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Operation Guardians - Executive Summary

Untreated bed sores and infections, residents left for hours lying in their own waste, a resident with maggots in a festering rectal wound. Despite a generation’s worth of state and federal laws to guarantee a satisfactory standard of care in California nursing homes, an alarming number of facilities are failing to deliver decent humane care to their residents. This is the takeaway from CANHR’s hair-raising review of fourteen reports from California’s Operation Guardians, a project of the state Department of Justice’s Bureau of Medi-Cal Fraud and Elder Abuse. The reports reveal a shameful state of affairs in the reviewed nursing homes that is fostered, in part, by a lack of statewide enforcement from the Department of Public Health (DPH).

Operation Guardians began in 2000 to conduct surprise, on-site inspections of California nursing homes in an effort to protect residents and improve care for elderly and dependent adult residents. (See Operation Guardians description) While the project has scaled back its number of inspections, it still manages to inspect about one new nursing home each month. Each inspection results in a report detailing the facility’s compliance with basic sanitation and quality of care standards. The reports are sent to DPH so it can conduct an independent investigation and issue appropriate enforcement actions. The reports are not made available to the public. CANHR made a Public Records Act request to obtain all reports issued from January 1, 2010 through March 7, 2012 and has subsequently posted the reports to its website. It is believed that CANHR is the first organization to publicly reveal the Operation Guardians reports.

The Reports

Most of the Operation Guardians investigations result in two reports, one assessing the general sanitation and care provided by the facility staff and another medical report written by an experienced medical doctor specializing in geriatrics. Invariably, the reports expose terrible conditions or severely neglectful care at the reviewed nursing homes. Among the myriad problems discovered were:

  • Bed sores that are under-reported and under-treated, resulting in painful skin ulcers that do not heal;
  • Overmedication with psychotropic drugs which are often administered without consent;
  • Elementary medication mistakes leading to harmful overdoses;
  • Residents left in feces and urine;
  • Filthy resident rooms, showers, and kitchens;
  • Falsified medical records and fraudulently billed services

The reports demonstrate that some nursing homes are houses of horror with life threatening filthy conditions, lack of staff to perform core functions, and poor management.

No Accountability

While we applaud the Operation Guardians team for its admirable work in its investigations and its commitment to thorough examinations of nursing homes, few, if any, changes have resulted from its efforts. The reports themselves, which are exceptionally valuable snapshots of a facility’s quality of care, are not made publicly available and no criminal or civil prosecutions have been forthcoming from the Attorney General’s office.

All Operation Guardians reports are sent to the Department of Public Health (DPH), Licensing and Certification for follow-up investigation and enforcement action. DPH is, after all, charged with enforcing California’s nursing home law and is the designated “consumer protection agency” for California’s nursing home residents. However, a CANHR review of DPH enforcement actions within 6 months of an OG investigation found few instances of specific enforcement actions as a result of the OG reports. DPH’s failure to follow-up with OG reports in a meaningful way is a statewide embarrassment.

The paucity of enforcement action is beyond confounding. These reports discuss grave conditions in the subject facilities, with residents who have died, been hospitalized, or suffered other serious adverse health consequences as a result of terrible neglect. Yet DPH has largely shrugged and reacted slowly to these reports. When the state agency charged with ensuring good quality care in nursing homes has an attitude of indifference to expert reports of wrongdoing, the conditions described in the OG reports are not so surprising.


  • Increase Operation Guardians investigations. The number of OG investigations has dropped from about 90 per year in 2003-2007 to less than 20. OG investigations uncover myriad grave problems in California nursing homes and should have robust support from California’s Department of Justice.
  • Publish the Operation Guardians reports. As informative as OG reports are, they would be invaluable to potential nursing home residents and their families in choosing facilities. Since DPH does such a poor job of enforcing state and federal nursing home standards, residents and their families crave information that will give them a true sense of whether a facility is good or bad.
  • Follow-up at the facilities that have been investigated. The OG reports reveal several California nursing homes in crisis. DPH knows the residents of these homes are in grave trouble. It should move swiftly to protect them.
  • Priority Investigations. The Department of Justice and the Department of Public Health should enter into a Memorandum of Understanding whereby OG reports will be given priority in DPH follow-up investigations. DPH should formally adopt a policy by which it gives priority investigative status to OG reports that allege health and safety violations that threaten nursing home residents.
  • The Attorney General should prosecute. California’s Attorney General should use OG reports as a basis for a criminal or civil prosecution of nursing home staff members, managers and owners responsible for the reprehensible care and conditions in the poor performing nursing homes. Nursing home residents will continue to suffer unnecessary and preventable injuries and even deaths until California’s regulatory and law enforcement agencies undertake action to enforce our state and federal standards for care.