Editor's Note: This story contains graphic descriptions that some readers may find disturbing.
This is part two of a two-part series. Read part one here.
The warning to Sally Renee Johnson-Komzelman could not have been more ominous or prophetic.
A social worker at Sharp Grossmont Hospital’s emergency room cautioned Johnson-Komzelman in July 2021 not to return her 90-year-old father to the Avocado Post Acute nursing home in El Cajon.
“She said, `You don’t want to send him back there, it’s a terrible place,’” Johnson-Komzelman said.
The public record supports the social worker’s perception of Avocado.
Since 2019, the number of complaints lodged against Avocado has totaled four times the state average among facilities with more than 100 beds, according to the California Department of Public Health (CDPH). And in April, federal regulators moved to decertify Avocado, citing the 256-bed facility’s failure to keep residents free of “abuse, neglect and exploitation.”
The order was later rescinded, with the Centers for Medicare & Medicaid Services (CMS) stating Avocado had “returned to substantial compliance.” Yet, records show that investigators continue to substantiate abuse and poor care at Avocado and CMS is now considering it for a program aimed at helping nursing homes with significant deficiencies.
Johnson-Komzelman said she took seriously the dire warning she’d received that July day. But with just a few thousand dollars a month to cover her father Robert Bradley’s care, and little time to find alternative help during a pandemic, she felt she had no choice but to place him back at Avocado.
Six weeks later, Bradley was dead, allegedly murdered by his roommate, Bezaleel Jefferson, according to the San Diego County District Attorney’s office.
“This beautiful man who pulled himself up by his bootstraps during the depression and made a life for himself,” Johnson-Komzelman said. “You want your dad to die peacefully.”
The records reveal a brutal ending to Bradley's life.
In the early hours of Aug. 19, 2021, an Avocado caregiver found Bradley in his room vomiting blood and in respiratory distress. The autopsy report states Bradley died from strangulation — he had abrasions and contusions on his neck. The San Diego County Medical Examiner ruled Bradley’s death a homicide.
Jefferson admitted to El Cajon police he had hit Bradley, records show. He was charged with murder but then deemed not mentally competent to stand trial, according to court records. He is currently at the Patton State Hospital, a forensic psychiatric hospital in San Bernardino.
Johnson-Komzelman and her three siblings have filed a wrongful death lawsuit against Avocado. The lawsuit claims Jefferson suffers from severe, chronic psychiatric illness. He has been under court-ordered conservatorships on and off for the past 30 years, according to county records.
The lawsuit alleges that Avocado knew Jefferson had attacked patients at the nursing home before that day in August 2021, and that he refused to take his medication.
Representatives for Avocado, CDPH and CMS did not respond to requests for comment on this case.
CMS emailed the following statement in response to questions about conditions at Avocado: “The health and safety of nursing home residents is a top priority for the Centers for Medicare & Medicaid Services. CMS continues to work closely with the state survey agency to monitor this facility.”
CDPH sent a statement citing state regulations governing the requirements for facilities that admit "patients who are mentally disordered." But the agency did not respond to questions regarding Avocado.
Given the alleged facts in the case, Scott Fikes, an attorney who filed the lawsuit on behalf of Bradley’s children, said Avocado was duty bound to protect other residents from Jefferson.
“Mr. Jefferson should have never been placed in the same room with any patient without somebody in the room directly supervising him,” Fikes said.
The lawsuit alleges that Avocado staff knew there had been a dustup between Bradley and Jefferson over a curtain but still did not place them in separate rooms.
A horrific discovery
Johnson-Komzelman said an Avocado nurse notified her later in the morning after the alleged attack that her father had gone into respiratory failure and had been transported to the hospital.
In an interview with KPBS, she said Avocado never told the family that Bradley had been attacked by his roommate nor gave her crucial details about her father’s visible injuries when staff discovered him.
She said the nurse only mentioned there had been an “altercation” over a curtain the night before between Bradley and Jefferson.
Johnson-Kozelman said she asked shortly after he was brought in what was wrong with her dad. They told her, “Well the nursing home says that he has lung cancer and that he’s in respiratory arrest.”
But because her father’s obvious wounds told another story, hospital staff contacted police, Johnson-Komzelman said. She said it was her first clue that her father had met with foul play. It wasn’t until hours later, when her father was moved to a hospice facility, that she learned the extent of what had happened.
Johnson-Komzelman said the head of the hospice facility told her, “You need to be prepared. Your dad was attacked by his roommate.”
The warning wasn't enough. She described feeling shocked, horrified, nauseous and on the verge of a panic attack when she walked into her father’s hospice room later that day and saw his injuries.
“He had huge welts and bruises across his upper chest, ” Johnson-Komzelman said. “And around his neck, it was swollen and bruised. On his face he had scratch marks and welts. His mouth and the inside of his mouth were swollen and pure black. And he had blood coming out of his mouth.”
Her father died early the next morning.
“He lasted maybe another six hours,” she said. “He never opened his eyes. He had a doll's eyes. They didn’t respond. The only thing that was moving were his toes. My sister and I figured out he was trying to get to heaven to be with mom.”
Mentally ill patients in nursing homes
Texas lawyer Ernie Tosh, who specializes in elder abuse, said nursing homes can admit patients with significant mental illnesses as long as they have the expertise and resources to manage their care. But housing those patients can still be fraught.
“Even if you have psych nurses available, they’re spread so thin, they may not be able to properly help a resident who is having a psychiatric episode and needs to be segregated from the rest of the population,” Tosh said. "And they’re not there to protect the population from the individual who is having a psych episode.”
And taking these patients requires nursing homes to prioritize safety.
“If the person is refusing to take their medication, and you suspect could become violent in doing so, you have an absolute duty to the other residents to discharge that patient to protect the rest of your patients,” Tosh said.
Fikes, who has knowledge of the investigation, said an Avocado nurse’s comments to El Cajon police detectives probing Bradley’s death were telling.
“She told police that they were going to need their help removing Mr. Jefferson from the facility and that she was concerned if they did it without police help, that he would whip their ass,” Fikes said.
The Bradley family lawsuit against Avocado argues the nursing home “accepted Jefferson as a resident and failed to discharge (him) because they were under financial pressure” to increase profits.
Johnson-Komzelman said her father paid the ultimate price and she wants the nursing home punished.
“He was just something to be tossed aside," she said. "I want that ... place to shut down. And I want the state of California to start paying attention to what's going on inside these nursing homes.”
The killing of a resident at an El Cajon nursing home raises questions about why the facility admitted a patient with a long history of severe psychiatric illness and allowed him to stay even though he had reportedly assaulted other residents. In other news, how San Diegans are mourning the death of Queen Elizabeth. Plus, we have some weekend arts events worth checking out.
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