Guardian Care and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Guardian Care and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 29, 2025

  Based on interview, and record review, the facility failed to provide adequate supervision and ensure an accident-free environment for one of three sampled residents (Resident 103) when, Resident 103 fell while left unsupervised and partially secured in her gurney, in a transportation vehicle during transportation to a dialysis clinic (outpatient facility that provides dialysis treatment to residents with end-stage renal disease (ESRD) or chronic kidney failure, helping to clean their blood of waste and excess fluid when their kidneys cannot) on 7/3/25.This failure potentially resulted in Resident 103 sustaining a mild compression fracture (when the bone is crushed or compressed but not completely broken) in the L3 (the third lumbar vertebra (bone) in the spine located in the lower back… […]

• No harm, potential for more than minimal, widespreadF727Aug 17, 2026

  Based on observation, interview, and record review, the facility failed to provide the services of a full-time Director of Nursing (DON) to lead, guide, and direct nursing care for a census of 104.This failure decreased the facility's potential to provide accurate and safe nursing care and lead to confusion among nursing staff regarding leadership for resident needs.Findings:A review of the facility provided, STATION 2 DAILY ASSIGNMENT SHEET, dated 8/17/26, indicated a line for the DON's name and signature. Review of the assignment sheet for the DON name was blank. […]

• No harm, potential for more than minimal, widespreadF865Aug 29, 2025

  Based on interview and record review, the facility failed to implement and maintain a comprehensive QAPI (QAPI- a data driven and proactive approach to improvement used to ensure services are meeting quality standards) program and plan when the facility did not adhere to its QAPI policy and did not provide documentation or evidence of ongoing QAPI activities.These failures had the potential to impede the facility's ability to identify and correct quality of care issues which could place the residents at risk for unmet physical, psychosocial, and overall health needs.Findings:During a concurrent interview and record review on 8/29/25, at 1:55 PM, the Administrator (ADM) reviewed the QAPI program and confirmed that they did not have an appropriate monitoring and documentation portion of the… […]

• No harm, potential for more than minimal, widespreadF812Jun 24, 2025

  Based on observation, interview, and record review, the facility failed to store, prepared, distribute and serve food in accordance with professional standards for food service safety when .1. Dishes were stacked on top of each other while wet; and,2. Pots, pans, and food holding containers were dirty and damaged from use; and,3. A container of scoops, serving ladles, and utensils were left open; and,4. A steamer container had a yellowish residue located inside of it; and,5. A stove top had black sticky grime and food residue on top of it.These failures had the potential of leading to food borne illness in the 94 residents eating facility prepared meals.Findings:1. […]

• No harm, potential for more than minimal, widespreadF814Jun 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure garbage and refuse was properly contained when 1 of 2 outside dumpster lids were observed to be propped open with a stick for a census of 91.This failure had the potential to expose the residents' environment to pests, odors, or diseases.Findings:During a concurrent observation and interview on 6/24/25 at 10:10 AM with the Dietary Services Supervisor (DSS) in the outside dumpster area of the facility, a dumpster was observed to have the lid propped open. The DSS confirmed that the dumpster had the lid propped open with a stick. During an interview on 6/24/25 at 1:19 PM with [NAME] 2, [NAME] 2 stated that the dumpster lids should always be closed. […]