The Seattle Times had a great article called "Seniors for Sale". The article discusses the unfortunate plight of Nadra McSherry. She needed an adult family home and settled on Narrows View Manor in Tacoma, owned by Arlie and Charlene Leno. They relied on the fact that adult homes were licensed by the state Department of Social and Health Services.
McSherry paid $3,500 a month for a bedroom, prepared meals and daily care delivered by a staff of aides. McSherry’s daughters had no clue that only weeks earlier, inspectors for DSHS had swept into the home and uncovered 14 safety and health violations. And they had no idea that Arlie Leno harbored a troubling past, one enabled by state regulators.
In 1990, Arlie Leno left his job as a nursing-home administrator and became his own boss, getting a state license to run a Tacoma boarding home with 16 adult residents. He called it Tule Lake Manor. Leno’s residents ranged from the bed bound to those with late-stage Alzheimer’s disease or Down syndrome. Despite his work experience, Leno got into trouble within a few months of opening Tule Lake Manor.
Inspectors for DSHS cited him for 18 violations including failing to properly train staff, notify family when a resident fell and broke a hip, and obtain medical care for a resident who fell and was injured. Inspectors found that one staffer had lost her nurse’s-aide license for "alcohol and drug issues"; another was on probation for a felony assault conviction and, by law, was not allowed to be alone with a vulnerable adult.
In 2000, DSHS revoked Leno’s boarding-home license, citing a decade of abuse and neglect and evidence that residents had "suffered actual harm." Between 1990 and 2000, state inspectors had cited Leno with 135 violations. He sold Tule Lake Manor for $422,000.
After Arlie Leno gave up his boarding home in 2000, he began taking a more active role at Narrows View. After that, inspectors cited the home more often for violations including failing to train staff and to screen them for infectious diseases.
In 2002, they declared bankruptcy. They said they netted about $30,000 a year from their business but had $316,000 in mortgage and other debts, including $40,000 in delinquent federal taxes.
More violations piled up at Narrows View Manor: They failed to create a "care plan" for each resident. The care plan is a critical blueprint that tells staff exactly what care each resident requires: what medications to take and when, how often a resident has to be turned to avoid bedsores, what diet to follow, and so on.
Arlie Leno also hired a woman convicted of felony assault to care for the residents. By law, her conviction barred her from working there.
In July 2003, the couple separated and Charlene Leno, then 60, moved out. Their breakup created problems for Arlie Leno as well as for his residents. His wife was listed on the state license as the "provider," meaning she was the owner responsible for overseeing care.
Arlie Leno’s solution was to lie repeatedly to inspectors about his wife’s whereabouts. For nearly a year, state records show, he told DSHS investigators that his wife was away on vacation or visiting family. DSHS officials finally discovered the deception. Leno had lied at least four times so DSHS fined them a measly $400.
That same year, 2004, Arlie Leno sneaked an extra resident into Narrows View. By law, he was limited to six residents, but he added a seventh, apparently to squeeze out more profits.
During a DSHS inspection in July 2004, Leno told a staffer that he had only six residents, five female and one male. The inspector became suspicious when he spotted a second male resident walk out of the staff bedroom, and asked his identity.
In another case, a resident fell on the bathroom floor and broke her leg but the caregiver refused to call an ambulance. "We don’t do that here," DSHS records recount the caregiver as saying. "We call the family to take them." The injured woman’s family wasn’t called until nearly three hours after she fell, records show.
Again, DSHS settled for modest fines.
All through this time, McSherry’s daughters and other family members visited her nearly every day at Narrows View; daughter Janice McDonald, who worked at a hospital nearby, would stop in after work. "One might wonder why we didn’t see what was going on," Elaine Matsuda would later explain. "There are some things that are so subtle. And what Arlie Leno didn’t want us to see is not going to happen while we’re there." The McSherry family knew nothing of Leno’s serious violations.
In June 2006, McSherry developed a small bedsore on her tailbone. The daughters arranged for a registered nurse to visit the Leno home and treat her wound. Once the wound had sufficiently healed, the nurse showed aides at Narrows View how to treat pressure sores. She told the staff to alert her or McSherry’s doctor if the sore flared again.
Within two months, McSherry’s pressure sore re-emerged, medical records show. But no one at the home recognized its danger and no one in McSherry’s family was told about it, nor were her doctor or nurse. The wound remained untreated for more than a month. Aides did rub an ointment on it each day. But the ointment was not suitable for pressure sores. In fact, records show, the ointment made it worse.
After sitting for a month with a painful festering bedsore, she finally said, "My bottom hurts," McDonald recalled. She undressed her mother, then gasped. "There was a quarter-size hole in the skin. It went to the bone," she said.
A nurse visiting Leno’s home at the time examined McSherry’s tailbone and was alarmed. It was the worst pressure sore she had seen in 20 years of practice, she later told DSHS investigators. It was a Stage IV ulcer, meaning it had eaten through her skin, muscles and connective tissue, down to the bone.
McSherry was rushed to the emergency room, then admitted to Allenmore Hospital. For nearly a month, doctors unleashed a medical arsenal against the raging infection and the pain. Nothing worked. She died.
Dr. Richard Waltman, who signed her death certificate, said McSherry died of a heart attack brought on by infection from the bedsore. "It was too much for her body to handle," he said.
"My mother died a horrifically painful death. She weighed 80 pounds when she died. They were giving her morphine that would have knocked out a 400-pound football player," Matsuda said. "She still would scream and yell and cry out in pain and delirium from the medication."
DSHS determined that Leno’s mistreatment of McSherry did not warrant revoking his license. It required him, for the first time, to post his violations publicly. And it did fine him $3,200: $100 for each of the 32 days that he failed to provide proper care to McSherry the price of one preventable death.
This infuriated Matsuda and her sisters. Since McSherry’s death, DSHS found more serious violations at Leno’s home. In May 2007, a female resident was found crawling in the middle of a four-lane street in a busy intersection. The woman, who had Alzheimer’s disease, ended up in a nearby emergency room with a head wound.
Finally in May 2007, Janice Schurman, a DSHS supervisor, wrote to her superiors that field investigators felt Leno should lose his license. Supervisors overruled her. DSHS supervisors ultimately ruled in favor of Leno, who will be 83 years old this year. He holds a dubious record: No adult-home owner has amassed as many serious violations as Leno has and still remained open for business.
McSherry’s daughters were haunted by their mother’s neglect. Matsuda contacted Seattle attorney Anthony Shapiro, who determined that Arlie Leno had no major assets and did not carry liability insurance. Shapiro embraced a novel strategy: He filed a civil suit against DSHS under the legal doctrine of "deliberate indifference." He had to prove that DSHS knew that a substantial risk to residents existed at Leno’s adult family home and chose to ignore it.
"This was not the only incident in Narrows View’s history where pressure ulcers and pressure sores cropped up among patients," Shapiro said. "They had a long history of people having pressure sores and DSHS knew about it and other than noting it, and coming in periodically, the practice at this home really never changed.
DSHS settled with McSherry’s family late last year for $565,000. Leno, also named in the suit, reached a confidential settlement with the family.
A Times reporter telephoned a DSHS regional office and, as any member of the public can do, asked about the enforcement history at Arlie Leno’s home. A DSHS staffer mischaracterized the bulk of Leno’s history of violations as minor infractions and "paperwork problems."
When she came to the 2006 violations regarding McSherry, the staffer noted that a resident had developed a "little pressure ulcer." When asked if the woman died from neglect, the DSHS staffer consulted the enforcement computer once again.
Oh, no, she said. "It doesn’t show anything about a death