff

regarding the Cell Extractions, stating that Inmate 2 had been part of an “assault” at EMCF.

She said that one of the other inmates had been rushed to the hospital “with her eye knocked

out of the socket.” Ricci emailed that information to Grade, copying Hicks, asking that it

be investigated. Ricci noted that she was not previously aware of any inmate going to the

hospital.

-46-
 At 5:45 p.m. on January 12, Ricci emailed Hicks directly, copying Grade, noting

that

REDACTED

Ricci said,

“This is a real concern.” Hicks stated during his interview with us that he first became

aware of the Cell Extractions on January 12 when Ricci emailed him.

In response to the above-mentioned email from Grade, the EMCF Principal

Investigator asked one of her investigators to review the video footage from the handheld

cameras used during the Cell Extractions. Upon reviewing a portion of the footage, the

investigator told her, “I think we have a problem,” which the Principal Investigator relayed

to Grade. That led to the entirety of the video footage being secured for further review.

On January 13, the EMCF SID unit obtained and reviewed the video coverage. They

then spoke to Grade about it, who advised them to inform law enforcement, which they

did.

At 11:44 a.m. that day, the NJDOC Managing Physician emailed Ricci about Inmate

3. He noted his “concern” about the use of pepper spray on a patient with a history of

asthma. He also noted that the initial nurse documented redness in Inmate 3’s eyes

following the use of pepper spray, but the next shift nurse noted a completely closed eye

with bruising. Ricci responded, copying Hicks and Grade, asking for additional details.

At 2:50 p.m., Ricci emailed the incident reports to Hicks. She again noted that

REDACTED
nor were the injuries in the

-47-
COD report. She requested that St. Paul be temporarily reassigned pending an

investigation and that Patricia McGill be moved to EMCF as Acting Administrator. Hicks

responded and approved the recommendations. He stated in his interview with us that after

learning there were injuries, the first thing he wanted to know was whether the inmates had

been medically assessed and received appropriate medical treatment. He said his second

priority was to find out what was on camera and how quickly the footage could be

produced.

On January 14, there were multiple outreaches to the OCO by, or on behalf of,

inmates involved in the Cell Extractions. First, Inmate 1’s sister contacted the OCO

alleging that one of the officers had ripped off her sister’s clothes, groped her and placed

his fingers in her vaginal area. The OCO provided that information to Grade and to the

EMCF PREA compliance unit. The PREA Compliance Coordinator responded that she

had initiated PREA protocols, which included moving Inmate 1 to a protective custody unit

until SID could interview her. Second, Inmate 3 called OCO. She alleged that she had

been physically assaulted and punched in the face. DiBenedetti emailed that information

to Grade and others in SID, copying Ricci. Grade responded that the matter was under

investigation by SID. Third, Inmate 4 called OCO and made similar allegations.

DiBenedetti personally spoke with Inmate 4 when she called, and he advised her that SID

would be speaking with her. DiBenedetti then emailed Central Office SID and EMCF SID

to refer Inmate 4’s allegations.

Also on January 14, EMCF SID delivered the video footage of the Cell Extractions

to Central Office SID. Grade viewed the footage later that day.

-48-
 The next morning, January 15, Grade reviewed the video footage with Hicks, Ricci

and other Central Office staff. (Hicks and his staff had obtained the video footage on

January 14, but because of technical difficulties, Hicks initially was not able to review the

footage.) When Hicks saw the videos, he decided to suspend the individuals involved,

pending further investigation. During his interview with us, Hicks said he was disgusted

and angered by the videos.

On Saturday afternoon, January 16, Hicks emailed senior officials at the Governor’s

Office informing them that the EMCF Associate Administrator had authorized four cell

extractions on January 11. He stated that at least two inmates suffered injuries, specifically,

“1 inmate suffered a broken arm and another suffered facial injuries.” Hicks further stated

that he placed 29 staff on leave pending an SID investigation for violation of policies and

potential use of excessive force, and that the Hunterdon County Prosecutor’s Office had

been contacted to review the incident for potential criminal prosecution. Hicks stated that

the Cell Extractions had not been authorized by anyone in NJDOC except the Associate

Administrator.

During his interview, Hicks told us that this method of communication is typical for

his dialogue with the Governor’s Office. He does not reach out directly to the Governor;

if an emergent issue arises, he will reach out to the Governor’s chief of staff or chief counsel

by email or phone.

Seven minutes after Hicks’ email, the Governor’s chief counsel responded, asking

if the Attorney General’s office had been notified. Hicks confirmed that they had,

-49-
specifically, a referral had been made to criminal authorities at the Office of Public

Integrity and Accountability.

In his interview with us, the Governor said that upon being briefed, he was

disgusted, deeply concerned and upset. He said that in response, separate from having

guilty parties brought to justice through the criminal process, he directed this outside

investigation to take place to determine what had happened and how it happened, and to

ensure it never happens again.

VII. CONCLUSIONS AND RECOMMENDATIONS

A. Conclusions

In addition to the findings noted above, the following are conclusions regarding the

events of the Cell Extractions.

1. Custody Staff Failed to Establish a Proper Basis for Conducting

Forced Cell Extractions on Third Shift

As noted above, third-shift cell extractions are reserved for emergency situations,

because there generally are not enough staff members during third shift to respond

appropriately if a situation becomes volatile. As a result, both the current and former

EMCF Administrators told us that had they been asked to authorize these third-shift Cell

Extractions, they would not have done so.

Administrator McGill said that from what she knew about the incident, there was

“no pressing need” to remove contraband from inmates’ cells. Former Administrator Davis

likewise said she would not have considered splashing to be an emergency justifying cell

extractions, particularly on third shift. She noted that she has witnessed riots during third

-50-
shift that were not determined to require cell extractions. Davis conveyed a sense of guilt

about the Cell Extractions and her absence from the facility, stating, “God knows this . . .

would not have happened” had she been present. Another EMCF supervisor similarly said

that she would have waited until first shift to conduct cell searches in response to splashing

incidents, because inmates are often out of their cells for recreational time during first shift,

obviating the need for forced extractions.

The lapse in time, including a shift change, between the last splashing incident

around 8:30 p.m. and the first cell extraction at approximately 10:30 p.m., indicates the

absence of a true emergency justifying a third-shift cell extraction. In the absence of a true

emergency, the motives underlying the conduct here become more apparent. As opposed

to an attempt to quell a legitimate emergency, the Cell Extractions were a misguided effort

by frustrated employees to restore order and mete out discipline in response to splashing

and other events.

2. Custody Staff Failed to Properly Record the Cell Extractions

As explained above, NJDOC policy states that once a cell extraction is approved, it

cannot proceed until “a custody supervisor with a video camera” arrives. The policy

provides specific tasks that must be completed on camera prior to the cell extraction, none

of which were present on the recordings described above. First, the supervisor recording

the cell extraction is to announce the date and time that the recording is beginning, his or

her name and title, the location of the recording, the reason for it, the name of the

correctional facility, and the name and identification number of the inmate(s) involved.

The video recordings did not include this required statement. Next, the custody supervisor

-51-
overseeing the extractions must provide an on-camera briefing, including the names and

responsibilities of all team members, and provide instructions for and describe the purpose

of the extractions. The team members themselves must announce their name, team number

and specific responsibility on camera. This announcement did not occur on video

recordings described above, and Commissioner Hicks noted the same in our interview of

him.

Once the pre-extraction briefings are complete, the entire incident must be recorded,

and the recording must not stop until after the inmate has been examined by medical staff.

Nonetheless, video recordings of the Cell Extractions were frequently filmed in such a way

that it was impossible to see what was happening to the inmate. Instead, the camera was

frequently positioned behind members of the Extraction Team, filming their backs instead

of filming the inmate involved, or filming a wall. For instance, the recording of Inmate 2’s

cell extraction does not depict Inmate 2 while an officer audibly punches her for about a

minute straight.

In addition, our investigation found that some Cell Extractions, or portions thereof,

were not recorded at all. For example, Inmate 3’s cell extraction, which resulted in her

suffering a skull fracture, was not recorded. The video footage of Inmate 3 shows her

already injured, with a visible, swollen black eye and bloody face, as she is transported to

the Medical Office. There is no video footage supporting officers’ claims in incident

reports that Inmate 3’s injuries were a result of her becoming “self-injurious” or “banging

her head on the door.” Likewise, there is no video supporting officers’ claims in incident

reports that Inmate 1 was discovered “unresponsive” in her cell and “became belligerent”

-52-
toward officers when she regained consciousness. Nor is there video footage that explains

Inmate 1’s broken arm that was placed in a cast.

Commissioner Hicks told us that in his opinion, the inadequate filming was

intentional. He said “there were instances where the camera was pointed at the floor, or it

wasn’t even on . . . . I don’t think that was coincidental. And it was completely inconsistent

with what our policies are.” We were similarly told by a former NJDOC official that

improperly filming cell extractions and telling non-resistant inmates to “stop resisting” are

tactics sometimes used to avoid detection of excessive force or to justify an inappropriate

use of force.

3. Custody Staff Used Excessive Force During Multiple Cell

Extractions

NJDOC policies and State regulations related to the use of force emphasize that any

use of force by correctional officers must be “objectively reasonable” and that custody staff

must exercise “the utmost restraint” when using force. Additionally, the policy governing

forced cell moves states that inmates must be provided “a reasonable amount of time to

comply” with orders before force is used, so long as there is “no immediate danger to the

inmate’s safety, or [of] serious damage to state property by the inmate.”

Custody staff failed to follow protocols related to use of force and used excessive

force during the Cell Extractions. First, pepper spray was used inappropriately during the

Cell Extractions. The use of pepper spray qualifies as a use of force pursuant to NJDOC

cell extraction policy. The policy states that once pepper spray is deployed against a

noncompliant inmate, the extraction team should wait “approximately two (2) minutes”

-53-
and then give the inmate another opportunity to comply with the instruction before

beginning the extraction. In contrast, video recordings of Inmate 2 and Inmate 4 show

custody staff deploying pepper spray and then immediately entering the inmate’s cell,

rather than providing an opportunity to comply. Commissioner Hicks confirmed that

officers should have given the pepper spray time to take effect such that the inmate could

“voluntarily surrender and comply.”

Second, we found that in at least three of the Cell Extractions, custody staff

employed a level of force that could not be considered “objectively reasonable.” Video

recordings showed an officer holding Inmate 2 by her hair while another officer repeatedly

punches her on the face, chest and back. She never appears to be resisting, but rather

appears to be attempting to cover her face to avoid being punched. Inmate 2 received

external medical attention and was ultimately diagnosed with a cervical sprain and a

concussion. Further, before Inmate 1 was strip searched, custody staff are visible on video

ripping her clothes in what appears to be an unnecessarily violent manner. Moreover, there

is no video footage showing how Inmate 3 sustained a skull fracture, nor how Inmate 1

sustained a broken arm. While we will leave assigning culpability among specific

individuals present that night to criminal prosecutors, overall conclusions regarding the

conduct that took place are fairly self-evident.

All of this taking place during an ongoing federal probe at EMCF, and after a critical

DOJ report, renders the conduct all the more jarring. Phrases used by NJDOC officials

describing their reactions included “blows my mind,” “shocking,” “beyond frustrating” and

“devastating.”

-54-
 4. Custody Staff Filed False Reports

NJDOC policy requires immediate reporting of use of force by “each staff member

who participated in or witnessed the event,” by way of a special custody report. The

“ranking custody staff member on the scene” must also complete and submit a “use of

force” report. The reports must include, among other facts, a description of the type of

force used, the reasons for employing the force and a description of any injuries sustained.

Our investigation revealed that custody staff filed false reports regarding several of

the Cell Extractions. For example, incident reports describing Inmate 1’s cell extraction

state: (i) female officers strip-searched Inmate 1; (ii) Inmate 1 was later found unresponsive

in her cell, then regained consciousness and became belligerent; and (iii) Inmate 1

sustained no injuries during the extraction. However, (i) male officers are visible inside

the cell while Inmate 1 is strip searched and appear to have participated in the search; (ii)

there is no video evidence suggesting Inmate 1 was at any point unresponsive; and (iii)

Inmate 1 sustained a broken arm, visible bruising and superficial scratches.

Incident reports describing Inmate 2’s cell extraction state that she: (i) refused

orders to be handcuffed; (ii) was “throwing punches” toward custody staff; and (iii)

sustained no injuries. In contrast, video recordings and medical reports we reviewed show

that: (i) Inmate 2 was not given an opportunity to comply after pepper spray was deployed;

(ii) Inmate 2 was neither resistant nor violent; and (iii) Inmate 2 sustained a swollen lip,

bruises on her eye, arm, and shoulder, a cut on her right hand, a concussion, and a cervical

sprain.

-55-
 Reports describing another inmate state that she became “self-injurious” and was

“banging her head on the cell door.” Thus, the reports would indicate that the injury

depicted in this publicly reported photograph was self-inflicted:

There is no video evidence to support these claims.

These false reports caused inaccurate COD reports to be circulated to NJDOC

officials, delaying their awareness of the fact that inmates had been seriously injured. For

example, a COD report circulated at 4:17 a.m. on January 12 states that no injuries were

reported following any of the Cell Extractions and it does not even list Inmate 3 as one of

the inmates removed from her cell. Even a “corrective late report” circulated by COD

more than twelve hours later, at 7:54 p.m. on January 12, states that no injuries were

reported, and it still does not mention Inmate 3.

5. Custody Staff Failed to Prevent Male Viewing of Inmate Strip

Searches

NJDOC policy provides that strip searches of inmates must be conducted by staff

of the same gender outside of emergency circumstances. It also states that searches must

be conducted “in a professional and respectful manner.” NJDOC officials we interviewed

-56-
said that because cell extractions typically include strip searches, it is “preferable” for

extraction teams at EMCF to be made up primarily of female custody staff. Others we

interviewed said that it was acceptable for males to be on extraction teams as long as they

do not participate in or view the strip search.

While “emergency circumstances” are not defined in NJDOC policies related to

strip searches, NJDOC officials and EMCF supervisors we interviewed generally felt that

the Cell Extractions were not conducted in circumstances that were emergent.

Nevertheless, video recordings of Inmate 1’s cell extraction show that male officers are

inside the cell while she is strip searched, and suggest that at least one male officer actively

engaged in the search, and potentially conducted a body cavity search. While the camera

is blocked by other officers as Inmate 1’s clothes are removed, she is heard asking, “Why

is it a man ripping my clothes off?” According to Inmate 1’s written statement, a male

officer also digitally penetrated her in the course of the strip search and caused vaginal

bleeding. Custody staff also failed to report this cross-gender strip search, contrary to

NJDOC policy. As noted in the previous section, incident reports falsely stated that only

female officers participated. In addition, this search certainly was not conducted in a

“professional and respectful manner”; custody staff are seen on video tugging at her

clothes, struggling to rip them off of her, and moving her between multiple cells in the

process. Male officers also were present for Inmate 2’s strip search.

-57-
 6. Unclear and Informal Authorization Protocols Likely
Contributed to the Occurrence of the Cell Extractions

NJDOC officials and EMCF supervisors we interviewed communicated differing

and inconsistent understandings of whose authorization is required to conduct cell

extractions, both in general and specifically on the facility’s third shift. NJDOC officials

told us that NJDOC Central Office issued a directive to all facility administrators last year

that Central Office approval is required to conduct cell extractions on the third shift. We

requested from NJDOC documentation reflecting that directive and were informed that it

was not communicated in writing. NJDOC policies were not updated to reflect the intended

change in authorization protocol.

The cell extraction authorization protocols that are set forth in written policy appear

to be inconsistent. In a span of three pages, the existing policy states that: (i) “[t]he decision

to force an inmate to move is made by senior custody supervisors in conjunction with the

facility Major and Administrator”; (ii) a forced cell extraction cannot proceed “without the

approval of the Administrator or On Call designee”; and (iii) a use of force may be

authorized by any “custody staff member with the rank of sergeant or above.” The policy

thus spells out three different protocols that all may apply to the same occurrence, which

makes the required authorization unclear. Seemingly in contrast to the policy, in his April

8, 2021 testimony before New Jersey Assembly committees, Commissioner Hicks stated

that “there has to be Central Office notification before a cell extraction takes place.”

Unsurprisingly, the EMCF Administrators we interviewed seemed to be less than

fully clear on when, if ever, Central Office authorization is required to conduct cell

-58-
extractions. Sarah Davis said she did not typically seek approval from Deputy

Commissioner Ricci to conduct cell extractions because the need to conduct an extraction

generally results from an “urgent situation.” She said when she did speak to Ricci about

a cell extraction, she would call Ricci saying, “this is what we’re planning to do,” as

opposed to seeking permission. Patricia McGill described providing more deference to

Central Office, and said that on the third shift specifically she would not authorize staff to

open any inmate’s cell door “without authorization” from Central Office. She said that in

true emergency (e.g., life or death, attempted suicide) situations, however, Central Office

authorization is not required.

Our investigation determined that the lack of a formal directive or policy stating that

Central Office must approve a third-shift cell extraction contributed to what happened on

January 11. While the available evidence indicates that Central Office generally had

denied permission to conduct third-shift cell extractions when asked in the past, there is

nothing in writing stating that such consultation had to take place. Nor are there any

records formally memorializing whether St. Paul sought Deputy Commissioner Ricci’s

approval here, or whether she granted it. Nor is there any evidence that Commissioner

Hicks was informed of any aspect of this highly volatile situation as it was developing or

before the Cell Extractions were carried out. Had NJDOC policy explicitly stated that

memorialized Central Office approval was required to conduct third-shift cell extractions,

we believe it would have been denied here, thereby avoiding all that followed.

-59-
 7. Conducting Unit-Wide Cell Extractions Made for an Even More
Disruptive and Volatile Situation

NJDOC officials and facility supervisors we interviewed uniformly told us that it is

highly unusual to conduct cell extractions across an entire housing unit. Administrator

McGill told us that she has never seen a situation where multiple cell extractions were

authorized and conducted simultaneously. Commissioner Hicks likewise stated that unit-

wide searches generally do not occur unless NJDOC has “evidence or intelligence that the

entire unit has contraband or something negative is going to happen.”

The Cell Extractions appear to qualify as a “mass search,” which NJDOC policy

documents state “may be authorized due to specific information received from a third party

believed to be reliable, or due to the personal observations of activities or conditions in

light of the staff member’s experience or knowledge of inmates.” In this instance, however,

none of the incident reports indicate that the entire unit was likely or even believed to

possess contraband. Instead, the reports indicate that three inmates at most attempted to

splash, or succeeded in splashing, correctional officers. Yet, 22 inmates were removed

from their cells. Expert consultants we spoke with said the fact that officers removed all

RHU inmates from their cells shows that “what the officers were trying to do [was] send a

message that they’re in charge.”

8. Delays in Planned Remedial Measures Likely Contributed to

Misconduct

As detailed in Part III.C of this report, NJDOC and EMCF have worked to

implement a range of remedial measures and other enhancements meant to improve

-60-
conditions at EMCF. However, our investigation found that delays in implementing some

remedial measures contributed to the occurrence and violence of the Cell Extractions.

For example, NJDOC has been working to implement an Early Warning System

(“EWS”) since 2018. The EWS is a comprehensive digital system that receives

information from various divisions within NJDOC and alerts NJDOC Central Office when

a correctional officer is flagged by the system because of disciplinary infractions,

attendance concerns, litigation alerts or other issues. Central Office is to review each alert

and determine what action, if any, to take, ranging from an investigation of the officer to

provision of counseling. As to the lapse in time between initial efforts in 2018 and recent

completion of the EWS in 2021, Commissioner Hicks said that the delay was partially due

to the need to aggregate information from various internal databases, upgrade related

systems, and develop EWS policies and procedures. He said that once Covid-19 became

an issue, resources that otherwise would have been allocated to EWS implementation were

diverted to pandemic-related needs. In external correspondence sent by Commissioner

Hicks in May 2020, he stated that the EWS would be operational by June 30, 2020.

Ultimately, however, it reportedly went live on April 1, 2021. Commissioner Hicks told

us that there is no doubt that if EWS had been operational before January 2021, it would

have flagged for further review some of the officers who were involved in the Cell

Extractions.

Similarly, EMCF is currently participating in a body-worn camera (“BWC”) pilot

program, and in May of this year the cameras began to be used at the facility, with 120

BWCs now in use there. According to draft NJDOC policies we reviewed, correctional

-61-
officers will utilize BWCs primarily “for the purpose of recording incidents, searches, and

encounters” including cell extractions and any use-of-force incidents, among other

occurrences. Half of the funding for the program was secured in 2018 through a grant from

the federal Bureau of Justice Assistance. Commissioner Hicks said that the three-year

lapse in time between receipt of the grant and the program’s implementation was due to an

issue with the original vendor’s bandwidth connectivity, which became apparent only in

December 2020. At that point, another vendor took over. No officers at EMCF were

outfitted with body cameras as of January 11. One of the issues we identified above –

custody staff’s failure to properly video record the Cell Extractions – likely would not have

occurred if officers were wearing BWCs when the extractions were conducted. Indeed, we

question whether, in that scenario, the Cell Extractions would have occurred at all.

B. Recommendations

It is clear that significant changes are necessary to break the current cycle of

misconduct at EMCF. The sexual abuses discussed in the April 2020 DOJ findings letter

occurred secretly and in hiding. In contrast, the conduct associated with the Cell

Extractions happened in the open, in the presence of numerous people and multiple video

cameras, revealing the significance of the challenges that remain at the facility.

As Commissioner Hicks has testified, the State is negotiating a final settlement

agreement with DOJ, which NJDOC expects will include numerous specific requirements

for EMCF to fulfill, in addition to the naming of a federal monitor. Consistent with our

charge, we leave those new requirements for discussion elsewhere and focus our

recommendations on the events of the Cell Extractions.

-62-
 1. Independent Oversight

i. Require the Presence of at Least One External Person, such

as Either SID or the Office of the Ombudsperson, to be
Present for Cell Extractions When Possible

The Ombudsperson stated in his interview with us that although his office is

available to participate in “special assignments” such as cell extractions, EMCF has never

called upon his office to participate and he and his staff have never sought to do so. He

agreed with us that having someone from OCO or an entity such as SID present to observe

a cell extraction “would absolutely have an impact” on officer adherence to protocol. We

note that during the course of our investigation, NJDOC directed that, going forward, a

SID investigator would be responsible for filming cell extractions at all NJDOC facilities.

We agree with that change.

ii. Independence of SID

More generally, a strong and independent SID is vital to the health of EMCF as a

facility. Currently, all SID investigators are themselves former correctional officers,

potentially having attended training at the Academy or even worked alongside the officers

whose conduct they now investigate. That may impact the impartiality, or at least the

appearance of impartiality, of those investigators.

While we recognize that SID has made efforts to remain independent and at arms’

length from correctional officers, recent events counsel in favor of revisiting the current

approach. Consideration should be given to having at least some SID investigators who

do not come from the ranks of correctional officers. As a former EMCF official stated to

us, other law enforcement perspectives and backgrounds would be valuable to SID, or at

-63-
least further inmates’ confidence in the impartiality of the process. We note that the current

SID chief is retiring at the end of this year, which provides an opportunity for a fresh start

and an examination of the unit. New ideas such as having, for example, an entity such as

the State Police involved in the work of SID, at least in the near term, should be explored.

iii. Strengthen the Ombudsperson’s Involvement at EMCF

Along similar lines, recent legislative amendments contemplated that the OCO,

which is now empowered with subpoena authority and a litany of other tools, would

become an aggressive and proactive actor in ensuring that inmate rights are respected.

Nonetheless, our investigation revealed that in the time leading up to the Cell Extractions,

OCO largely had become, in effect, an office that receives complaints and then simply

refers them to another party to resolve them. As one inmate reported in her interview, the

OCO “is invisible to us.” The publicly announced upcoming retirement of the

Ombudsperson presents an opportunity. We recommend that OCO be more aggressive and

proactive in its involvement at EMCF specifically and focus more of its resources on that

facility.

2. Authorization Protocols for Cell Extractions Must be Clarified

and in Writing

Independent oversight of cell extractions will help, but it is important that those

overseers, and those whose conduct they are reviewing, have an awareness of the rules that

need to be enforced. The policies and procedures for cell extractions must be in writing

and clearly communicated to staff both during initial training and at regular intervals.

Those procedures should include protocols for seeking authorization to conduct cell

-64-
extractions. The approvals themselves in each instance should be memorialized in some

form, such as via e-mail. Greater personal accountability and related internal controls are

vital to establishing an environment of best practices at EMCF.

3. Staff Recruitment, Retention and Training

i. Increase Number of Gender-Restricted Posts

Getting the right people to carry out cell extractions and similar measures is also

critical. In a February 2018 memorandum, the then-Administrator at EMCF stated there

was a “crucial need for more Gender Restricted Posts,” meaning, more female staff at the

facility. The Administrator requested 90 gender-restricted posts. Despite some legal

hurdles, progress has been made since that time. Records indicate that currently, a total of

55 posts (split among three work shifts) are gender-restricted at EMCF and as of March

2021, EMCF employed 166 female officers, indicating that 46 percent of officers are

female. Based on our discussions with subject matter experts, we believe that increasing

that percentage to 60 or 70 percent could begin to tip the scales favorably on some of the

cultural issues at the facility.

A greater number of female officers at EMCF would enable greater female oversight

of and participation in cell extractions, which Commissioner Hicks agreed should be a goal.

Protocols should be reviewed with an eye towards decreasing the involvement of male

officers in events taking place in the cells of female inmates.

-65-
 ii. Explore Corrections Officer Recruitment and Retention
Strategies

Even with the above as a goal, our interviews revealed that NJDOC has had

difficulty recruiting high-quality staff and female officers to EMCF, particularly because

of its remote location and the starting salary. The starting salary for an entry-level NJDOC

correctional officer is $44,479.39. In addition to recruiting challenges, NJDOC reported

seeing significant turnover of staff in their first five years due to the salary not being

competitive, resulting in the loss of top-performing employees to other State agencies that

offer higher salaries in more attractive geographic locations. For example, NJDOC’s chief

of staff noted to us that certain county jails offer their corrections officers significantly

more money than what NJDOC can offer. In short, top law enforcement candidates often

can find work that is both safer and higher-paying. In view of the recent $20.8 million civil

settlement relating to EMCF, it is evident that additional compensation designed to attract

top candidates may ultimately be cost-effective for the State. Greater pay also could be a

component of union negotiations relating to some of the other issues referenced in this

report.

Other creative recruitment techniques should be considered as well. For example,

NJDOC should consider whether all posts require correctional officers to be trained in the

use of firearms and carrying a firearm on duty. Applying for a role that requires the

individual to train in and carry a firearm may deter some applicants who would otherwise

be qualified. A corrections consultant informed us that another state had some success

recruiting more female officers when firearm requirements were revisited.

-66-
 Moreover, we recommend that State policymakers consider whether to exempt

EMCF from the New Jersey First Act, N.J.S.A. 52:14-7, which imposes New Jersey

residency requirements on most State officers and employees. Allowing EMCF to expand

its recruitment efforts to people who live in Pennsylvania, which is less than 20 miles from

EMCF, would increase the pool of potential candidates. It is vital to the success of the

facility that it attract competent, professional and psychologically strong correctional

officers.

iii. Ensure Comprehensive and Recurring Training on De-

escalation and Communication Techniques, and Practical
Training on Cell Extractions

EMCF should revisit its curriculum for gender-responsive training with an eye

towards more robust teaching on de-escalation and communication techniques. A

consultant we interviewed noted that the current level of training that new staff receives

appears to be inadequate in these areas. Using de-escalation efforts before resorting to the

use of force is key to promoting safety and trust at EMCF.

EMCF also should develop a more robust practical training program for cell

extractions. Several people we interviewed as part of our investigation noted that such

practical, hands-on training would be helpful.

iv. Environmental and Related Cultural Issues

Ultimately, EMCF will be best positioned for success if it creates an environment

of order, fairness and predictability. Along these lines, we found stark differences in

perspectives between staff and inmates about the culture within the facility and their

relationship with each other. Inmates reported that no one is looking out for them and their

-67-
rights are being abused. On the other hand, officers have reported that the inmates are

effectively in control of the facility and that inmates do not respect their authority. Though

anecdotal, an outside professional, with decades of corrections experience including as the

commissioner of another state’s department of corrections, reported to us her observations

upon visiting EMCF’s RHU. She was surprised to find inmates yelling at her using vulgar

language as she walked through the unit. She remarked that it is unusual for female inmates

in restrictive housing to feel comfortable interacting with third parties in that manner.

We recommend that as part of the ongoing work of the consultant currently engaged

at EMCF, attention be directed at the perspectives and attitudes of the inmates and staff.

The consultant should speak with stakeholders, observe the environment and make

recommendations for improvement, focusing on bridging the gap between staff and

inmates to facilitate a more effective relationship between the two groups. Progress must

be made on vindicating the constitutional rights of EMCF inmates while concurrently

ensuring order and enforcement of rules at the facility.

4. Implementation of the Body-Worn Camera Program and Early

Warning System

For the reasons stated previously, NJDOC should complete and monitor

implementation of its EWS and new BWC policy. NJDOC should use its EWS to more

aggressively screen for potential problematic conduct by its correctional officers and

consider appropriate (re)assignments for those officers, before significant misconduct takes

place. It is consistent with common sense, moreover, that use of body cameras will

promote proper conduct on the part of anyone being recorded, officer or inmate.

-68-
 5. Physical Facility

i. Consider Ceasing EMCF’s Operations or Diversifying

Where Female Inmates Can Be Incarcerated in New Jersey

Lastly, in view of the lengthy negative history of misconduct at EMCF, whether that

conduct can best be shifted to the past by closing the facility altogether should be

considered. One of the experts we interviewed, who has decades of experience in

corrections, questioned, in light of the momentum of negative issues at and attention to the

facility, whether EMCF can be “saved” in a reasonable amount of time. In light of our

findings, we recommend that NJDOC consider closing down EMCF and relocating its

inmates to another facility.

With the facility being more than 100 years old, it is in any event in need of

significant repair and improvement. In addition, as described above, NJDOC has

encountered difficulty recruiting female staff to EMCF’s location in western New Jersey.

A different, more centrally located facility has the potential to address these issues.

On May 3, 2021, Commissioner Hicks testified before the New Jersey Assembly

Budget Committee that during his administration, NJDOC has shut down two prisons and

intends to close a third facility, which is located approximately six miles from EMCF. He

testified that NJDOC saw a decrease of approximately 5,000 inmates across all of its

facilities from 2020 to 2021, indicating that space considerations at NJDOC facilities may

not be as critical as previously had been the case. In our interview with him, Hicks agreed

that the feasibility of a shut-down of EMCF should be explored. While the expense and

-69-
effort associated with a closure, and transfer of inmates, would be significant, the State

may find another valuable purpose for the many acres of land on which the facility sits.

At a minimum, we recommend that NJDOC diversify where female inmates may

be incarcerated so there is more than one New Jersey correctional facility that can house

female prisoners. NJDOC officials and EMCF supervisors we interviewed said the fact

that EMCF is New Jersey’s only women’s prison makes it very difficult to effectively

separate inmates from staff or other inmates with whom they have continuing issues. They

noted that male inmates are frequently transferred between correctional facilities in New

Jersey as a way to halt patterns of bad behavior and provide a “change of scenery,” an

opportunity that EMCF inmates are not afforded. Under this alternative, EMCF would

continue to operate and exist, but with a reduced population. Its inmates could be

transferred when deemed necessary or to better separate an inmate from an accused staff

member, for example.

The availability of another location for female inmates also would further facilitate

EMCF’s compliance with PREA requirements. Currently, separating an inmate who has

alleged sexual abuse from her alleged abuser may require temporarily placing her in

segregated housing, which inmates may view as punitive. See 28 C.F.R. § 115.43. Access

to another facility would help to address those issues.

ii. Improvements to and Modernization of Infrastructure

If EMCF is going to continue to serve as a women’s prison, significant repairs are

warranted to ensure the safety and wellbeing of inmates and staff. Multiple interviewees

mentioned infrastructure as an issue, and its impact is supported by academic literature.

-70-
For example, the “broken windows theory” posits that “disorder and crime are usually

inextricably linked.” George L. Kelling & James Q. Wilson, Broken Windows, The Police

and Neighborhood Safety, The Atlantic (Mar. 1982),

https://www.theatlantic.com/magazine/archive/1982/03/broken-windows/304465/; see

also Roger P. Alford, A Broken Windows Theory of International Corruption, 73 Ohio St.

L.J. 1253, 1256–57 (2012); Louise A. Ellis, et al., An Empirical Application of “Broken

Windows” and Related Theories in Healthcare: Examining Disorder, Patient Safety, Staff

Outcomes, and Collective Efficacy in Hospitals, BMC Health Servs. Rsch. 20, 1123 (Dec.

4, 2020), https://doi.org/10.1186/s12913-020-05974-0 (discussing the broken windows

theory as it relates to the effect of disorder on staff and patients in hospital settings). “One

unrepaired broken window is a signal that no one cares, and so breaking more windows

costs nothing.” Kelling & Wilson, Broken Windows,

https://www.theatlantic.com/magazine/archive/1982/03/broken-windows/304465/.

At EMCF, the disrepair of the physical facility can signal to inmates, as inmates

indicated during our interviews, that because the State does not “care” enough to fix the

facility, it does not care about the inmates or their behavior, good or bad. This also applies

to staff members. Research has shown that in environments where individuals have a lack

of control over certain stressors, the individual may “react with anger, blam[e] others, . . .

or [engage in] aggressive retaliation.” Ruthanne DeWolfe & Alan S. DeWolfe, Impact of

Prison Conditions on the Mental Health of Inmates, 4 S. Ill. U. L.J. 497, 508–09 (1979).

“In order for a correctional building to function as a tool for rehabilitation, the design of a

correctional facility should: [be] based on the premise that people are capable of change

-71-
and improvement, with the built environment conveying the message that incarcerated

people are worth something.” Marayca López, How to Build for Success: Prison Design

and Infrastructure as a Tool for Rehabilitation, Penal Reform Int’l (July 24, 2014),

https://www.penalreform.org/blog/build-success-prison-design-infrastructure-tool-

rehabilitation/. “Older jails, some built more than a century ago, can also pose significant

health and safety risks to both staff and the incarcerated population through [their]

designs.” Chris Mai, et al., Broken Ground: Why America Keeps Building More Jails and

What It Can Do Instead, Vera Inst. of Just. (Nov. 2019),

https://www.vera.org/downloads/publications/broken-ground-jail-construction.pdf. A

functional facility needs to provide basic, minimum living conditions (e.g., clean water,

functioning toilets and sinks, natural light), while allowing for the proper regulation and

control of inmate movement.

The problems associated with EMCF’s facility have been documented elsewhere,

including in legislative testimony. These include electrical issues and other problems

related to the facility’s outdated infrastructure. For example, on May 10, 2021, it was

publicly reported that EMCF suffered a power outage beginning on May 8, and although

power was restored to most of EMCF a few hours later, power was out for about 40 hours

in the Stowe and Randall buildings, which temporarily left almost 200 inmates without

electricity until they were moved to other housing areas. In late April, there had also been

reports of mold in the facility’s Hillcrest housing unit, which was described as “black

sludge found in sinks, drains, toilets and showers, leaking sewage, brown and black water”

by reporting sources. Inmates in that unit were transferred to other housing units. While

-72-
it is beyond the scope of this investigation to examine such issues in detail, it was nearly a

universal sentiment across our investigation that the poor condition of the physical facility

has contributed to low morale among both inmates and staff and interfered with best

practices in a correctional setting.

The abandoned buildings on the site have presented additional opportunities for

abuse. Though those buildings now are locked and tagged in a manner that makes

unauthorized entry unlikely, in the past they have been used by correctional officers as a

place to engage in illegal sexual acts. In short, the structure and design of the facility itself,

in addition to its condition, provides unique challenges for both facility staff and inmates.

As a State, we can and must do better.

-73-