Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Guardian Care Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not submit the required Payroll Based Journal (PBJ) staffing data for the 4th quarter of fiscal year 2024. This was discovered through a review of CMS PBJ Staffing data reports, which showed no submission for the period from July to September 2024. The Administrator acknowledged the issue, citing a system glitch and HR department turnover as reasons for the oversight.
The facility failed to complete accurate PASARR Level I Screens for several residents, leading to unrecognized potential Serious Mental Illness (SMI) diagnoses. Residents with conditions such as major depressive disorder, PTSD, and bipolar disorder were not properly identified in their PASARR forms, resulting in a lack of appropriate services and placement. The Social Services Director and Director of Nursing acknowledged the discrepancies and the need for correction.
The facility failed to adhere to professional standards for food storage, with multiple items in the kitchen and dry storeroom found unlabeled, undated, or improperly sealed. The walk-in refrigerator's temperature was not recorded for two days, and several food items were discarded due to being outdated or improperly stored. The CDM acknowledged these issues, which posed a potential risk to all residents consuming meals from the facility's kitchen.
The facility was cited for a repeat deficiency in F689 due to a cognitively impaired resident exiting through an unsecured and unalarmed door. Despite monthly QAPI meetings and audits, insufficient oversight led to the recurrence of this issue, similar to a previous incident. The Executive Director noted the current situation involved a resident attempting to find his wife, but did not explain how the door was opened without staff knowledge.
The facility failed to document consent, refusal, or medical contraindication for the pneumococcal vaccine for three residents. The DON and ADON confirmed the lack of documentation, noting that the previous ADON only documented for influenza vaccinations. The facility's policy requires offering the pneumococcal vaccine upon admission and every five years, which was not followed for these residents.
A resident with moderate cognitive impairment and high elopement risk exited an LTC facility unsupervised due to inadequate security measures. The resident, who required substantial assistance and used a wheelchair, did not have a wander alarm. Staff were unaware of the resident's elopement risk, and the doors used were not alarmed or locked, allowing the resident to leave the facility unnoticed for 35 minutes.
The facility failed to maintain resident dignity by referring to residents needing dining assistance as 'feeders.' A CNA used this term while training another CNA, and an RN also used it when discussing residents requiring meal assistance. The DON acknowledged this as a dignity issue and noted prior staff instruction against using such labels.
A resident with multiple mental health diagnoses, including bipolar disorder and PTSD, was admitted without a required Level II PASARR evaluation. The facility's oversight was acknowledged by the Social Services Director, who noted that the admissions department and clinical team failed to identify the need for further evaluation despite the resident's serious mental illness and routine use of antipsychotic medications.
A facility failed to provide adequate dialysis care for a resident with ESRD, resulting in inconsistent documentation of vital signs and condition before and after dialysis sessions. The resident, with severe cognitive impairment, was scheduled for dialysis three times a week, but only eight reports were found out of 17 visits. The facility's records showed inaccurate documentation, and vital signs were not consistently monitored, failing to meet standards of practice.
The facility failed to provide ongoing monitoring and mitigate triggers for two residents with PTSD, both veterans with cognitive impairments. Despite being identified with PTSD, their care plans lacked focus on trauma-informed care, and staff were unaware of their specific needs. Loud noises, identified as triggers, were not addressed, and the facility's policy on trauma-informed care was not effectively implemented.
A facility failed to coordinate hospice services for a resident with end-stage heart disease. The Medical Director ordered IV fluids due to dehydration risk without notifying hospice, contrary to the care plan and facility agreement. The DON assumed communication with hospice had occurred, but hospice staff confirmed they were not informed about the IV fluids, leading to a deficiency in care.
A CNA and a trainee failed to perform hand hygiene between delivering meals to residents in the East wing, despite a Contact Precautions sign. The DON observed the incident and reminded the trainee to disinfect her hands, which she did, but the primary CNA did not take immediate action. The facility's policy mandates hand hygiene between residents during meal delivery.
Failure to Submit PBJ Staffing Data for FY 2024 Q4
Penalty
Summary
The facility failed to submit the Payroll Based Journal (PBJ) staffing data for the 4th quarter of the fiscal year 2024. This deficiency was identified through a review of the Centers for Medicare and Medicaid Services (CMS) PBJ Staffing data report, specifically the Certification and Survey Provider Enhanced Reports (CASPER Report 1705D), which showed no staffing data submission for the period from July 1, 2024, to September 30, 2024. During an interview on March 12, 2025, the Administrator acknowledged the oversight and attributed it to a system glitch and turnover in the Human Resources department, which resulted in the failure to submit the required data.
Failure to Complete Accurate PASARR Level I Screens
Penalty
Summary
The facility failed to complete a Pre Admission Screening And Resident Review (PASARR) Level I Screen for five out of six residents reviewed for PASARR who were later identified with a possible Serious Mental Illness (SMI). This deficiency was identified through observation, interview, and record review. The residents involved were part of a total sample of 34 residents. The PASARR Level I Screen is crucial for identifying residents with potential mental illnesses to ensure they receive appropriate services and placement. Resident #20, a female with multiple diagnoses including major depressive disorder and anxiety disorder, was admitted from an acute care hospital. Her PASARR Level I Screen, completed by the hospital, did not indicate any suspected mental illness, despite her medical record showing additional diagnoses such as delusional disorders. The Social Services Director confirmed that the PASARR form was not updated to reflect these diagnoses, as she believed it was not necessary unless new behaviors were observed. Similarly, residents #42, #72, #28, and #75 had discrepancies in their PASARR Level I Screens. For instance, resident #42's screen did not include his PTSD diagnosis, and resident #72's screen failed to list any possible mental illness diagnoses. The Social Services Director acknowledged these errors and confirmed that the forms needed correction. The Director of Nursing expressed that the facility should have updated the PASARRs when new diagnoses or changes occurred, indicating a need for a comprehensive audit of the facility's PASARR accuracy.
Food Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, which had the potential to affect all residents who consumed meals prepared in the facility's kitchen. During an inspection, it was observed that the walk-in refrigerator's temperature was not recorded for two consecutive days. Various food items, including shredded cheese, sliced meats, Parmesan cheese, sour cream, applesauce, corn, and gravy, were found without proper labeling or dating, indicating when they were opened or their use-by dates. Some items, such as the Parmesan cheese, were past their manufacturer's use-by date, and others, like the sour cream and leftover applesauce, were discarded upon discovery. The Certified Dietary Manager (CDM) acknowledged these oversights and discarded several items that were improperly stored or outdated. In the dry food storeroom, there were additional issues with food storage, including unsealed plastic bags of dry pasta and unwrapped graham crackers. The CDM confirmed that each person using the food items was responsible for sealing, labeling, and dating them to prevent pest attraction and ensure freshness and safety. The facility's policy on food receiving and storage required all food stored in the refrigerator or freezer to be covered, labeled, and dated with a use-by date, but it did not specify how long different food items could be kept after opening. This lack of adherence to the policy and professional standards for food safety posed a potential risk to all residents consuming meals from the facility's kitchen.
Repeat Deficiency in Resident Supervision and Security
Penalty
Summary
The facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted effective performance improvement activities to sustain prior improvement measures. During the current recertification survey, the facility was found to be in noncompliance with F689, as a cognitively impaired resident exited the facility through an unsecured and unalarmed door. This incident mirrored a previous deficiency cited during the last recertification survey, where another cognitively impaired resident exited the facility unsupervised due to inadequate supervision and a lack of a secure environment. The Executive Director reported that the QAPI committee met monthly and held Ad HOC meetings when issues arose, using monthly reports and audits to identify areas of concern. Despite these measures, the facility did not implement sufficient auditing and oversight to prevent the repeat citation. The Executive Director attributed the previous situation to a door malfunction and noted that the current incident involved a resident attempting to locate his wife. However, she did not clarify how the resident was able to open the door without staff knowledge if it had been alarmed, and acknowledged that not all exit doors were alarmed after the previous elopement incident.
Failure to Document Pneumococcal Vaccine Consents
Penalty
Summary
The facility failed to provide documentation of consent, refusal, or medical contraindication for the pneumococcal vaccine for three residents out of a sample of five reviewed for immunizations. Specifically, residents #20, #9, and #59 had no records indicating whether they had consented to, refused, or had a medical contraindication for the pneumococcal vaccine. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed the absence of such documentation and acknowledged that the previous ADON was responsible for obtaining consents but only documented for influenza vaccinations. The facility's policy mandates offering the pneumococcal vaccine upon admission and every five years thereafter, but this was not adhered to for the mentioned residents.
Resident Elopement Due to Inadequate Supervision and Security Measures
Penalty
Summary
The facility failed to provide a secure environment to prevent a vulnerable resident from exiting the facility unsupervised. Resident #87, who had moderate cognitive impairment and was at high risk for elopement, managed to leave the facility without staff awareness. The resident had a history of dementia and other cognitive and mobility issues, requiring substantial assistance for transfers and using a wheelchair for mobility. Despite being identified as an elopement risk, the resident did not have a wander/elopement alarm at the time of the incident. On the evening of the incident, the assigned CNA was unaware of the resident's elopement risk, as there was no indication on the Kardex, and she had not been informed. The resident was last seen by the CNA around 7:00 PM and by the RN at approximately 8:00 PM. The resident exited the building through a door that was not alarmed or locked because he did not have a wander alert bracelet. The doors were supposed to lock or alarm if a resident with a wander alert bracelet approached, but this system was not in place for Resident #87. The resident was outside the facility for approximately 35 minutes before being noticed by a CNA who saw him through a window. The Maintenance Director confirmed that the doors used by the resident were emergency exit doors and were not alarmed at the time of the incident. The Executive Director acknowledged that the resident had been identified as an elopement risk and that the care plan was active, but the necessary precautions were not in place to prevent the resident from leaving the facility unsupervised.
Failure to Maintain Resident Dignity by Using Inappropriate Labels
Penalty
Summary
The facility failed to ensure residents were treated with dignity by referring to them as 'feeders' based on their care needs. This issue was observed when a CNA was training another CNA and referred to a resident as a 'feeder,' instructing the trainee to bring food to the resident and return to feed him after serving others. Additionally, an RN used the term 'feeders' when discussing residents who required assistance with meals. The Director of Nursing acknowledged that using such labels was a dignity issue and noted that staff had been previously instructed not to use such terms during meal times.
Failure to Conduct Level II PASARR Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to refer a resident with identified mental illness for a Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination. The resident was admitted with multiple diagnoses, including unspecified sequelae of cerebral infarction, unspecified mood disorder, cognitive communication deficit, dementia, post-traumatic stress disorder, and bipolar disorder. The Minimum Data Set (MDS) assessment indicated moderate cognitive impairment and active diagnoses of non-Alzheimer's Dementia, Bipolar Disorder, and other mental health conditions. The resident was receiving antipsychotic medications routinely and had a behavior care plan due to agitated behavior, including refusing care and physical aggression. The Level I PASARR screening form identified the resident as having anxiety and psychotic disorders, with behaviors that could pose a danger to himself or others. Despite these findings, the facility did not complete a Level II PASARR evaluation, which was necessary due to the resident's serious mental illness. The Social Services Director acknowledged the oversight, stating that the admissions department was responsible for obtaining Level I PASARRs, which were then reviewed by the clinical team. The facility's policy required a screening for mental illness or mental retardation before admission, but the need for a Level II evaluation was missed in this case.
Inadequate Dialysis Monitoring and Documentation
Penalty
Summary
The facility failed to provide adequate dialysis care and monitoring for a resident with end-stage renal disease (ESRD) who required regular dialysis treatments. The resident, who also had severe cognitive impairment, was scheduled for dialysis three times a week. However, the facility did not consistently document the resident's vital signs and condition before and after dialysis sessions. Out of 17 dialysis visits, only eight reports were found, indicating a significant gap in monitoring and documentation. The North Wing Unit Manager and the Assistant Director of Nursing acknowledged that nurses were expected to chart progress notes whenever residents left for dialysis and upon their return. However, there were several instances where documentation was missing or incomplete, including vital signs and assessments of the dialysis port site. The facility's records showed inaccurate documentation of dressing findings, and vital signs were not consistently monitored, which did not meet the standards of practice for a resident with hypertension or dialysis needs. The facility's undated Dialysis Protocol required assessments of vital signs and other conditions before and after dialysis treatments, but this was not consistently followed. The Assistant Director of Nursing confirmed that the resident's vital signs and condition were not adequately monitored, and the communication form used between the facility and the dialysis center was not properly utilized. This lack of documentation and monitoring led to unreliable assessments of the resident's condition post-dialysis.
Failure to Provide Trauma-Informed Care for Veterans with PTSD
Penalty
Summary
The facility failed to provide ongoing monitoring and mitigate triggers of identified past trauma for two residents with PTSD. Resident #42, a male veteran with moderate dementia and PTSD, was admitted from a Veteran's acute care hospital. His care plan did not include a focus on PTSD, and staff were unaware of his background and specific needs related to his condition. Despite being identified with PTSD on admission, there was no ongoing monitoring or interventions to address his triggers, such as loud noises, which were observed to cause irritability and anger. Resident #72, another male veteran with severe cognitive impairment and PTSD, also lacked appropriate trauma-informed care. His care plan included a focus on PTSD, but he reported not receiving any special services for his condition. Staff were unaware of his specific needs, and his room was frequently exposed to loud alarms, which were identified as triggers for his PTSD. The facility's Social Services Director confirmed that PTSD was not included in the PASARR, and there was no follow-up assessment to monitor his triggers. The facility's Trauma Informed Care Policy aimed to provide a supportive environment for residents with past trauma, but it was not effectively implemented. The policy included measures to minimize noise and train staff to recognize signs of distress, but these were not observed in practice. The Director of Nursing acknowledged the facility's higher population of veterans with special mental health needs, yet the necessary ongoing monitoring and interventions were not in place for the residents reviewed.
Failure to Coordinate Hospice Services for Resident
Penalty
Summary
The facility failed to ensure proper coordination of hospice services for a resident receiving hospice care. The resident, who was admitted to the facility following hospitalization for congestive heart failure exacerbation, was on hospice care due to end-stage heart disease. Despite the care plan indicating that the facility nurse should notify hospice regarding changes in patient status, there was no documentation of hospice being informed about the initiation of intravenous fluids for the resident. The Medical Director ordered the IV fluids due to the resident's risk for dehydration, based on an abnormal lab result and discussions with CNAs, but did not notify hospice of this new order. The hospice supervisor and registered nurse confirmed that they were not informed about the IV fluids, which were not typically part of hospice care goals. The Director of Nursing entered the order into the system but assumed that communication with hospice had already occurred. The facility's agreement with hospice required immediate notification of any changes in the condition of a hospice patient, which was not adhered to in this case. This lack of communication and coordination between the facility and hospice led to the deficiency in care for the resident.
Failure to Perform Hand Hygiene During Meal Delivery
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the transmission of communicable diseases by not enforcing proper hand hygiene practices among staff. On the morning of March 12, 2025, a Certified Nursing Assistant (CNA) and a trainee CNA were observed delivering meals to residents in the East wing without performing hand hygiene between rooms, despite a Contact Precautions sign indicating the necessity of hand hygiene. The Director of Nursing (DON) witnessed the incident and reminded the trainee to disinfect her hands, which she then did, but the primary CNA only acknowledged the reminder without taking immediate action. The facility's policy requires staff to wash hands or use hand sanitizer between residents when delivering meal trays, which was not adhered to in this instance.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Orlando
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster Towers | 2.1 mi | ★★★★★ | 0 | 0 |
| Orlando Health And Rehabilitation Center | 2.2 mi | ★★★★★ | 3 | 0 |
| South Orange Health And Rehabilitation Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Courtyards Of Orlando Care Center And Rehab | 2.4 mi | ★★★★★ | 5 | 0 |
| Delaney Park Health And Rehabilitation Center | 2.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.