• In March 2017, the California Department of Public Health issued eight citations and levied $160,000 in administrative penalties to Brius’s Eureka Rehab and Wellness Center for patient care, staffing, and administrative violations. Click here to read more.
• In July 2016, California’s Department of Public Health blocked Brius’s acquisition of five nursing homes, citing the company’s poor regulatory track record over a three-year span: June 22, 2013, to June 22, 2016. Brius’s 386 infractions were enough evidence for the state’s health department to determine that California’s largest nursing home operator showed an inability to “comply with statutes and regulations related to the operation of a skilled nursing facility” in the state. Click here to review all five denial letters.
• In August 2015, the California Attorney General’s office files criminal charges in connection with patient deaths at two Brius nursing home facilities: Mesa Verde Post Acute Center (Costa Mesa, CA) and Verdugo Valley Skilled Nursing and Wellness Centre (Montrose, CA).
• In October 2014, a class action lawsuit is filed on behalf of Brius nursing home residents alleging Shlomo Rechnitz and his Brius corporation has “chronically understaffed and under-resourced its skilled nursing facilities to “create ill-begotten profits.”
• In August 2014, California’s Attorney General files an emergency motion to block the sale of 19 skilled nursing facilities to Shlomo Rechnitz, calling him a “‘serial violator‘ of rules within the skilled nursing industry.”
• Molly Davies, the administrator for Los Angeles’ Long-Term Care Ombudsman Program, refers to the chronic pattern of substandard conditions her staff has observed at some of Brius’ nursing homes as evidence of the company’s “flagrant disregard for human life.”

On November 13, 2014, CDPH brings a formal accusation against Brius’ Wish-I-Ah Healthcare and Wellness Center (Auberry, CA) for its alleged  pattern of harming the “health, morals, welfare, and safety of its patients.” The state’s legal action comes after the nursing home was placed on a termination track that would bar it from participating in the Medicare program, issued civil monetary penalties, and denied payment for new admissions. The state’s action marked the first time since 2008 that the California Department of Public Health (CDPH) had issued a suspension order against a skilled nursing facility, according to the Sacramento Bee. According to the state’s allegations, inspectors cited the nursing home for such deficiencies as a resident’s death and a poorly maintained sewage treatment system that forced nursing home workers to dispose of human waste in garbage bags manually.

On November 4, 2015, CDPH hit Brius’ Verdugo Valley Skilled Nursing and Wellness Centre (Montrose, CA) with a Class AA citation, the Department’s most severe citation, and a $100,000 administrative penalty, the maximum dollar amount the Department can issue for a second subsequent deficiency where a nursing home resident(s) is placed in immediate jeopardy. The citation and penalty were the results of an investigation that found the nursing home directly responsible for the death of a resident. According to the inspector’s report, the nursing home failed to ensure that the resident, who had a history of respiratory problems, was assessed for signs of respiratory distress daily;  failed to notify a physician when the resident became unresponsive and had breathing that became labored; and failed to call 911 paramedics promptly when the resident’s health condition showed a significant change.

On February 25, 2015, the California Department of Public Health cited Brius’ Alameda Healthcare & Wellness Center (Alameda, CA) for failing to implement policies and procedures that prohibit the neglect and physical harm of its nursing home residents. The citation came after CDPH inspectors responded to a complaint made against the nursing home over the death of one of the nursing home’s residents. According to the inspector’s report, the nursing home failed to call 911 after one of its residents suffered from shortness and fluctuating vital signs. The report goes on to state that, “as a result of this neglect, Resident 1 did not have the benefit of acute hospital services when her heart stopped and she was pronounced dead, six and one-half hours after her initial symptoms of shortness of breath first appeared.”

Below are copies of other state and federal violations cited at Brius’ nursing homes:

2017

2017-06-08  – On June 8^th the California Department of Public Health (CDPH) sent a letter to Brius’s San Rafael Healthcare and Wellness Center (San Rafael, CA) alerting it of the Department’s decision to penalize the nursing home $15,000 for failing to meet the state’s minimum nurse staffing requirement. CDPH Investigators visiting the nursing home on September 27, 2016, reviewed staffing records for randomly selected days between March 17, 2016, and June 16, 2016. The state’s analysis of these records determined that the nursing home had failed to meet the minimum 3.2 Nursing Hours Per Patient Day (NHPPD) standard on more than 10% of those randomly sampled days. This is two times the 5% rate the state will allow before it issues an administrative penalty.

2017-03-04  –  The California Department of Public Health (CDPH) hit Eureka Rehabilitation and Wellness Center with a Class B citation and a $2,000 administrative penalty for the facility’s failure to keep resident’s safe and free from abuse when one resident blocked the doorway of another resident’s bedroom, refused to let her and two others out of the room, threw hairbrushes and a garbage can, and then threatened to “kill” the resident. The facility also failed to report the incident of resident-to-resident abuse to the CDPH, local Ombudsman office, and local police department as required.

2017-02-28 – On February 28, 2017, the California Department of Public Health (CDPH) tagged Brius’ Eureka Rehabilitation and Wellness Center (Eureka, CA) with a Class A citation, the second highest level of citation the state’s health department can issue. The citation came after CDPH investigators determined that the facility was at fault when seven different nursing home residents, some of whom suffered from blindness, dementia, and muscle weakness, experienced a series of falls. Each of the named residents required regular assistance and supervision from nursing home staff when walking and/or toileting. According to the citation, however, “(t)he facility did not provide adequate supervision and assistance.” As a result, some of the falls experienced by these residents resulted in serious injuries such as a broken arm, a broken nose, and a fractured pelvis. One nursing home resident had as many as five falls in one month, according to the citation. The Class A citation is accompanied by a $20,000 penalty.

2017-02-28 – The California Department of Public Health (CDPH) hit Brius’ Eureka Rehabilitation and Wellness Center (Eureka, CA) with a Class A citation. The citation came after CDPH investigators determined that the facility was at fault when one of its nursing home residents experienced five falls in a four week period (8/12/2016 – 9/14/2016), one of which resulted in the resident sustaining a head injury that required medical attention at a nearby hospital. According to the citation, the resident was admitted to the home with diagnoses of Alzheimer’s disease, and dementia. The nursing home’s assessment of the resident indicated he displayed high-risk for falls due to complications from his mental status and history of falls. The nursing home’s care plan for the resident did not specify how it would prevent the resident from falling. According to the citation, the facility failed to, “provide adequate supervision and assistance, revise fall risk care plans and implement the care plans,” for this nursing home resident. The nursing home’s failings resulted in the resident suffering three more falls between 10/26/2016 and 11/26/2016. The Class A citation is accompanied by a $20,000 penalty.

2017-02-28 – The California Department of Public Health (CDPH) handed Brius’ Eureka Rehabilitation and Wellness Center (Eureka, CA) a Class A citation. The citation came after CDPH investigators determined that the facility “failed to ensure adequate nursing staff to provide quality care, which caused harm to their residents.” During an interview with facility staff members, CDPH investigators asked them to itemize all the routine tasks required to do during their shift along with the time it took to complete each task. Investigators then calculated the listed tasks with the time required to complete these tasks. The results of the CDPH investigators’ calculation for one staff member’s routine tasks revealed, “a minimum of 1593 minutes [26.55 hours] were required for one CNA to complete all the tasks, including breaks, for an AM shift. The 510 minutes [8.5 hours] allotted for the morning Shift starting at 7:15 a.m. was not enough; it required more than 3 times of that (1593) minutes to provide an adequate care for the residents.” This failure to staff appropriately resulted in several resident falls, and injuries that required hospital visits and/or stays. The Class A citation is accompanied by a $20,000 penalty.

2017-02-28 – The California Department of Public Health (CDPH) came down on Brius’ Eureka Rehabilitation and Wellness Center (Eureka, CA) after investigators determined that the facility was at fault when one of its residents experienced repeated falls over a six-month period (5/22/2016 – 11/25/2016). CDPH handed the nursing home a Class A citation along with a $20,000 penalty.  According to the citation, the resident was admitted to the nursing home on 3/25/2016 with diagnoses of Alzheimer’s disease, epilepsy, and depressive disorder. The nursing home’s assessment of the resident placed her as being at-risk for falls due to complications from her mental status. According to the citation, the nursing home resident was observed, “walking down the hallway back and forth multiple times without being accompanied by anyone.” The nursing home’s failings “presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.”

2017-02-28 – The California Department of Public Health (CDPH) slapped Brius’ Eureka Rehabilitation and Wellness Center (Eureka, CA) with a Class A citation and a $20,000 penalty following an investigation by CDPH officials revealed the facility failed to maintain an accident hazard-free environment, and provide adequate supervision and assistance to a nursing home resident with a history of falls. The deficiency resulted in one nursing home resident suffering three separate falls in a four-week period (8/16/2016 – 9/17/2016). According to the citation, the resident was admitted to the nursing home on 4/1/2010  with diagnoses of high blood pressure, an irregular heartbeat, schizophrenia, and general muscle weakness. The nursing home’s assessment of the resident classified him as being at risk for falls due to complications from his mental status and muscle weakness. While the nursing home’s care plan for the resident required a staff member to assist him when walking in the corridor and toileting there was no detail that indicated how it would prevent the resident from falling. According to the citation, the nursing home’s failings resulted in the resident suffering three more falls between 10/13/2016 and 10/17/2016, one of which resulted in the resident suffering a broken nose.

2017-02-28 – The California Department of Public Health (CDPH) slapped Brius’ Eureka Rehabilitation and Wellness Center (Eureka, CA) with a Class A citation and a $20,000 penalty. The citation came after CDPH investigators determined that the facility had failed to maintain an accident hazard-free environment, and provide adequate supervision and assistance to a nursing home resident with a history of falls. According to the citation, a frail and elderly resident who suffered from dementia, blindness in both eyes, and general muscle weakness, suffered a fall on 8/28/2016 which resulted in a broken arm. The nursing home’s own assessment of the resident indicated that she was a high-risk for falls due to complications from her mental status and muscle weakness. According to the CDPH’s citation, the nursing home failed to adhere to its care plan for the resident, which indicated she required a staff member to assist her when walking in the corridor and toileting.

2017-02-28 – The California Department of Public Health (CDPH) slapped Brius’ Eureka Rehabilitation and Wellness Center (Eureka, CA) with a Class A citation. The citation came after CDPH investigators determined that the facility failed to maintain an accident hazard-free environment, and provide adequate supervision and assistance to three nursing home residents, each with a history of falls. According to the citation, the residents were admitted to the nursing home with diagnoses that included difficulty walking, dementia, disorientation, and poor vision, and general muscle weakness. According to the citation, each resident was assessed by the nursing home as being high-risk for falls. The nursing home’s failings “presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result,” according to the citation. The Class A citation is accompanied by a $20,000 penalty.

2017-02-28 – The California Department of Public Health (CDPH) hit Brius’ Eureka Rehabilitation and Wellness Center (Eureka, CA) with a Class A citation. The citation came after CDPH investigators determined that the facility was at fault when one of its nursing home residents experienced five falls in a four-week period (8/12/2016 – 9/14/2016), one of which resulted in a head injury that required medical attention at a nearby hospital. According to the citation, the resident was admitted to the nursing home with diagnoses of Alzheimer’s disease, and dementia. The nursing home’s assessment of the resident placed him as being at high-risk for falls due to complications from his mental status and past history of falls. The nursing home’s care plan for the resident did not specify how it would prevent the resident from falling. According to the citation, the facility failed to, “provide adequate supervision and assistance, revise fall risk care plans, and implement the care plans,” for this nursing home resident. The nursing home’s failings resulted in the resident suffering three more falls between 10/26/2016 and 11/26/2016. The Class A citation was accompanied by a $20,000 penalty.

2017-02-08  – Regulators with the California Department of Public Health (CDPH) have slapped Brius’ Vernon Healthcare Center nursing home with a Class A  citation for leaving a 59-year-old obese, mentally ill resident in a prone position on her bed where she was later found dead. The citation issued against Vernon Healthcare Center – one of the most troubled nursing homes run by Brius CEO Shlomo Rechnitz – is the second most severe class of citations available to state regulators. CDPH investigators found that the nursing home repeatedly failed to follow protocol in caring for the resident, who experienced a “behavioral episode” the day before her death during which she began screaming and fell off her bed three times. The facility failed to have a nurse assess her sudden deterioration or alert her doctor as required. Investigators also determined that staffers “did not receive appropriate training to manage a behavioral episode of a mentally ill, obese resident.”

2017-02-03 – The California Department of Public Health (CDPH) slapped Brius’ Cupertino Healthcare and Wellness Center (Cupertino, CA) with a Class B citation and a $2,000 penalty after one of its residents developed a Stage II pressure sore. The nursing home’s assessment of the resident revealed that he had “impaired cognition, required assistance with bed mobility, transfer, hygiene and bathing,” as well as being “at risk for the development of a pressure ulcer,” according to the citation. When initially admitted to the nursing home on 9/11/2016 he had no pressure sores. By 1/9/2017 the nursing home reported he had developed a Stage II pressure sore on the inner portion of his left heel.

2017-02-03 – The California Department of Public Health (CDPH) slapped Brius’ Cupertino Healthcare and Wellness Center (Cupertino, CA) with a Class B citation and a $2,000 penalty after their investigation revealed that the nursing home failed to maintain an accident hazard-free environment, and provide adequate supervision and assistance to prevent accidents. The nursing home’s failure resulted in one resident sustaining an injury near her left eye and a broken left clavicle when she tried to use her bedside commode but lost her balance and fell. According to the citation, the nursing home resident had diagnoses of dementia, seizures, an unsteady gait, and a history of falls, and as a result, was assessed for being at high risk for falls. The nursing home’s care plan indicated that she required assistance from a staff member when toileting, according to the citation. This is the first of two citations issued against the nursing home stemming from this 63-page survey deficiency dated January 20, 2017.

2017-02-03 – The California Department of Public Health (CDPH) hit Brius’ Cupertino Healthcare and Wellness Center (Cupertino, CA) with a second Class B citation and a $2,000 penalty following the results of Department’s January 20, 2017 survey of the facility. According to the citation,  the nursing home failed to prevent the development of pressure sores. The nursing home’s failure resulted in one resident developing a stage II pressure sore on his inner heel. According to the citation, the nursing home resident required, among other things, assistance while moving around and getting in and out of bed.

2016

2016-12-28 – The California Department of Public Health (CDPH) slapped Brius’ Seaview Rehabilitation and Wellness Center (Eureka, CA) with a Class A  citation and $20,000 penalty after its investigators found the facility was at fault when a 57-year old resident fell and broke her ribs while being transferred out of her bed. According to the nursing home’s assessment, the resident, who suffered from multiple sclerosis, was totally dependent on nursing home staff and required the assistance of two staff members when getting in and out of bed. According to the citation, a lone staff member attempted to use the Hoyer lift – a hydraulic patient lift – to transfer the resident out of bed. The nursing home’s administrator informed the state’s investigation team that the facility requires two staff members when transferring residents using a Hoyer lift. The facility’s failure to ensure its policy was followed resulted in the resident falling from the lift and suffering several cuts and pain to her right arm and several fractured ribs, according to the citation.

2016-12-08 – Investigators with the California Department of Public Health (CDPH) slapped Alameda Healthcare and Wellness Center (Alameda, CA) with a Class B citation and $2,000 penalty after they discovered that a resident was physically abused by one of the nursing home’s staff members. According to the investigation, a frail and elderly resident who spoke only limited English was pushed back onto her bed and later struck in the head by a nursing home employee after twice calling for help to be moved from her bed to her wheelchair. The abuse suffered by the resident left her feeling scared and fearful.

2016-11-01 –  The California Department of Public Health (CDPH) tagged Grand Avenue Healthcare and Wellness Centre (doing business as Country Villa Belmont Heights Healthcare Center) with a Class A citation and a $16,000 administrative penalty. Health inspectors surveyed the facility after a complaint was made against the nursing home alleging a lack of care and treatment after one resident developed a series of Stage 3 and 4 pressure sores to his abdomen, hips, and thigh area. The resident was rushed from the facility to a local acute care hospital, where he was quickly admitted to the intensive care unit. According to the citation, the resident was hospitalized for 21 days and treated with “multiple IV antibiotics and aggressive wound care twice a day..pain medications… for care and treatment of the many infected pressure sores that led to sepsis,” a life-threatening infection to the bloodstream.

2016-10-27 – The California Department of Public Health issued a deficiency to Alameda Healthcare and Wellness Center (Alameda, CA – Alameda  County) for failing to prevent the spread of infection when they found unsanitary conditions in a resident’s room. According to the report, inspectors, responding to a complaint, observed a blow-tip call light with a build-up of brownish debris on the plastic mouthpiece. The resident who had been issued a blow-tip call light was a complete quadriplegic who suffered from acute respiratory failure.

2016-08-16 – Seaview Rehabilitation and Wellness Center (Eureka, CA) was tagged by the CDPH with Class A citation and a $20,000 penalty after one of its residents developed a preventable Stage 4 pressure sore.

2016-08-16 – The California Department of Public Health hit Brius’ Seaview Rehabilitation and Wellness Center (Eureka, CA) with Class A citation and $20,000 penalty after the nursing home failed to alert a resident’s physician or his family members immediately after they realized that he had developed a preventable Stage 4 pressure sore. According to the citation, the resident “developed a pressure ulcer and fever for three days before the physician was notified. These failures resulted in harm to Resident 1 when he did not receive the necessary care and services to alleviate a worsening condition of a pressure ulcer which led to sepsis.”

2016-06-13 – Granada Rehabilitation and Wellness Center (Eureka, CA – Humboldt County): The CDPH issued a Class A citation and a $20,000 administrative penalty to this Brius nursing home after one of its residents was rushed to an emergency room at a nearby hospital after suffering a cardiac arrest. At the hospital, the resident was diagnosed as having a preventable Stage 4 pressure sore, acute kidney failure, urinary tract infection, blood pooled between resident’s chest wall and lung, poorly controlled diabetes, and a heart attack.

2016-02-09 – The Rehabilitation and Wellness Center of Dallas (Dallas, TX – Dallas County): The federal Centers for Medicare and Medicaid Services (CMS) cited this nursing home for not properly assessing a resident who suffered from mental illness and developmental disabilities for specialized services. According to the CMS report, inspectors observed the nursing home resident, who was totally dependent on staff for fulfilling all activities of daily living, with yellow matter stuck to the corner of her eyes, dirty and jagged fingernails, dry and crusty lips, teeth and tongue coated with a thick white mucus-type substance, two preventable pressure sores, and lying in a urine and feces-filled incontinent brief.

2015

2015-12-14 – Verdugo Valley Skilled Nursing and Wellness Centre (Montrose, CA – Los Angeles County): The CDPH hits this Brius nursing home with a Willful Material Falsification (WMF) citation and a $10,000 administrative penalty for falsifying a nursing home resident’s medical records.

2015-11-15 – San Rafael Healthcare and Wellness Center (San Rafael, CA – Marin County): CDPH cited this Brius nursing home for failing to maintain its kitchen in sanitary conditions, and storing expired food. The inspector’s report also notes the nursing home’s failure to staff a full-time dietary supervisor.

2015-11-04 – Alameda Healthcare & Wellness Center (Alameda, CA – Alameda County): CDPH issued a Class B citation and $2,000 penalty to this Brius nursing home for failing to respond to a resident’s initial symptoms of shortness of breath and fluctuating vital signs. According to the inspector’s report, “as a result of this neglect  Resident 1 did not have the benefit of acute hospital services when her heart stopped and she was pronounced dead, six and one half hours after her initial symptoms of shortness of breath first appeared.”

2015-09-01 – The California Department of Public Health (CDPH) tagged Alameda Healthcare and Wellness Center (Alameda, CA) with a Class B citation after a resident suffered first and second degree to her thighs. A nursing home staff member was preparing the resident’s breakfast tray when she knocked over and spilled a cup of very hot water onto the resident’s lap. According to the report, the temperature of the water was hot enough to cause third-degree burns in as little as five seconds. Along with the citation, the CDPH issued a $1,500 penalty against the nursing home.

2015-08-04 – Los Feliz Healthcare and Wellness Centre (Los Angeles, CA – Los Angeles County): California’s Department of Public Health hit this Brius nursing home with a Class AA citation and a $75,000 administrative penalty after inspectors, who were responding to a complaint made over a nursing home resident’s death, found that the nursing home failed to monitor a resident with a known history of being a high risk for falls, and to keep resident areas from accidents and hazards.

2015-05-26 – Windsor Healthcare Center of Oakland (Oakland, CA): Brius took control of this nursing home in October 2014. Less than one year after, inspectors with California’s Department of Public gave the facility a citation for placing some of its residents in immediate jeopardy and neglecting several others. According to the report, family members of a paralyzed resident urged the nursing home to have their loved one rushed to an emergency room at a nearby hospital. At the hospital, emergency room staff noted the nursing home resident was covered in feces from his upper-legs to his mid-torso, and that his wound dressings and “massive” Stage 4 pressure sore were similarly soiled in feces. The emergency room staff immediately rushed the patient to the ICU and treated him for life-threatening septic shock.

2015-05-06 – The California Department of Public Health (CDPH) slapped Brius’ Vernon Healthcare Center (Los Angeles, CA) with a Class A citation and a $60,000 penalty after investigators determined that the facility had failed to provide adequate supervision and assistance to a nursing home resident with a history of wandering behavior. According to the citation, the resident, who suffered from dementia, wandered throughout the facility and into the rooms of several other nursing residents at various times between 4/25/2014 and 9/20/2014. In several instances, the resident physically assaulted staff members and other nursing home residents. During an interview on 9/21/2014,  CDPH investigators brought to the nursing home administrator’s attention a note written by a staff member dated 8/16/2014.  According to the citation, the note indicated, “Resident 1 hit Resident 2 in the stomach and a security staff at the front door…Resident 1 also hit CNA 1 with a closed fist four (4) times and twisted the CNA’s right arm and right index finger, and Resident 1 continued to wander in and out of other resident’s rooms.”

2015-03-31 – The California Department of Public Health (CDPH) slapped Brius’ Vernon Healthcare Center (Los Angeles, CA) with a Class A citation and a $20,000 penalty after investigators determined that the facility had failed to provide adequate supervision and assistance to a nursing home resident that was high-risk for falls. According to the citation, the resident was readmitted to the nursing home on 1/21/2013 (originally admitted on 11/12/2012). The nursing home’s assessment of the resident dated 11/15/2012 indicated he had “long-term and short-term memory problems, required extensive assistance…to total assistance for bed mobility, transfer, ambulation,” according to the citation. On the night of 5/19/2013, a caregiver heard a noise that came from the resident’s room. She went to the resident’s room and found him sitting on the floor next to his bed. A licensed nurse assessed the resident and determined he had sustained no injuries. On 5/20/2013 the resident’s condition changed and was observed shaking, with high blood pressure, rapid breathing, a fever, and an elevated heartbeat. Paramedics were called and he was rushed from the nursing home to an emergency room at a nearby hospital. It was revealed at the hospital that the nursing home resident had suffered a grand mal seizure while at the nursing home, and had a serious head injury with bleeding in the brain. The resident spent ten days at the hospital before being discharged to another skilled nursing facility under hospice care. The resident died while on hospice care, ten days after his discharge from the hospital. According to the citation, the nursing home ignored its policy and procedures on falls when it failed to keep the resident’s bed at a low height, have a bed alarm in place, or to provide a landing pad near the bed in the case of a fall.

2015-03-19 – Gridley Healthcare & Wellness Centre (Gridley, CA – Butte County): CDPH issued this Brius nursing home a Class B citation and an administrative penalty of $2,000 for the mistreatment of nursing home residents.

2015-02-19 – San Rafael Healthcare & Wellness Center (San Rafael, CA – Marin County): The California Department of Public Health cited this Brius nursing home for ignoring infectious control policy as it continued to admit residents amidst a Norovirus outbreak at facility.

2015-02-19 – Presidio Health Care Center (Spring Valley, CA – San Diego County): The CDPH cited this Brius nursing home for failing to safeguard against the potential for fire and food-borne illness at the nursing home.

2015-01-22 – Alameda Healthcare & Wellness Center (Alameda, CA – Alameda County): CDPH inspectors issued a violation to this Brius nursing home for failing to take the necessary precautionary measures against the potential spread of an infectious disease when the facility failed to treat a nursing home resident’s scabies prior to her leaving on an overnight visit with her family or to inform her that the disease is contagious.

2014

2014-11-25 – South Pasadena Convalescent Hospital (South Pasadena, CA – Los Angeles County):  The California Department of Public Health issued the nursing home a Class A citation after a resident with significant mental illness was allowed to check herself out of the nursing home and leave the grounds unsupervised. According to the inspector’s report, the resident walked to a nearby gas station, purchased some gasoline. She then entered a nearby alley where she doused herself in the gasoline before lighting herself on fire. The report notes that the resident eventually died in the emergency room of a nearby hospital as a result of her wounds.

2014-11-13 – Clairemont Healthcare and Wellness Centre (San Diego, CA – San Diego County): CDPH issued the nursing home with a violation for failing to discharge a nursing home resident safely and appropriately. The nursing home’s administrator hastily ordered the resident to be discharged as a CDPH inspection team was surveying the facility. In an unusual step, nursing home staff quickly wheeled the resident through the nursing home and out the rear exit where a cab waited to take her from the nursing home to her mobile home. Hours later, police officers responded to calls from concerned neighbors and found the former resident lying on her bed and in need of immediate medical attention. The officers took her to an emergency room at a nearby hospital where medical staff found that the nursing home had failed to remove the woman’s catheter. The catheter bag was full, its tubing clogged, and the woman smelling strongly of urine and feces, and suffering from severe pressure ulcers on her foot.

2014-09-19 – Clairemont Healthcare & Wellness Centre (San Diego, CA – San Diego County): CDPH issued the Brius nursing home a deficiency after for failing to care for a resident in a dignified and respectful manner when it let a nursing home resident sit in his urine-soaked incontinent brief for nearly 30 minutes.

2014-07-14 – Gridley Healthcare & Wellness Centre (Gridley, CA – Butte County): California’s Department of Public health cited this Brius nursing home for failing to keep one of its residents free from abuse.

2014-05-15 – Pacific Rehabilitation & Wellness Center (Eureka, CA – Humboldt County): CDPH issued the nursing home a violation for its failure to care for nursing home resident’s skin rash when first informed. According to the report, the nursing home staff had been unresponsive to the resident’s complaint about the severity of his itchy skin despite his having open wounds and bleeding as a result of his aggressive scratching.

2014-03-14 – San Rafael Healthcare & Wellness Center (San Rafael, CA – Marin County): CDPH cited this Brius nursing home for failing to maintain its facility in a clean and sanitary fashion. According to the inspector’s report, one nursing home resident referred to the conditions at the facility as slum-like.

2014-02-25 – San Rafael Healthcare & Wellness Center (San Rafael, CA – Marin County):  CDPH inspectors cited the Brius nursing home for failing to repair a malfunctioning furnace. According to the report, the nursing home’s furnace had been malfunctioning over several days of unusually cold weather.

2014-01-28 – San Rafael Healthcare & Wellness Center (San Rafael, CA – Marin County): CDPH cited this Brius nursing home for failing to staff its nursing unit properly despite having residents that required regular one-on-one supervision and care.

2013

2013-12-20 – Pacific Rehabilitation & Wellness Center (Eureka, CA – Humboldt County): CDPH issued the nursing home with a violation for placing all 57 of the nursing home’s residents in immediate jeopardy when inspectors found that the portable space heaters the nursing home had been using to compensate for its malfunctioning heating system were placed in resident care areas that presented a clear risk for fire.

2013-05-16 – Oakhurst Healthcare & Wellness Centre (Oakhurst, CA – Madera County): CDPH issued the nursing home with a violation for its failure to prevent the spread of infectious diseases. According to the report, seven nursing home residents and one staff member were all placed in immediate jeopardy of contracting a gastrointestinal illness when proper handwashing and linen handling procedures were not thoroughly followed.

2012

2012-12-07 – Novato Healthcare Center (Novato, CA – Marin County): CDPH issued the nursing home with a Class B citation and a $1,000 administrative penalty for failing to staff its nursing home with sufficient caregivers. According to the report, the lack of sufficient caregivers resulted in an unsupervised nursing home resident with wandering tendencies to fall and break her collar bone.

2012-12-04 – Novato Healthcare Center (Novato, CA – Marin County): The CDPH tagged the nursing home with a Class B violation and a $1,000 administrative penalty after inspectors found the nursing home failed to ensure that the resident environment is as free of accident hazards as possible. According to the report, the facility violated the regulation when a nursing home resident, who had been placed on a soft diet by her physician, had to be rushed to an emergency room at a nearby hospital after she choked on a large piece of fruit.

2012-08-01 – Presidio Health Care Center (Spring Valley, CA – San Diego County): A CDPH inspector issued the nursing home with a violation after determining that the thawed chicken that sat in the nursing home’s refrigerator had been there for 10 days. The thawed chicken, which was observed sitting in a pool of its own blood, had the potential to infect residents with a food-borne illness.