ORLANDO, FL — Federal health inspectors cited Guardian Care Nursing & Rehabilitation Center for multiple deficiencies during a March 12, 2025 survey, including a repeat citation for failing to prevent a cognitively impaired resident from exiting the building through an unsecured door. The facility, located at 350 South John Young Parkway, also received citations for infection control failures and incomplete pneumococcal vaccination documentation.
Cognitively Impaired Resident Exits Through Unalarmed Door
The most significant finding from the federal inspection involved Resident #87, a cognitively impaired individual who exited the facility through a door that was neither secured nor equipped with a functioning alarm. According to the inspection report, the resident left the building in an attempt to locate his wife.
What makes this citation particularly concerning is that it represents a repeat deficiency — meaning Guardian Care had been previously cited for the same type of violation and had failed to implement adequate corrective measures.
Elopement — the term used in long-term care when a resident leaves a facility without staff knowledge or authorization — represents one of the most serious safety risks in nursing home care. For residents with cognitive impairment, including those with dementia or Alzheimer's disease, unsupervised departures from a facility can lead to exposure to traffic, extreme weather, dehydration, falls, and disorientation. In Florida, where temperatures regularly exceed 90 degrees during much of the year, an unsupervised resident outdoors faces heightened risks of heat-related illness.
Federal regulations under F689 require nursing facilities to ensure that the environment is free from accident hazards and to provide adequate supervision based on each resident's assessed needs. For residents with known cognitive impairments and wandering behaviors, this typically means secured exits, functioning alarm systems, and staff awareness protocols.
Prior Citation Did Not Lead to Adequate Correction
During the March 2025 survey, the facility's Executive Director told inspectors that the Quality Assurance and Performance Improvement (QAPI) committee met monthly and held additional meetings when issues arose. She described a process where monthly reports and departmental audits were used to identify areas of concern, with patient safety given top priority.
The Executive Director stated that the committee "always looked to identify a root cause to prevent the event from recurring" and that auditing measures and documentation were placed on the facility's Performance Improvement Plan.
However, when asked about the repeat nature of the citation, the Executive Director characterized the previous elopement as the result of a door malfunction and described the current incident as a different situation. She could not explain how Resident #87 was able to open the door and leave the building without staff knowledge if the door had in fact been alarmed.
Critically, the Executive Director acknowledged that not all exit doors had been alarmed following the previous elopement event. Emergency-exit-only doors — which residents should not be using for routine egress — remained without alarms, creating pathways for cognitively impaired residents to leave undetected.
In standard nursing home safety practice, when a facility receives an elopement citation, the expected corrective response includes a comprehensive audit of all potential exit points, installation or repair of door alarms on every exterior door, implementation of wander-guard or similar electronic monitoring systems for at-risk residents, and staff retraining on elopement prevention protocols. The failure to alarm all exits after a known elopement event represents a significant gap in the facility's corrective action.
Infection Control Violations During Meal Service
Inspectors also documented infection prevention failures under F880, observing staff members who failed to perform hand hygiene while delivering breakfast trays to residents on the East wing.
On the morning of March 12, a Certified Nursing Assistant identified as CNA F, along with a trainee designated CNA G, entered a resident's room that had a Contact Precautions sign posted at the door. Contact Precautions signage indicates that the resident has a known or suspected infection that can be transmitted through direct or indirect contact, and anyone entering the room is required to perform hand hygiene and follow additional protective protocols.
Despite the posted precautions, neither CNA F nor CNA G performed hand hygiene before entering the room or after leaving it. CNA F then proceeded to enter the next resident's room — again without washing or sanitizing her hands — before returning to the food cart, retrieving another meal tray, and delivering it to yet another resident's room, all without hand hygiene at any point.
The Director of Nursing was present in the area and observed the trainee's failure to perform hand hygiene. She reminded CNA G to disinfect her hands between residents. When the observation was brought to CNA F's attention, the experienced aide "only nodded and stated, OK," according to the inspection report.
Why Hand Hygiene Failures Matter in Nursing Homes
Nursing home residents are among the most vulnerable populations for healthcare-associated infections. Many have compromised immune systems, chronic wounds, urinary catheters, or respiratory conditions that make them particularly susceptible to infections transmitted through contaminated hands.
Contact Precautions are implemented specifically because a resident is known or suspected to harbor an organism — such as MRSA, C. difficile, or VRE — that poses a transmission risk. When staff members bypass hand hygiene protocols in a Contact Precautions room and then proceed to handle food trays for other residents, they create a direct pathway for cross-contamination.
The facility's own policy, titled Hand Hygiene and Resident Cleanliness Policy During Meal Times, explicitly requires staff to wash hands or use hand sanitizer between residents when delivering meal trays. The observed behavior violated not only federal infection prevention standards but also the facility's internal protocols.
The fact that a trainee was involved adds another dimension to this finding. New staff members learn workplace norms from the experienced employees who train them. When a seasoned CNA demonstrates through her actions that hand hygiene is optional, it establishes a culture of non-compliance that can be difficult to reverse.
Missing Pneumococcal Vaccination Records
The third citation, issued under F883, addressed the facility's failure to maintain proper documentation for pneumococcal vaccinations. Inspectors found that three out of five residents reviewed for immunization records — Residents #20, #9, and #59 — had no documentation showing consent, refusal, or medical contraindication for the pneumococcal vaccine.
When confronted with the finding, the Director of Nursing and Assistant Director of Nursing confirmed they could not locate any records for these residents. The DON acknowledged that staff "could not find documentation to show if the residents had previously received the vaccination, refused it or if the vaccination was even offered."
The DON attributed the gap to the previous Assistant Director of Nursing, who had been responsible for obtaining consents and apparently only documented influenza vaccinations while neglecting pneumococcal records.
Guardian Care's own policy states that all residents must be offered a Pneumococcal Polysaccharide Vaccine upon admission and every five years thereafter. Pneumococcal disease can cause pneumonia, bacteremia, and meningitis — conditions that carry particularly high mortality rates among elderly nursing home residents. The CDC has identified nursing home residents as a high-priority population for pneumococcal vaccination due to their age, congregate living environment, and prevalence of underlying health conditions.
The absence of documentation means it is unknown whether these residents were ever offered the vaccine, creating both a regulatory compliance gap and a potential gap in their preventive care.
A Pattern of Oversight Failures
Taken together, the three citations from the March 2025 inspection paint a picture of systemic oversight weaknesses at Guardian Care Nursing & Rehabilitation Center. The repeat elopement citation suggests that the facility's QAPI process — despite the Executive Director's description of robust monthly meetings and root-cause analysis — did not translate into effective corrective action on the ground. Exit doors remained unalarmed. Infection control protocols were not followed even when a supervisor was present. And vaccination documentation fell through the cracks due to inadequate staff transitions.
For families with loved ones at Guardian Care, or those considering placement at the facility, the full inspection report is available through the Centers for Medicare & Medicaid Services website at medicare.gov/care-compare. The report contains detailed findings and the facility's plan of correction for each deficiency.
Guardian Care Nursing & Rehabilitation Center is required to submit a plan of correction addressing each cited deficiency and demonstrating how it will prevent recurrence. The facility's compliance will be subject to follow-up review by state survey staff.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Guardian Care Nursing & Rehabilitation Center from 2025-03-12 including all violations, facility responses, and corrective action plans.
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