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Operation Guardians Reports

Florin Healthcare Center – Sacramento


“Deficient resident care and resident care practices were identified in almost every case.” In three months, one resident had acquired six pressure sores from the nursing staff’s failure to take preventative measures. The pressure sores were infected, and cellulitis surrounded the surface areas of the sores. When asked why the facility did not provide treatment, the social services representative informed inspectors that the resident’s boyfriend had been making medical decisions for the resident, even though he lacked the legal authority to do so. The inspectors then spoke to the resident physician to determine why the patient had developed six pressure sores at the facility, but was never treated. The physician “had not seen the wounds until (the inspectors) were there.” She was transported to an acute care hospital upon the inspectors’ request, but died the following day.

One resident was sexually assaulted at the facility by another resident. The resident informed staff, but could not communicate effectively because of a recent stroke. A physical examination was never conducted, nor was the victim taken to the hospital.

Another conserved resident had a long history of leaving the facility without permission. An inspector observed her leave the facility without permission. Her Wanderguard alert system did not activate when she left. The staff was unaware that she had left until she returned.

Finally, the facility had employed seven physical therapy staff to perform eight hours of physical therapy each. However, the inspectors only observed a maximum of three residents at one time in the physical therapy room. The observable physical therapists sat at a table for most of the day and gossiped, while billing for their “services.”