Here are some articles on some of the types of people who are employed at nursing homes:

The Seatttle Times had an article about three employees of a nursing home being fired after nude photographs of residents were taken and shared with strangers.  Three employees of Kitsap Health & Rehabilitation Center have been fired amid allegations that they took nude cellphone pictures of residents.  Staff members said in written statements that the suspects had shown the pictures to other staff members as a joke some weeks ago.  The pictures were taken around Christmas, the suspect said. He said he has deleted all photos of residents.  Witnesses also reported seeing other photographs.

One suspect, a 41-year-old Retsil resident who is a licensed practical nurse, told Bremerton police he and the two other suspects had sent "funny" pictures of residents to each other but denied having taken inappropriate photos.

The suspect said someone — he said he didn’t know who — had sent him a photo of a resident of unknown gender bending over, with naked buttocks showing. He reported deleting the image and telling the other two suspects not to send any more cellphone pictures of residents.

The other suspects are women, ages 26 and 27, both nurse aides from Bremerton. All three employees at first were suspended and later fired. The three have been reported to a medical panel for review of alleged violations.  See more information at King5 here.
__________________________________________________________________  had a story about  Sharon Kaiser who was accused of stealing from people in a nursing home.   She is charged with grand theft, exploiting the elderly, suspicion of fraudulent use of credit cards, petit theft,  bank fraud, and fraudulent use of personal identification information.. Police say the woman was stealing blank checks from the residents and then giving them to other people to be cashed.

Kaiser worked at the Cypress Village retirement community.  "We were assured by Dr. Felix that it was a safe environment, that all employees had a background check," said Jack Slaughter, whose mother was a resident. He said she lost thousands in jewelry.

The police reports said one elderly resident reported that someone stole a $5,000, a 14-karat charm bracelet, and a $2,500 ring from her. Another victim reported having a $1,600 necklace and an $1,800 gold chain swiped.

Some victims in the report said this problem is widespread. In the one report, a victim claims "there has been around 90 items stolen from different patients from Cypress Village." Police arrested Kaiser after police reported linking jewelry found at pawn shops to her.

"We went to the authorities at Cypress Village and informed them of what my mom was telling us, and we were led to believe that it could be paranoia brought on by her Alzheimer’s disease," Slaughter said.  See News4Jax for more information.
____________________________________________________________________ had a story about Eric Machigashira who is accused of stealing narcotic pain medication from resdients of the nursing home where he worked. They say management provided evidence that he had been taking morphine and other drugs from nursing home patients and from the home’s emergency supplies over a period of several months.



Reuters had an article discussing the overuse of feeding tubes with demented residents. Whether or not a person with advanced dementia winds up with a feeding tube  have more to do with economic concerns than his or her wishes, suggests a new study out in JAMA (Journal of the American Medical Association).  Dr. Joan M. Teno of Brown University in Providence, Rhode Island, and her colleagues found that hundreds of patients who had specified, in writing, that they did not want a feeding tube received one anyhow.

Feeding tubes don’t extend survival for people with advanced dementia who can no longer swallow, and provide no other apparent benefits to these patients, according to two reviews of the medical literature, Teno and her team note in their report.

Tube feeding can also cause harm, the researcher added in an interview; demented patients who are bothered by the tube and try to remove it may be physically restrained or placed on heavily sedating drugs.

Up to a third of nursing home patients with advanced dementia have a feeding tube, Teno and her colleagues note in their article. In two-thirds of these cases, the tube was inserted while a patient was in the hospital.

To investigate what factors might influence whether or not a hospital would use feeding tubes in people with advanced dementia, Teno’s team looked at 2000-2007 records for nearly 2,800 hospitals, all of which had admitted at least 30 patients who were 66 or older, had advanced dementia, and were living in nursing homes. Their analysis included Medicare claims for 163,000 patients and nearly 281,000 hospital admissions.

Twelve percent of the hospitals didn’t insert a feeding tube in a single patient with advanced dementia throughout the eight-year study period, the researchers found. But at one quarter of the hospitals, patients had a 1 in 10 chance of feeding tube insertion; hospitals with the highest rate of feeding tube use inserted them nearly 40 percent of the time.

For-profit hospitals were more likely to use feeding tubes, as were larger hospitals and those with the highest level of intensive care unit use for patients in their last six months of life.

Recognition is growing that dementia is a terminal illness that affects the body as well as the mind, Teno told Reuters Health. And when a patient with dementia begins having trouble eating, she said, this indicates the final stage of the illness has arrived. For these patients, she added, careful hand feeding can offer a safer and more comfortable alternative to feeding tube insertion, "but it takes staff time and effort."

According to Buchman, the amount of caregiver time and effort to work with patients and try to feed them by mouth and to do it safely is "substantial."

Emory University Hospital’s 2006-2007 rate of feeding tube insertions for patients with advanced dementia was 24 per 100; Buchman said he did not want to comment on those figures, given that he has only been working at the hospital since July 2009.

The hospital had one of the highest rates of feeding tube use in patients with advanced dementia, according to Teno’s study, with 37.5 insertions for every 100 admissions of such patients in 2006-2007.

Although her study didn’t investigate why hospitals opted for feeding tube insertion, Teno said it’s likely that cost concerns are a factor. Most of these older patients are on Medicare and Medicaid, and the way that reimbursement works means nursing homes tend to ship them to hospitals when they get sick. Then, hospitals will try to discharge these patients back to the nursing home as quickly as possible. Inserting a feeding tube allows the hospital to discharge a patient faster, Teno added, while for nursing homes, tube feeding is less time consuming than hand feeding.

It’s questionable, Teno noted, whether hospitalizing these patients in the first place is helpful. "It can be very disruptive and very stressful to take someone who is in the throes of dementia and put them in an acute care hospital," Teno said. "I’m really concerned that the financial incentives now are aligning with hospitalizing these people rather than trying to keep them in a less restrictive environment and treat them in a nursing home."

For a person with advanced dementia, the onset of eating difficulties should be "a stop sign to say listen, we need to talk about what are the patient’s wishes and values for future medical care," she added. "Helping people make the best decision for their loved one is very important."

Teno and her team have compiled a list of hospitals and their rate of feeding tube insertion in patients with advanced dementia, which is available online here

SOURCE: Journal of the American Medical Associations, February 10, 2010.

NY Daily News had an article about Judge "Kung Fu" Phillips who died at a nursing home as a result of neglect and negligence.  Prospect Park Residence – where Judge John Phillips lived for eight months until his death two years ago – refused to give him a diabetic menu and frequently missed giving him required insulin shots.

Phillips – known as the "Kung Fu judge" during his 17 years on the Civil Court bench for his habit of making martial arts moves in court – died at 83 in February 2008 after collapsing in a Prospect Park Residence elevator.

Phillips’ nephew, the Rev. Samuel Boykin, who is managing his estate, said he noticed signs of trouble soon after Phillips moved into the Prospect Park West nursing home.  He insisted poor care – not just advancing age – led to Phillips’ decline, noting the judge was "a health fanatic."

"My uncle was a 10th-degree black belt in Asiatic martial arts," he said. "He never drank. He never smoked cigarettes. He went to bed every night at 8 o’clock.


Call for Medical Liability Reform a Red Herring Proffered byOpponents of Meaningful Health Care Reform.  Crisis Does Exist, But it Is in Patient Safety, Not Malpractice Litigation.

With President Barack Obama’s health care summit pending, a lot of politically expedient misinformation about medical liability reform is being spread. Public Citizen issued a new report this week to correct the record and highlight the five key points in the malpractice crisis that have largely been ignored:


1. Medical malpractice payments have fallen steadily for years and are now at or near historic lows;


2. Although an experiment in Texas has been promoted as proof of the potential benefits of so-called "tort reform," health care cost increases in that state have far outpaced the national average since it instituted strict liability limits in 2003. Meanwhile, its worst-in-the-nation uninsured rate has gotten even worse;


3. Most of the money paid out for medical malpractice is for serious outcomes, such as death or quadriplegia. Tort reform proponents call for damage caps that would affect the ability of seriously injured people to obtain reasonable compensation; the caps would not reduce the incidence of alleged "junk lawsuits";


4. A serious patient safety crisis does exist; and


5. Addressing senseless medical errors would save several times as much money as the combined costs of the medical malpractice litigation system, including those for verdicts and settlements, defense litigation, and liability insurance companies’ profits and overhead.


Medical malpractice litigation has fallen steadily throughout most of the past decade and is now at or near the lowest level on record, analysis of the federal National Practitioner Data Bank shows.


The real crisis surrounding medical malpractice is not the cost of litigation but rather the amount of malpractice. Only about 11,000 malpractice payments are made on behalf of doctors every year. The true inequity in the malpractice system is that so few victims receive any compensation at all. But even if injured patients were to receive compensation for their medical needs, that still would fail to address the tragedies inflicted by medical malpractice.


As policymakers become aware of the truth – that medical malpractice litigation is quite rare and represents only a tiny fraction of overall health care cost – the outspoken tort reformers have turned to a new argument. Now they claim that it is not litigation, but the fear of litigation, driving skyrocketing health care costs, with doctors ordering excessive tests and procedures (so-called "defensive medicine"). In reality, the cost of the entire medical liability system – including payments, litigation costs and insurance company profits and overhead – amounts to less than six-tenths of 1 percent of national health care expenditures, according to Public Citizen’s analysis.


For more information, Public Citizen’s report assessing national medical malpractice data is available at Public Citizen’s report analyzing Texas’ 2003 liability law is available at



Public Citizen is a national, nonprofit consumer advocacy organization based in Washington, D.C.


For more information, please visit Contact: Taylor Lincoln (202) 454-5197, Barbara Holzer (202) 588-7716

The Washington Post reported OmniCare’s profits soared because of recent settlements for kickbacks decreased their anticipated legal defense costs.  Omnicare Inc., which dispenses drugs to nursing homes and long-term care facilities, said its profit almost tripled in the fourth quarter after it resolved allegations it paid kickbacks to nursing homes, and received money for buying and recommending drugs.

In June, Omnicare agreed to pay $98 million to settle the investigation. The terms were completed in November. The Justice Department said Omnicare paid $50 million to Mariner and Sava Senior Care owner/operators Murray Forman, Leonard Grunstein, and Rubin Schron to gain their business, while also asking for and getting kickbacks from two drug companies for recommending their products.

In the fourth quarter, the company said its profit rose to $80 million, or 68 cents per share, from $27.6 million, or 24 cents per share, a year earlier. Omnicare said it earned 74 cents per share from continuing operations, but that includes a tax benefit of 11 cents per share. Its revenue fell 2 percent to $1.54 billion from $1.57 billion

Analysts expected a profit of 63 cents per share and $1.55 billion in revenue, according to a Thomson Reuters survey.

The company reported a total of $5.7 million in pretax litigation costs in its latest quarter, compared to $48.1 million pretax a year ago.

Omnicare said its pharmacy services revenue fell 1 percent to $1.51 billion from $1.53 billion. The decline came from greater use of low-cost generic drugs, smaller reimbursement payments for certain drugs, and a decrease in the amount of beds served. The company said it did more business with assisted living facilities, which typically don’t buy as many drugs as acute care centers or other facilities it does business with.

Revenue from Omnicare’s clinical research business slipped to $34.3 million from $49.1 million.

In 2009, Omnicare said its profit jumped 51 percent to $211.9 million, or $1.80 per share, from $140.5 million, or $1.19 per share. Revenue decreased less than 1 percent to $6.17 billion from $6.21 billion.



Numerous websites and news organizations have written about the recent settlement between the DOJ and Murray Forman, Rubin Schron, and Leonard Grunstein, owners and operators of hundreds of nursing homes through various entities such as Mariner, Sava Senior Care and Fundamental Long Term Care Holdings.  See articles and press releases here, here, here, here, here, here, here, here, here, here, here, and here.

What is incredible and disappointing about the settlement is the DOJ only made these criminals  pay $14 million but did not make them testify, admit guilt, payback the kickback, or take away their ability to continue owning and operating nursing homes.  What kind of penalty is $14 million when they have stolen millions more from Medicare and Medicaid?  Why did the DOJ make the now defunct Mariner pay but not their successor Sava Senior Care?   Why did they allow the Complaint to be dismissed before the settlement?  Why did they allow Forman and Grunstein, the masterminds behind the illegal scheme deny any responsibility or wrongdoing?  Why didn’t they make Forman and Grunstein pay the kickback back to Medicaid and Medicare?

The settlement resolves the United States’ allegations that the defendants solicited and received kickback payments from Omnicare, Inc. (“Omnicare”), the nation’s largest pharmacy that specializes in dispensing drugs to nursing home patients.  

"As outlined in the government’s complaint, Rubin Schron, Leonard Grunstein and Murray Forman tried to disguise an unlawful kickback payment," said Mary Louise Cohen, a Washington, DC, attorney with Phillips & Cohen LLP, which represents the whistle-blower. "Omnicare’s $50 million payment for a small unit of Mariner Health Care — which had less than $3 million in assets and only two employees — just didn’t add up without figuring out what else Omnicare was getting as part of the deal."

In a Complaint filed in March 2009 and unsealed in November 2009, the United States alleged that Omnicare, Mariner, Sava, Grunstein, Forman, and Schron conspired to arrange for Omnicare to pay $50 million in exchange for agreements by Mariner and Sava to use Omnicare’s pharmacy services for 15 years.   In 2004, Grunstein and Forman proposed that Schron provide financial backing for the acquisition of Mariner, which at that time was one of Omnicare’s largest customers. Grunstein and Forman attempted to arrange the Mariner acquisition so that Schron would have to contribute as little cash as possible. To achieve this end, Grunstein and Forman pursued a plan to sell to Omnicare the right to continue providing pharmacy services to Mariner, even though Forman was warned by lawyers that selling the right to provide pharmacy services would constitute an illegal kickback.

Grunstein and Forman thereafter arranged for Omnicare to pay them $50 million to purchase a  Mariner company that had only two employees and no tangible assets.  Omnicare paid $40 million of this amount up front, prior to actually acquiring the Mariner business unit, and simultaneously obtained new 15-year pharmacy contracts from Mariner and from Sava, a new nursing home chain that Grunstein and Forman created from Mariner. Grunstein and Forman illegally tied the new pharmacy contracts to Omnicare’s agreement to purchase the small Mariner business unit, and that the total $50 million purchase price for the business unit actually was a kickback by Omnicare to keep the future business of Mariner and Sava. In 2006, after the Government issued subpoenas concerning the transaction, the individual defendants created backdated documents in a further attempt to hide the kickback.

In November 2009, the United States and Omnicare entered into a $98 million settlement agreement that resolved Omnicare’s civil liability under the False Claims Act for paying kickbacks to keep the Mariner and Sava business.  So Forman and Grunstein coerced OmniCare to pay them a $50 million kickback and Omni had to pay $98 million but Forman and Grunstein and their companies only had to pay $14 million!?!

As part of the settlement, Mariner has entered into a corporate integrity agreement. This agreement provides for Mariner to put in place procedures and reviews to avoid and promptly detect conduct similar to that which gave rise to this matter. At the same time, OIG-HHS has reserved its rights to seek exclusions of Sava, Grunstein, Forman, and/or Schron from participation in Medicare, Medicaid, and all other Federal health care programs.

"I suspect that if you got [Grunstein, Schron and Forman] all in a room and asked them whose fault this was, they’d all be pointing at someone else," says one person familiar with the case. "And that’s really what this transaction was about –setting up all these different entities and shells and moving pieces so that nobody had responsibility."

Rubin Schron, a New York real estate investor who along with National Senior Care Inc., bought Mariner Health Care Inc., which is at the center of the kickback scheme. — Leonard Grunstein, a New York real estate attorney who was a partner with the law firm, Troutman Sanders. He was Schron’s agent in the purchase of Mariner Health Care Inc. and in the alleged kickback scheme. — Murray Forman, an associate of Grunstein’s and Schron’s who also is president of a Long Island school board. — Mariner Health Care Inc., a Delaware corporation with headquarters in Atlanta, Georgia, that operates nursing homes and, according to the government’s complaint in this case, is controlled by Schron. — SavaSeniorCare Administrative Services LLC, a privately held Delaware company with headquarters in Atlanta, Georgia, also reportedly controlled by Schron. Sava affiliates lease and operate nursing homes.

This settlement is part of the government’s emphasis on combating health care fraud. One of the most powerful tools in that effort is the False Claims Act, which the Justice Department has used to recover approximately $2.2 billion since January 2009 in cases involving fraud against federal health care programs. The Justice Department’s total recoveries in False Claims Act cases since January 2009 have topped $3 billion


See article from CBS News legal analyst Andrew Cohen in The Atlantic, where he calls tort reform, "one of the most blatantly anti-democrat concepts to have hit the legal system in the past century."

If President Barack Obama has to hand his adversaries a bauble in order to achieve success with health care reform, it might as well be the misnomer commonly known as "tort reform." The ends of providing insurance for millions of uninsured Americans, never mind whatever good it might do for the rest of us, is worth the means of giving Corporate America yet another legally-sanctified level of protection against the wailing interests of its customers, consumers, patients, and just plain innocent bystanders.

But let’s not kid each other any longer. As we brace ourselves for yet another round of wrangling over the tail and not the dog, let’s all stipulate that "tort reform" is one of the most blatantly anti-democrat concepts to have hit the legal system in the past century. It takes control over damage awards in many civil cases away from local judges and juries and gives them to state politicians, who often are just shills for their corporate campaign contributors and lobbyists. It protects corporations from punishment for their worst excesses. It diminishes good incentives for corporate carefulness and increases bad incentives for shoddy work and services.

"Tort reform is little more than a scam by an unpopular minority (corporations) against an enormous majority (anyone who is eligible to serve on a jury or who ever already has)." Wouldn’t it be great if the President forced those words out of the mouth of the Chamber of Commerce president in exchange for even friendlier litigation rules for Big Business as it confronts changes to our national approach to health care?


I don’t use the word "scam" lightly above. Supporters of tort reform, invariably corporatists and others who believe in this self-defeating supply-side notion of justice, have scammed or otherwise brainwashed millions of Americans into thinking that tort reform will save them from despicable "trial lawyers," a convenient target group in this ever-litigious world. But no ‘trial attorney" ever went into the jury room and voted for a large verdict against a greedy corporation which purposely hid health risks from its customers. No "trial judge" ever put a gun to a foreperson’s head and made that man or woman sign off on a big reward against an environmental polluter or tobacco company or maker of unsafe toys.

Instead, these verdicts came from jurors, one of the justice system’s–one of all of governments’–few remaining unassailable cogs. Each time a jury awards a large sum to a plaintiff against a negligent defendant, it’s a statement from jurors that the sort of conduct alleged and proven is worthy of punishment by the community. Sometimes, this is the only time in the lives of these people, these jurors, when they will have such an extraordinary say about the events of their time and place. Sometimes they are right. Sometimes they are wrong. But at least in these circumstances they make a difference based solely upon the fact that they are residents of a particular venue.

Make no mistake–the "reform" in "tort reform" is about eliminating or reducing the ability of trial juries to act as levelers of the playing field; as avengers of otherwise toothless victims; as the voice of a community in meting out justice. It is about helping corporations before individuals; about the bottom line and not the bottom rung. Alas, many of the same folks who tout individualism and freedom and liberty against government control evidently have no qualms about using support for tort reform as their ticket to worship at the Altar of corporate control.

The reason the topic is again in the headlines is because opponents of health care reform evidently don’t have anything better to argue about in their efforts to stop passage of the pending legislation. Fine. The President and his fellow Democrats should concede on tort reform. And at the same time, he should figure out a way to track whether reductions in jury awards, and concomitant decreases in the costs of malpractice insurance, reduce the ultimate cost to consumers of health care and at the same time generate better quality of service.

Of course, we all know what the answers to those questions will be. Which now that I think about it is another thing we ought to be honest about.

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