Attorney General Lockyer Announces Results of Surprise Nursing Home Inspections in California

"Operation Guardians" Prompts Better Care for Elderly and Dependent Adults

Wednesday, January 21, 2004
Contact: (916) 210-6000,

(SACRAMENTO) – Attorney General Bill Lockyer today announced Operation Guardians conducted 150 surprise inspections of California skilled nursing homes from April 2001 to March 2003, sparking corrections of dangerous conditions and improving the quality of care and living conditions for the facilities' residents.

"Operation Guardians is helping ensure that the 250,000 elderly and dependent adults who reside in the state's 1,400 skilled nursing homes are receiving the care they deserve," Lockyer said. "This program is succeeding in preventing loss, injury and death by identifying health and fire hazards, theft of patients' trust account funds and failures to provide adequate medical services to these vulnerable citizens before they can escalate into life-threatening problems."

Established in April 2000 by Lockyer as a pre-emptive, pro-active program, Operation Guardians uses multi-agency teams to conduct unannounced inspections of facilities and identify problems that threaten the dignity, safety, welfare and quality-of-life of the residents. Operation Guardians operates and inspected facilities in 16 counties: Alameda, Contra Costa, Fresno, Humboldt, Los Angeles, Monterey, Napa, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, Santa Barbara, Santa Clara, Sonoma and Ventura. Additional inspections were conducted at the request of three counties: Marin, San Mateo and Yolo.

"Elder abuse and neglect are very serious problems in California's nursing homes," said Patricia McGinness, executive director of the California Advocates for Nursing Home Reform, California's largest nursing home watchdog group. "Attorney General Lockyer's Operation Guardians program provides the scrutiny needed to protect the residents of the state's nursing homes."

"When we entrust the care of a loved one to a nursing home, we expect them to receive the best possible care in a clean, safe and caring environment," said Tom Porter, state director of AARP, the nation's largest elder advocacy organization. "Operation Guardians creates a strong incentive for nursing homes to maintain the quality of their staff and facilities and ensure patients receive the best care possible."

Lockyer said most of the nursing homes inspected during the past two years quickly responded by making improvements in the facilities and the medical and health care provided. The most prevalent problems identified were failure to meet the state's minimum staffing requirements of 3.2 nursing care hours per day, ensure that nurse assistants possess valid certification, document tuberculosis tests of employees and prevent and document the loss of residents' property.

The inspections showed performance levels ranged from near compliance with federal and state standards of care to situations which required referrals to law enforcement, regulatory or licensing agencies. The inspections resulted in two felony convictions. In one, a licensed vocational nurse was convicted of stealing narcotic pain medication intended for residents in an Oxnard facility. In another, an administrator-in-training at a Napa facility was sentenced to three years in state prison for stealing $49,000 from facility residents and their families, and using threats and intimidation to discourage them from reporting the theft.

"Although the goal of Operation Guardians is to prevent injury by identifying even the smallest of problems that, if left unchecked, could grow into dangerous situations for residents," Lockyer said, "we also are there to root out criminal activities that then can be prosecuted."

Of the 38 facilities statewide that underwent follow-up inspections, more than half either had corrected or were in the process of correcting the problems identified. All of the 328 fire safety-related violations discovered were corrected or in the process of being corrected. Three physicians were referred to the California Medical Board for investigation; two were sanctioned and one is still under investigation. At least 34 facilities have received Department of Health Services-issued deficiencies substantiating Operation Guardians' findings, and in several cases in which the loss or theft of residents' property was identified, the residents have received compensation.

Deficiencies discovered during the Operation Guardians inspections were divided into five general categories:

1. Environmental Non-Compliance, ranging from foul odors emanating from urine and fecal matter, to loose handrails and improperly stored food items.
2. Resident Care Non-Compliance, ranging from failure to adequately document patient care, implement medical staff orders, safely store controlled substances and medical instruments, to over-medicating patients and failing to report alleged abuse to appropriate authorities.
3. Administrative Non-Compliance, which includes failure to maintain proper personnel files of medical staff, protect patients' personal items or document required tuberculosis (TB) tests.
4. Fire Safety Violations, which include inoperable fire extinguishers or fire alarms, obstructed fire exits, exposed wires and unsafe chemical storage.
5. Staffing Level Non-Compliance. Of the 116 facilities in which staffing levels could be inspected, 79, or 68%, failed to meet state laws requiring a minimum of 3.2 hours of nursing care per resident per day. Nursing care does not include services provided by housekeeping, maintenance, kitchen, clerical or non-clerical staff.
Headed by the Attorney General's Bureau of Medi-Cal Fraud and Elder Abuse (BMFEA), Operation Guardians includes local elder abuse ombudsmen, fire departments, prosecutors, police and the University of Southern California School of Medicine. The inspections complement regular inspections conducted no less than every 15 months by the Department of Health Services, which is responsible for licensing and regulating the state's skilled nursing facilities.

The program illustrates the Attorney General's commitment to combating elder abuse, both through prevention efforts and aggressive prosecution. Since Lockyer began his first term as Attorney General in 1999, the Attorney General's BMFEA has increased criminal prosecutions of elder abuse in the state's skilled nursing homes by 749 percent, and convictions by 574 percent.

The "Operation Guardians, 2001-02 and 2002-03" report may be viewed at

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