California Nursing Homes Investigation Reveals “Shameful State of Affairs”

A “confounding” lack of statewide enforcement from California’s Department of Public Health is partially to blame for a “shameful state of affairs” in several nursing homes that are the subject of reports by California’s Operation Guardians, a project of the state Department of Justice’s Bureau of Medi-Cal fraud and Elder Abuse, says a review by the California Advocates for Nursing Home Reform (CANHR). 

Back in 2000, Operation Guardians  began conducting surprise, on-site inspections of California nursing homes in an effort meant to protect residents and improve care quality. The fodder for CANHR’s “hair-raising” review was 14 reports issued between January 2010 and March 2012 by the initiative that uncovered untreated bed sores and infections and residents left lying for hours in their own waste, among other conditions. 

Some problems highlighted in the Operation Guardians reports include under-reported and under-treated bedsores; overmedication with psychotropic drugs that are often administered without consent; medication mistakes leading to harmful overdoses; unsanitary conditions in resident rooms, showers, and kitchens; and 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,” says CANHR.

Now that these conditions in some state nursing homes have been brought to light, there needs to be more accountability and enforcement, says the advocacy group. A CANHR review of Department of Public Health enforcement actions within six months of an Operation Guardians 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.”

These reports are not indicative of all nursing homes, however, says the California Association of Health Facilities (CAHF), as the 14 facilities with health and safety issues are a small portion of the skilled nursing providers who give care to 300,000 patients each year. 


“There is no excuse for poor treatment and neglect,” says Deborah Pacyna, the director of public affairs at CAHF. “However, this report focuses on outliers and does not reflect the high standard of care provided at most of the state’s skilled nursing facilities.”

CANHR made several recommendations to increase OG investigations, publish the resulting reports, follow-up at facilities that have been investigated, and make certain investigations a priority. It also recommends that California’s Attorney General should use the reports as a basis for criminal or civil prosecution of nursing home staff members, managers, and owners responsible for poor care and conditions in under-performing facilities. 

Access the 14 Operation Guardian reports.

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Written by Alyssa Gerace

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