Hell Hath No Fury Like a Nursing Home on Fire

Introduction to Leslie Andino-

In 2003, a 23-year-old woman named Leslie Andino was described as “the worst mass murder in Connecticut’s history,” which conjures up all kinds of images. 

Was she a serial killer, some evil character portrayed on Investigation Discovery for the world to gawk, or even worse? 

Often, a criminal is a victim of their upbringing, environment, poor choices, and on and on. However, when their evil acts outweigh their former life circumstances, it is difficult to sympathize with the perpetrator.

 Early on, her crime was determined to be intentional despite her claims of “accident.” 

Not much is known of her early life, but it is known that she used hard drugs, crack cocaine and heroin, and had three children. She was in an abusive relationship with her live-in boyfriend, Norman Ortiz, against whom she sought and was granted a restraining order in 2001. 

Claims of physical, verbal, and sexual abuse were reported against Andino. 

At some point in time, it’s reported she has a ‘rare form’ of Multiple Sclerosis. 

The more common type of MS can be described as a progressive disease caused by attacks on the body’s immune system. Nerve fibers of the brain and spinal cord lack the insulating sheath (myelin). As a result, those afflicted have periods of exacerbations and remissions. Symptoms include weakness, abnormal sensations in the limbs, vertigo, and vision problems. As MS progresses, other symptoms appear, such as tremors, decreased motor coordination, pain, extreme emotional lability, speech & swallowing problems, fatigue, loss of bowel & bladder control, changes in memory and cognitive abilities. MS symptoms are worsened by heat. The incidence ranges between 2 and 150 per 100,000. Prognosis is difficult to predict, depending upon many factors.

 However, in general, the life expectancy of patients is 5 to 10 years lower than those without MS. In addition, Andino also suffered from seizures.

In 2001, Leslie’s mother, Maria Feliciano, sought custody in the probate court of the three children, in addition to filing a restraining order against both Ortiz and Lesley for continuous harassment against her, always asking for money for drugs.

 She was awarded custody of the three children in 2001 and obtained a restraining order against boyfriend -heroin- crack addict Nelson Ortz and her daughter.

One can only imagine what long-term drug use, seizures, and MS does to a person’s brain. But, as it turned out, it was “the perfect storm.” 

In the early morning hours of February 26, 2003, at 2:30 a.m. just one month after being admitted to Greenwood from the Institute of Living, Leslie obtained a lighter from another patient and began flicking it for an extensive time. She ignited her bedsheets, killing her elderly roommate. It spread to an adjacent room and into the eaves of the building. Detectives and fire officials soon confirmed it could not have been an accident. She was charged with 16 counts of arson murder a month later.

Causes of this disaster -Inappropriate admission to Greenwood; Failure to adequately supervise, Lack of automatic sprinkler systems throughout the facility, Lack of proper fire codes and legislation, Lack of a ‘consistent staff total concept safety response”, Failure of the Institute of Living to properly evaluate before the transfer, failure of the probate judge to ensure appropriate placement. Of course, one could argue that Leslie’s entire life was on the verge of collapse. 

A Brief History of Mental Health in Connecticut

The General Hospital for the Insane of the State of Connecticut was born in 1868 to transform psychiatric care specializing inhumane treatment for the mentally ill such that a properly designed and controlled environment could have a positive influence on mental health. This moral treatment philosophy was initiated in Europe.

It was an innovative concept that mental illness could be treated with medication and other medical attention versus being ‘incurable,’ and in their belief, a symptom of demons and criminal behavior.

 Before the public institution, within the private sector, The Hartford Retreat for the Insane was a pioneer in 1822, serving those who could afford care. As demand for care increased, the need for a public institution grew, endorsed by Dorothy Dix, a national mental health care advocate. A Select Committee of the Legislature passed a bill in 1866 for the institution on the Connecticut River in Middletown. The town granted the State 150 acres of sprawling farmland and paid $35,000. The decor was somewhat lavish for an institution trying to mimic a refined home. They implemented a kind of architectural, structural reward system for well-behaved versus the violent patient – at ‘the wings’ of the building.

Unfortunately, these proved to be lofty goals without a proper understanding of the causes of mental illness., in addition to overcrowding.

Its name was changed to Connecticut Valley Hospital and now includes addiction treatment.

Norwich State Hospital for the Insane- and Fairfield Hills

From the National Historic Register to the show “Ghosthunters- these two epic hospitals for the mentally ill were described by some as torture chambers. 

Norwich State Hospital was built in 1904 and closed its doors for good in 1996.

According to internet sources, in its heyday, NSH had 30 operational buildings down to 2 at its closure.

With its labyrinth of spooky tunnels, Norwich Hospital had a series of tragic events over the years. They say a patient hung himself, a water heater exploded, killing two, several patients died during treatment, and a nurse took her own life. They also say that the hospital gained enough reputation that there were multiple investigations into cruelty to patients over the years.

Fairfield Hills Psychiatric Hospital in Newtown, CT, consisted of 16 buildings and 4,000 patients. It has operated for more than 60 years.

It remained vacant for many years with various ‘dead-end proposals’ until the Town of Newtown bought it from the state in 2004 for future redevelopment. Part of the building is reportedly used as municipal offices, while other sections are popular with ghost hunters. 

Political Expediency – Close the Hospitals and Move Them to the Community- De-Institutionalization-

Former Governor John G. Rowland had a budget plan in 1995 in which these two State hospitals would be closed in 1996 and 1997. It was a numbers game, and it ‘looked good on paper.’ Nine thousand patients among the three large hospitals were down to 600. Connecticut Valley Hospital in Middletown, along with the Whiting Forensic Institute, would continue to house a total of 560 patients including, 90 for the criminally insane and 250 for those with drug and alcohol addiction. In addition, the plan was to include the advent of community facilities, short-term treatment, and former hospital workers following them to community programs. (Unlike New York, where state hospitals were closed relatively quickly, leaving patients to become homeless or unsupervised in one-room hotels.) 

The Mental Health Commissioner, Albert Solnit, pledged that he would make it work. 

Under the Carter Administration, the concepts of “least restrictive environment” (The objective of maintaining the most significant degree of freedom, self-determination, autonomy, dignity, and integrity of body, mind, and spirit for the individual while they participate in treatment or receives services) and ‘free choice’ under self-determination “(i.e., maybe a shelter bed, a cardboard box, the streets, or a jail cell) were NOT humane options. 

Why did the mass exodus, whether slowly or rapidly, fail miserably? 

An excerpt from a 1997 PBS’ Frontline narrative explained –

“Most of those who were de-institutionalized from the nation’s public psychiatric hospitals were severely mentally ill. Between 50 and 60 percent of them were diagnosed with schizophrenia. Another 10 to 15 percent were diagnosed with manic-depressive illness and severe depression. An additional 10 to 15 percent were diagnosed with organic brain diseases — epilepsy, strokes, Alzheimer’s disease, and brain damage secondary to trauma. The remaining individuals residing in public psychiatric hospitals had mental retardation with psychosis, autism, other childhood psychiatric disorders, alcoholism, and drug addiction with concurrent brain damage. The fact that most de-institutionalized people suffer from various forms of brain dysfunction was not as well understood when the policy of de-institutionalization got underway.”

Therapy, medication, community supports were not in place for most who needed them, thus creating a crisis and, in effect, also created a 

‘no room the inn’ situation for any new mentally ill persons in the future.

This crisis has continued to the present time. There is no doubt Lesley Andino was caught in this no man’s land in 2003. 

A Brief Look at Past Fires Nursing Home Fires

Katie Jane Memorial Home for the Aged in Warrington, Missouri, became a death trap on February 15, 1957;

  • The fire killed 72 people and started in a first-floor linen closet during religious services;
  • Causes contributing to the high death count included that the building was over 50 years old and constructed of wood, there were no fire alarms or sprinkler systems, inadequate fire escapes, and the facility operating without a license. Locking patients in their rooms was a common practice during that time as well.
  • The building’s roof caved in, and they were engulfed in smoke and flames;
  • In March 1957, Governor James Blair legislatively established “minimum safety standards for nursing homes in Missouri;
  • *** At the 60th Anniversary of the fire, on February 8, 2017, Fire Chief Bill Hamlisch, whose grandmother died in the 1957 fire, lamented that sprinklers of any kind were still not in place, least of all ‘complete coverage automatic sprinklers.’

The Golden Age Nursing Home was a historic fire in Norwalk, Ohio, on November 23, 1963 – the day after President John F. Kennedy’s Assassination.

  • The fire began around 4:30 a.m and spread rapidly.
  • It was the deadliest fire in the nation in 5 years;
  •  Timing is everything. People were so engrossed with the assassination and search and charging of Lee Harvey Oswald that this tragedy did not receive the attention and resources it might otherwise have had. There were 65 deaths, 21 survivors;
  • Causes were many in this former toy factory- including faulty electrical wiring starting in the attic, which shorted the phone system, no fire alarm, no evacuation plan, wheelchairs blocking narrow doorways, thick glass block windows prevented escape as multiple patients restrained to their metal beds. 
  • A passerby called the fire department. 
  • On November 29th, 21 unclaimed people were buried in a mass, 60-foot grave in Woodlawn Cemetery in Norwalk. The 22nd body of John Rook, a veteran of World War I, was buried in a separate grave on the same day.
  • Numerous changes were made in the nursing home industry as a result.

National Health Care Center was a second nursing home fire in 2003 in Nashville, Tennessee, on September 25, 2003.

  • The fire began at 10:15 p.m in a patient’s second-floor room of the four-story building built in the 1960s;
  • There were 116 residents in total, with eight killed ranging in age from 76 to 86 years and 16 critically injured;
  • Among those who died was 96 year old “feisty” Mary Connelly, mother of the District Fire Chief. Bobby Connelly;
  • Although no specific source was identified in later publications with arson ruled out, Lack of sprinklers was at least a secondary cause;
  • Older nursing homes were not required, ‘grandfathered in’ according to the 1994 building code, unless the building was to receive “extensive renovation”;
  • Democratic state Sen. Roy Herron, who has pushed for nursing home reform laws, was sharply critical of the exemption of older nursing homes from the sprinkler requirement. “The cost of grandfathering in those nursing homes has been paid for by the grandfathers and grandmothers who were killed,” Herron said. “I’m sure a number of the families think the cost of providing safe nursing homes would have been worth it.”
  • The sole sprinkler required was one over the grill for cooking;
  • According to the Tennessee Public Health Department, NHC Center “passed their fire code inspection every year, but failed a fire drill in May 2003. Reportedly that “failed to shout ‘Code Red’ and failed to sound the alarm. [Why not use their public address system??] Subsequently, in June 2003, 3 months before the deadly fire, they passed the next fire drill.

[Postscript – There is fascinating material about the Station Nightclub Fire in West Warwick, R.I on February 20, 2003, killing 200, injuring 230 more due to pyrotechnics and overcrowding, Lack of sprinklers As this nightclub fire occurred just one week before the Hartford Greenwood Nursing Home Fire and was in the neighboring State of Rhode Island, was included in the research. The Reference section below contains articles, a PBS podcast; a future film called TheGuestList at TheGuestListFilm.com; and a book called “Trial by Fire, A Search for the Truth” by Scott Jones.]

Senator Edith Prague

Edith G. Prague is a self-made woman living in Eastern Connecticut. She began as a teacher in 1965, became a Licensed, Certified Health Insurance Consultant, a newspaper columnist on matters of Medicare, started her training as a medical social worker, and practiced from 1976-1982. She was elected to the Connecticut Legislature in the House of Representatives in 1982 through 1990, followed by the State Senate from 1994 to 2012. Then, she returned to college to become a Social Worker, completed at age 50. She was also appointed as Commissioner of the Department of Aging twice. Her political career spanned more than 30 years. 

The following link is a classic article from the indomitable former Connecticut Senator Edith Prague just before her reluctant retirement. She NEVER wanted to retire, but after a series of TIA’s (mini-strokes), she was forced to resign as her new Commissioner of Aging at age 87 in 2014. https://www.courant.com/news/connecticut/hc-xpm-2014-06-03-hc-edith-prague-out-20140603-story.html

As it relates to the elderly in Connecticut and Lesley Andino, Edith Prague remained a fierce advocate.

She was horrified that sprinkler systems were not required in skilled nursing facilities. Leslie Andino’s actions set the stage for change in Connecticut.   

 As of May 2003, State Sen. Edith Prague said she would push for legislation to prevent patients with severe psychiatric problems from being placed into nursing and convalescent homes. In 2002, Senator Prague introduced a bill that would set restrictions on who could be 

 In her words, “There is no place to put people in this state who have psychiatric problems except to put them in nursing homes. Leslie Andino should never have been admitted to a center like Greenwood.”

 In 2002, Senator Prague introduced a bill to restrict who could be committed to private nursing homes as Co-Chairman of the Select Committee on Aging.

Under the 2003 fire codes, Greenwood was not required to have a sprinkler system. According to the state officials, twenty of Connecticut’s 241 licensed nursing homes were not fitted with sprinkler systems.

After the 2003 Hartford fire, the CT General Assembly passed a law requiring all state nursing homes to install sprinklers throughout their facilities. According to the DSS report, officials estimate the total cost of installing or updating sprinkler systems for the houses would be $14.6 million. The average price per home for updating would be $270,000, while complete installation would likely cost $363,000 per home. 

At the Federal level, it was still under discussion in July 2007. The Nursing Home Fire Safety Act of 2007 would require that every nursing home in America become equipped with automatic fire sprinkler systems within five years. In addition, the legislation would authorize more than a half-billion dollars in loans and “hardship” grants to qualifying nursing homes. 

Reps. John Larson (D-CT) and Peter King (R-NY) introduced the bill in the House in late May. Sens. Christopher Dodd (D-CT) and Richard Burr (R-NC) unveiled identical legislation in the Senate in mid-June. 

Sponsors and providers are hoping for a better fate this time around with a Democrat-controlled Congress, particularly in the wake of a fire that killed ten people at a Missouri facility in November.

Despite the dollar value of the bill, advocates, including nursing home leaders, point out that it is a measure that would not require more funding later. 

Providers maintain they could not afford the costs of retrofitting the many older, marginal buildings without sprinklers without federal help.

In December 2007, the Centers for Medicare & Medicaid Services issued a call for comments on a proposed rule that would mandate full sprinklers in all nursing homes. 

As it turns out, CMS issued a ‘final rule” on August 13, 2008, requiring the installation of automatic sprinkler systems in all nursing homes in the U.S. without waiver or exception with a deadline date of August 13, 2013.

Investigation & Mandates from the Connecticut Department of Public Health and the Federal Centers for Medicare and Medicaid Services

The investigation of the response by the Connecticut Department of Public Health revealed that even though three nurses on the midnight shift showed extraordinary heroism by rescuing residents closest to the flames. “Others did not appropriately follow the facility’s emergency evacuation plans on duty during the fire. There was evidence that not all of the on-duty staff responded. Some who did respond had to be told what to do. “Many died of smoke inhalation in which the Lack of response played a critical part. In addition, it was reported that staff on the midnight shift had not been doing required fire drills. These critical lapses were unnoticed by the CT DPH just one month before the fire!

The edict by CMS concerning mandatory sprinklers had severe consequences. If they failed to meet the deadline, they would not qualify for continued reimbursement by Medicare/Medicare – (Their ‘proverbial bread and butter.’ Further, they would face other financial penalties.

According to the National Fire Prevention Association, in 2006-2010, of those nursing home fires occurring, 70 percent had sprinklers present.

Of the 13 percent where they were not effective, it was because they were turned off!

A Courageous and Controversial Judge- 

Probate Judge Robert J. Killian, Jr. did not pass the buck. He admitted his part in the decision to commit Lesley to Greenwood was part of the problem. But, he said, “If there’s going to be indictments, let there be a blanket of indictments against the State of Connecticut, the Department of Mental Health and the courts… and all of us who failed miserably with not only Leslie Andino but hundreds and thousands of others like her who were not able to help.”

In 2012, Judge Killian created a stir from many mental health advocates with his controversial proposal. During testimony, he described a vicious cycle in which those with mental health problems may repeat a scenario such as one woman suffering from delusions about dangerous people living in the cellar. When non-compliant with her medication, she calls the police, who come to reassure her. Then, after several calls, she’s taken for re-evaluation and is admitted to a hospital. 

In a hospital setting, they don’t receive disability benefits, they fall behind on the rent and may lose their home. In addition, he may see the same people three to four times a year for commitment.

His proposal – Mandate medication be forced on specific persons who are ‘profoundly mentally ill’ leaving psychiatric facilities, for 120 days while in the community with the court appointing a conservator to enable them to achieve stability so that they don’t lose their housing (Which is very difficult to locate.) 

 Reportedly, this practice is followed by many other states.

Advocates were adamant that this philosophy goes against client choice. The need for supportive housing was the one point of agreement.

Those with a history of psychiatric disorders testified that coercion would drive them further from treatment and discount medication side effects and try to build trusting relationships providing treatment. Person-centered treatment and choice is always the better option for the majority. 

Leslie Now

Little is known precisely. However, in March 2019, Courant reporter David Owens provided an update on her case. At that time, she was 38 years old. Sixteen cases of arson murder are still pending against her. Once a year, her subject appears on the court docket for a status report. In 2019, her public defender told the court – “She is severely disabled. She has multiple sclerosis, requires intensive care, and cannot eat without supervision because she’d likely choke.”  

In 2020, we were in full pandemic mode, and the courts were shut down. 

There have been no public updates in 2021. I have never been able to locate a single photo. So I am confident in saying she is no more competent today than in 2003. 

Greenwood Health Care Center was taken over by the ICare Health Network in January 2019, taken out of state receivership for more than $3 million, and re-named the150 bed facility as Parkville Care Center. 

One hundred fifty people were in the process of being hired. iCare was founded in 2001, and operates 11 nursing homes, and employs 1,700 workers in Connecticut 

Conclusions – 

What else can be said about Leslie Andino? Some may feel compassion, others horror. But, I would say, who is remembering the victims of her actions?

May we continue the battle for total residents’ rights for all who call a nursing home their home.

*********************************************************************

References-

 1) Deadliest American Disasters and Large loss of Life Events 2oo3

     (Ten or More Lives Lost with Notable Exceptions);

Fireland Video- https://www.youtube.com/watch?v=AaVTrmx-59o

The GuestList Film.com about the Station Nightclub Fire-

https://www.theguestlistfilm.com/about;

Golden Age Nursing Home – November 23, 1963, Fitchville, Ohio

2)https://www.latimes.com/archives/la-xpm-2003-Feb-27-na-nursing27-story.html’

3) The New York Times “Suspect in Hartford Fire Isa Troubled Patient”

     February 28, 2003; 

4) Journal Inquirer,” Police Get Arrest Warrant in Nursing Home Fire”

     May 14, 2003; 

5)https://www.sandiegouniontribune.com/sdut-some-of-the-deadliest-nursing-home-fires-in-the-us-2014oct03-story.html; By THE ASSOCIATED PRESS

OCTOBER 3, 2014 12:52 PM PT;

6)https://ctmirror.org/2012/03/30/judges-frustrations-lead-proposal-outcry-advocates/;

7)https://www.courant.com/news/connecticut/hc-hartford-arson-murder-leslie-andino-0302-20190301-mpl3bqwfanabbkd2zztumifyxi-story.html;

8)https://www.hartfordbusiness.com/article/hartford-nursing-home-acquired-renamed;

9)https://donnagore.com/2011/07/31/little-girl-justice-arent-55-surgeries-enough/;

10)https://connecticuthistory.org/designed-to-heal-the-connecticut-general-hospital-for-the-insane/;

11) Behind The Walls of CT’s Abandoned Norwich State Hospital | https://i95rock.com/behind-the-walls-of-cts-abandoned-norwich-state-hospital/?utm_source=tsmclip&utm_medium=referral;

12) https://www.courant.com/news/connecticut/hc-xpm-1995-03-07-9503080050-story.html;

13) https://www.pbs.org/wgbh/pages/frontline/shows/asylums/special/excerpt.html;

14) https://www.latimes.com/archives/la-xpm-2003-sep-27-na-fire27-story.html

15) https://www.foxnews.com/story/eight-killed-in-fire-at-nashville-nursing-home

16) http://www.cnn.com/2003/ALLPOLITICS/09/26/wbr.nursing.home/;

17) https://en.wikipedia.org/wiki/Warrenton_Nursing_Home_fire;

18) https://www.mcknights.com/news/lawmakers-revisit-sprinkler-legislation/;

19) https://www.firehouse.com/home/news/10518123/cashstrapped-connecticut-nursing-homes-may-miss-sprinkler-deadline

 

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