Day 3: Lost in Life and Death
Assisted Living Facility's Chaos Bred Wide Neglect
Home Racked Up Care Violations, but Va. Kept It Open
By David S. Fallis
Washington Post Staff Writer
Tuesday, May 25, 2004; Page A01
Third of four articles
For three days, Sharon Moore's chair stood empty at meals. Aides at Kensington Gardens, a sprawling assisted living facility in Richmond, recorded her absence in the medication records, in the 24-hour resident report and on the dining room attendance list.
But nobody searched for her. Nobody reported her missing to police.
Only after Moore's parents came looking did her caretakers find a key to unlock her room. There, they found the 41-year-old woman dead, a teddy bear tucked under her arm.
Moore's death is one of dozens in a vast, buried archive of abuse and neglect at Virginia's assisted living facilities. Her story and others are partially told in records that are legally open but in practice are hidden behind a bureaucratic system that makes them essentially unavailable to the public. Often, families are never told about lapses in care. And the files are systematically vanishing under a policy that calls for their destruction after five years. In the past year, most records on Kensington Gardens have been destroyed.
The result is countless untold stories, of vulnerable adults suffering poor care and mistreatment, often with no one held publicly accountable.
The records that were handed over show that in a state whose assisted living facilities have been plagued by thousands of cases of abuse and neglect, Kensington Gardens was among the most troubled. Outside, the building was an unremarkable brick high-rise. Inside, its corridors were dark and chaotic, inspectors said. Its residents were mentally retarded, schizophrenic, depressed, drug addicted, suffering from dementia or, like Moore, plagued by a mix of physical and psychological problems.
Mario Gomez, Moore's psychiatrist, said he would sometimes find music blaring and the corridors reeking of marijuana. "It was like a college atmosphere with a bunch of grown kids hallucinating and out of control," he said.
Richmond police were dispatched there several times a week to investigate problems ranging from sex crimes to missing persons to fights. In Moore's last days there, the state issued a letter vowing to deny the home a new license, calling it "unhealthy and unsafe" and noting that residents had been abused and neglected.
Moore hated where she was living. She told friends she felt hopeless and trapped. She felt as if she were "swimming in a lake" of disorder, her doctor said. She begged her parents to let her move back home.
A week later, she was dead.
Searching for Relief
Moore's path to Kensington Gardens was a sad, slow search for the right home, beset by diminishing options. Kensington, which is now closed, would serve as a last resort for her, as it had for many others with mental illness or other disabilities.
She had grown up in a middle-class, educated family. Her father, Freeman Moore, was a banker. Her mother, Kitty, was a trained pianist and a botanist for the state of Virginia who gave up her career to be a full-time mother.
The Moore family was often happy, routinely packing into the car for vacations along the North Carolina beaches. "We had nice stuff, nice clothes, nice friends," said Robin Moore, Sharon's younger sister. "When times were good, they were really good."
But Freeman Moore struggled with a drinking problem and changed jobs frequently. Sober, he was a perfect gentleman and loving father, but when he drank, he was erratic, Robin said. Their mother was a "romantic" and strived for a sense of normalcy. But the unpredictable home life "was a madness my sister could not handle," Robin said.
Sharon, petite and pale with striking dark eyes and hair, immediately endeared herself to those she met. She earned good grades and talked of going to college. But in high school, she began skipping school for days at a time. She and her father got into shoving matches, her sister said. Sharon said that her menstrual cramps were so bad she needed narcotics.
After graduation, she joined the Navy and specialized in cryptography and communications. But while stationed in Hawaii, she started to complain of oppressive headaches.
"That's when the Navy doctor tried every kind of medication there was to give her relief," said Nadine Proffitt, one of Sharon's aunts.
Robin Moore said her sister began to inject Demerol.
The headaches drove her from the Navy, and by the late 1980s, her list of doctors, drugs and treatments had grown. She tried hypnotherapy, acupuncture and biofeedback, but her headaches persisted. At one point, she had electroshock therapy.
Her parents exhausted resources, sending her to expensive private treatment centers for months at a stretch. Eventually, Sharon quit work, began to draw disability payments and moved back home with her parents. But their relationship was volatile. One night, her parents retreated to a motel room because they feared for their lives, Proffitt said.
Gomez, Moore's psychiatrist, concluded that she suffered from depression and addiction to painkillers and believed it imperative that she move out of her parents' home. At the suggestion of Moore's social worker, Gomez arranged an intervention during a joint counseling session, when her father told her that she could no longer live with them. "She really, really resented that," Gomez said. "Her father for allowing it, and her mother for not protecting her."
Gomez said they all agreed that she should move to Kensington Gardens, because she had been spending her days there in therapy sessions with him. He was worried that if she lived alone, she would overdose on drugs. Kensington staff could provide some supervision, especially for medication. They would administer codeine for her headaches, which he would prescribe in weekly, instead of monthly, allotments.
Gomez saw that Kensington had problems but that it also had positives: art and chess clubs, a younger crowd, counseling sessions with various doctors. Some of his patients, he said, "thought the place was heaven-sent."
Frightful Living Conditions
Moore moved to Kensington in spring 1996, taking with her some books, photographs and a television. She was first given a room where she had to share a bathroom with a male resident. Then she moved to Room 414, a cramped space with drab walls, linoleum floors and a single window. She tacked a poster on the wall.
"I like people to think I am up," she told her friend Jim Sherwood. But she was miserable.
Her friend Donna McGovern, who brought her cigarettes and York Peppermint Patties, said much was horrible about Kensington, a former hospital. "Her room was so small, it was damn depressing."
The home, licensed for more than 300 residents, was chronically understaffed, said Paula Saxby, who was then licensing administrator in Richmond for the Department of Social Services. That left patients unsupervised and the home unkempt. In parts of the facility, she said, "your feet stuck to the floor from dried urine."
At the time, the facility was on notice with state regulators that it had to correct persistent violations. Before Moore moved in, a staffer had "struck a demented resident repeatedly" while another stood by, according to inspectors. One resident with heart problems was hospitalized after the facility let her medication run out. Inspectors found one aide in charge of 250 residents.
In the midst of this chaos, Moore saw Gomez at least weekly for counseling. Close friends would drop by, taking her out for meals or to see a movie.
"I'm not getting anywhere," Moore told McGovern after several months at Kensington. "Look at this [expletive] place I am living in. I don't have a car. I don't have anything. I am going down instead of up."
Moore and the other residents were supposed to line up downstairs for daily pill calls, when staff members would dispense medications and record it in their charts. But in the nine months that Moore lived there, records show, the home was reprimanded for mismanaging medication a dozen times.
Gomez said he thinks that Moore may have been hoarding her pills or getting illegal drugs from dealers. She had started spending time with a drug dealer who had unfettered access to the facility, according to Gomez and several friends.
As the holidays approached, Moore seemed upbeat. She spent Thanksgiving 1996 with family at her Aunt Nadine's. "She was beautiful. . . . I don't know if she was a really good actress or what," her aunt said.
In December, she sent out cheery Christmas cards and gave Donna McGovern a bracelet and another friend a fruit basket. She dropped in at Gomez's office and handed him a card between appointments. She was saying goodbye, he realized later.
"Everyone got something," Gomez said, "but nobody ever put it together."
Planning Her End
In Kitty Moore's day planner, the days in December 1996 are without notations, except for three:
Dec. 22: "Sharon + George. Dinner here."
Dec. 24: "Sharon came for Christmas!"
Dec. 31: "Sharon here. She watched the ball down!"
When Moore begged to stay longer, her parents said no.
She returned to Kensington on Jan. 3 and promptly arranged for the maintenance department to change the locks on her room. She had vowed to do that, her aunt said, because "she didn't like the people that wandered" the halls.
Locked in her room, she slipped on a blue nightgown and penned a note. She swallowed a toxic dose of codeine, pulled a plastic bag over her head and drew it tight around her neck with a cord.
If Kensington Gardens had failed Sharon Moore while she was alive, it did no better at the time of her death.
On Monday, Jan. 6, Kensington records first note that she was missing. A nurse tried the door to her room that day but gave up when she couldn't unlock it with the master key, according to state records.
After not hearing from Moore for several days, her parents called Kensington, asking about their daughter. They finally drove there to insist that staff check her room.
"They were checking the rooms. As far as I could remember, they were looking for her," said Mary L. Oney, who had just resigned as Kensington administrator and was working there as a nurse. Oney was summoned to Moore's room with other staff. They opened the door and found her body.
The bear tucked under her arm was a gift from a friend who had picked it up free at a jewelry store's grand opening.
The note on the vanity was written longhand, in pen. Her sister remembers the message:
"I love you all. I love you mom, dad. You have been wonderful to me, and I love you Robin. I'm sorry I'm such a miserable failure. Things have not been right since my life is either addiction or death, and I am choosing death."
Days later, Robin Moore and Proffitt cleaned out Sharon's room. They gave her clothes, books and other belongings to residents who had gathered outside her door. In the closet, they found a leather boot crammed with a variety of pills.
Moore's ashes were scattered in the Blue Ridge Mountains, a wish she had made known in her suicide note.
Her parents met with some of the friends their daughter had listed in her tiny address book, sharing her autopsy report and suicide note. But they never felt like they got many answers, Robin Moore said. Within a few years, both her parents died.
Gomez believes that Moore had long thought about suicide but that living at Kensington pushed her to go through with it.
"She was forced to go there. . . . It eventually got very depressing to her, realizing there was no other way out."
Gomez said he initially wondered what he could have done differently in treating her. But he came to believe that "there was nothing anybody could have done."
'A Train Out of Control'
After Moore's death, the state initiated a new round of investigations and ultimately faulted the facility in her care, noting a "pattern of serious, repetitive and frequent" violations affecting many residents.
Rick Oakley, who had been brought in by the corporate owners to help run Kensington and was there when Moore died, could not say who was at fault or how she could have been missing for three days without triggering a search. "I'm not sure who would have been in charge at that time," he said in an interview.
Kensington was in a period of turmoil, with three administrators in four months.
"It was unbelievable how horrific" the facility was, said Matthew Farmer, who was recruited and hired after Moore died. He said that the home took in dangerous residents, was in disrepair and was poorly managed. He quit after several days. "It was a train out of control. "
Jack Turesky, the former chief of operations for Delaware Avenue Partners, the company that owned Kensington, said the home was not the nightmare depicted by inspectors, who he said appeared to have a vendetta and were intent on closing the facility. The home delivered good care to a difficult population, he said.
"I thought we were running a pretty good show," he said. "Did we have some problems? Of course -- we had 300-odd residents. You are going to have issues that occur."
Despite the state's threat in January to close Kensington, it was still open three months later when resident Dennis Hixon, 48, told his mother that he was not getting his heart medicine and was afraid he was dying. When his mother called the home, she said she was told he was "just acting out." Hixon died the next day, prompting a state finding that the home mismanaged his medication.
The home was still open the next month, in April 1997, when a resident, his brother and girlfriend died in a double murder-suicide at the home. No one reported hearing gunshots. Staff members discovered the bodies later that day only after the girlfriend's mother asked that they check the room, according to state records.
After the series of deaths at the home, internal memos make it clear that state officials were willing to keep Kensington open if it corrected its problems. But owners decided to close the facility because it was losing money and, Turesky said, the conflict with the state "was the icing on the cake."
Residents were scattered to other homes. One was sent to Grace Home, where she was raped by a psychotic housemate. Another was sent to Dooley Madison, where she was physically abused by an aide, records show.
Eventually, those two homes were also closed, not by the state but under pressure from local building inspectors who cited dangerous conditions. And once again, the residents were shipped out to other homes.
Staff researcher Bobbye Pratt contributed to this report.
© 2004 The Washington Post Company