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Operation Guardians Reports

Winsor House Care Center (aka. Orchard Post Acute Care) – Vacaville


“There were deficient facility practices in the areas of pain management, infection control, physical restraints, weight loss and nursing services in general.” This facility’s charting reflects that it has administered medication to the wrong patient on four separate occasions. One time, a resident received the wrong medication, and a covering physician recommended the resident be monitored every half hour for vital signs. The chart reflects that shortly after the order, the patient was “alert and oriented” with normal vital signs. No further charting was done until the next shift, at midnight. At 3:00 A.M., the patient was found non-responsive with a critical oxygen saturation reading of 83% and was hospitalized.

The facility’s weight log establishes that numerous residents have lost weight since being admitted to the facility. One resident had lost 51.4 pounds since her admission. One resident had a nasogastric tube placed due to a small bowel obstruction. The resident pulled the tube out, rendering her seriously ill. During the next two days, no charting was done regarding the patient’s status. However, the medication log reflected that she had been administered the maximum medication possible to control severe nausea and pain. Her physician and hospice were never notified, and the resident died shortly thereafter. The inspecting physician was “appalled by this apparent neglect…she died a miserable death due to the facility’s failure to take appropriate action on her behalf over the course of (at least) 3 days.”