State regulators have slapped a Brius nursing home with a severe patient care citation for leaving a 59-year-old obese, mentally ill resident in a prone position on her bed where she was later found dead.

Vernon Healthcare Center – one of the most troubled nursing homes run by Brius CEO Shlomo Rechnitz — received the Class A citation in March 2017, according to a California Department of Public Health citation obtained by Brius Watch. The agency has not yet announced financial penalties for the violation, which is the second most severe class of citations available to state regulators.

Investigators found that the nursing home repeatedly failed to follow protocol in caring for the patient, 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.”

Moreover, administrators at the home were unaware that the death merited an investigation and autopsy. The investigators wrote:

“When asked if the Director of Nursing knew that the resident was found not breathing and pulseless in a prone position, she answered, “Really?” Who told you that?”

The facility’s medical director told investigators he failed to investigate the death or request an autopsy because he was never informed that the resident was lying in a prone position when she was found unresponsive.

The Vernon facility is no stranger to major violations. Two years ago, the CDPH slapped it with a Class A citation and $20,000 fine for failing to provide adequate supervision and assistance to a nursing home resident that was at high-risk for falls.

That same year, the agency also fined it $60,000 for another Class A citation for failing to provide adequate supervision and assistance to a nursing home resident with a history of wandering behavior.

[gview file=”https://briuswatch.org/wp-content/uploads/2017/06/Vernon-Class-A-complaint.pdf”]