Oakland nursing home allegedly drugged resident to stop his wandering, death came soon

Alando Williams, a fixture for years selling the Street Spirit newspaper outside the Berkeley Bowl supermarket on Oregon Street, was admitted to Oakland nursing home Brookdale Wellness in December 2022. Less than a month later, he was dead, aged 64.

Now his daughter is suing the facility on Fruitvale Avenue and its owner, claiming the drugs used to keep Williams from wandering contributed to his death.

The Berkeley native suffered from leukemia and mild cognitive impairment, and needed help with daily living and fall prevention, according to the lawsuit filed late last month in Alameda County Superior Court by his daughter Kyomi Williams.

Brookdale staff knew Williams was “prone to wandering” and said he wanted to get out of the facility, the lawsuit against the facility and owner Shlomo Rechnitz claimed. Five days after he was admitted, Williams left the building, according to the lawsuit. His daughter was called, and found him in a nearby crosswalk, the lawsuit alleged.

Rechnitz, who owns numerous nursing homes in California, could not immediately be reached for comment.

Instead of creating a plan to keep Williams from leaving and protect him from falling, Brookdale staff began using the sedative Ativan and the powerful painkiller morphine to keep him “a prisoner that required chemical restraints,” the lawsuit claimed.

Facility staff — allegedly overworked and undertrained to keep costs low and profits high — routinely administered morphine and Ativan to Williams without consulting his doctor as required under state regulations, the lawsuit claimed. Overuse of the medications caused complications including disorientation, confusion, loss of balance and susceptibility to falls, the lawsuit alleged.

Despite knowing Williams was at substantial risk of a life-threatening fall, the facility failed to create an effective prevention plan, and he died a few days after a fall, the lawsuit claimed.

“As a result of these failures, Mr. Williams suffered untold pain, suffering and ultimately death,” the lawsuit claimed.

The death certificate lists leukemia and cardiac arrest as the causes of Williams’ death. But Ed Dudensing, a lawyer representing his daughter, said if the case gets to trial, a doctor specializing in care for elderly people will testify that dosing him with morphine and Ativan was “a substantial contributing factor to the death.”

Attempts to reach Rechnitz by phone, message and requests to a lawyer who has represented one of his companies were unsuccessful. According to a 2021 CalMatters investigation, Rechnitz has bought 81 nursing homes in California since 2006. His facilities, including Brius Healthcare, named along with Windsor Healthcare as parent companies of Brookdale, have a spotty regulatory record.

A 2018 California State Auditor’s report on skilled nursing facilities said Brius had “received more federal deficiencies and state citations compared to the rest of the industry.”

That year, Robert Barbendel, a resident of Cupertino Healthcare & Wellness Center, filed a lawsuit accusing Rechnitz of short-staffing the facility, and 13 other California nursing homes he owned, including three in the Bay Area, to increase profit. The lawsuit was settled with undisclosed terms last year.

The Medicare system gives Brookdale an overall rating of four stars out of five, with four stars for health inspections and quality measures, and three stars for staffing. The time nurses and nurse aides spend with residents is slightly higher than the national average, but time spent by registered nurses — those with the highest skills — is considerably lower. Turnover of registered nurses and administrators was much higher than the national average.

The facility’s most recent inspection report by the Centers for Medicare & Medicaid Services, from August 2023, found Brookdale lacked consulting services from a licensed pharmacist, leading to “consistent occurrence of high medication error rates.”