Cycle 1
Health 2025-03-12 · Fire 2025-03-12
12 health deficiencies
Top issue: Administration (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Orlando, FL
Guardian Care Nursing & Rehabilitation Center
3-star overall rating with 2-star inspections with $15,737 in total fines with 12 recent health deficiencies
350 South John Young Parkway, Orlando, FL
(407) 295-5371
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
92
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.67
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.32
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.37
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.64
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.75
CMS adjusted RN staffing hours
Adjusted total hours
3.89
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.52% · Performance 23.13% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 8.52% · Performance 9.69% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 4.35 hours · Performance 0.76 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.61% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 6.15% · Lower 95% interval 6.42% |
| Discharge to community | 47.58% |
50.57%
3 pts worse
|
No Different than the National Rate · Eligible stays 39 · Observed rate 35.9% · Lower 95% interval 34.87% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 46 · Denominator 46 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 46 |
| Discharge self-care score | 75% |
53.69%
21.3 pts better
|
Numerator 24 · Denominator 32 |
| Discharge mobility score | 68.75% |
50.94%
17.8 pts better
|
Numerator 22 · Denominator 32 |
| Pressure ulcers or injuries, new or worsened | 4.35% |
2.29%
2.1 pts worse
|
Numerator 2 · Denominator 46 · Adjusted rate 3.18% |
| Healthcare-associated infections requiring hospitalization | 9.69% |
7.12%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 18.42% · Lower 95% interval 5.84% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 158 |
| Staff flu vaccination coverage | 3.33% |
42%
38.7 pts worse
|
Numerator 5 · Denominator 150 |
| Discharge function score | 75% |
56.45%
18.5 pts better
|
Numerator 24 · Denominator 32 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.1
0.2 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.5 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.2
0.8 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.4 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.8% |
97.8%
3 pts worse
|
93.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 97.7% · Q3 89.2% · Q4 97.5% · 4Q avg 94.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.0% |
99.2%
13.2 pts worse
|
95.5%
9.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
2.6%
0.5 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.2% · Q3 3.6% · Q4 2.5% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
3.7%
2.7 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.3% · Q3 1.3% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
5.9%
1.3 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.9% · Q3 6.5% · Q4 4.1% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.2% |
15.7%
5.5 pts better
|
19.6%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 11.1% · Q3 11.2% · Q4 9.5% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.7% |
9.8%
3.9 pts worse
|
16.7%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 14.0% · Q3 14.5% · Q4 11.1% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.2% |
11.7%
14.5 pts worse
|
16.3%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 27.0% · Q3 24.9% · Q4 28.1% · 4Q avg 26.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.8% |
9.8%
12 pts worse
|
14.9%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 14.5% · Q3 24.7% · Q4 22.4% · 4Q avg 21.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.4%
0.1 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
0.8%
0.5 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 14.8% |
12.5%
2.3 pts worse
|
19.8%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 15.2% · Q3 14.5% · Q4 16.4% · 4Q avg 14.8% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.1%
1 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.5% · Q3 3.0% · Q4 3.1% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
94.3%
4.5 pts better
|
81.7%
17.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 100.0% · Q3 100.0% · Q4 99.1% · 4Q avg 98.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.4% |
9.3%
6.9 pts better
|
12.0%
9.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 2.4% · Observed 2.6% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.0% |
26.2%
3.2 pts better
|
23.9%
0.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.0% · Observed 23.1% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-07-29 · Fire 2023-07-29
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-02-17 · Fire 2022-02-17
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-07-29
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-09-01
E · Potential for more than minimal harm
2022-02-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-17
E · Potential for more than minimal harm
2022-02-17
K932 · Smoke Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-03-17
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-12
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2025-04-12
E · Potential for more than minimal harm
2025-03-12
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-04-12
E · Potential for more than minimal harm
2025-03-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-12
E · Potential for more than minimal harm
2025-03-12
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-04-12
E · Potential for more than minimal harm
2025-03-12
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-03-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-03-12
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-03-12
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-03-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-03-12
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-03-12
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-03-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-12
J · Immediate jeopardy
2023-07-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-01
D · Potential for more than minimal harm
2023-07-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-09-01
D · Potential for more than minimal harm
2022-02-17
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-03-17
D · Potential for more than minimal harm
2022-02-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-03-17
D · Potential for more than minimal harm
2022-02-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-03-17
D · Potential for more than minimal harm
2022-02-17
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-03-17
D · Potential for more than minimal harm
2022-02-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-03-17
Penalties and ownership
What sits behind the stars
$15,737
2023-07-29
Fine
Fine · fine $15,737
Fine
Ownership
Abrahams, Eloise
Corporate Director · Individual
Abrahams, Eloise
W-2 Managing Employee · Individual
Garrett, Mark
Corporate Officer · Individual
Reddick, Alzo
Corporate Officer · Individual
Richardson, Johnny
Corporate Officer · Individual
Ricks, Jim
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Westminster Towers
Orlando, FL
3-star overall rating with 2-star inspections with $22,133 in total fines with 7 recent health deficiencies
#2
Orlando Health And Rehabilitation Center
Orlando, FL
1-star overall rating with 1-star inspections with abuse icon flag with $65,951 in total fines with 22 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
South Orange Health And Rehabilitation Center
Orlando, FL
4-star overall rating with 4-star inspections with $14,442 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Jump out