CareGuard is a Patient Safety Organization listed by the Agency for Healthcare Research and Quality, PSO P0268. It is a program of Sevadar Foundation Inc. and it is the most consequential thing this foundation carries.
The problem it exists for
There is usually a long distance between the person who notices a problem in a care facility and the person with the authority and the budget to fix it. A site manager knows about the broken call button. An owner two states away finds out when it becomes a claim. Everyone in between has a reason not to pass it along.
That distance has a measurable cost. In the most recent national study of its kind, the HHS Office of Inspector General reviewed a sample of Medicare skilled nursing facility stays and found that an estimated 22 percent of Medicare beneficiaries experienced adverse events during their SNF stays, with a further 11 percent experiencing temporary harm events. Physician reviewers judged 59 percent of those events clearly or likely preventable. Those figures describe stays sampled in August 2011 — they are the most recent national incidence estimates OIG has published, and their age is part of the point.
Falls are the most familiar version of the same problem in the wider population: the CDC reports that more than one in four adults aged 65 and older — over 14 million people — report falling each year, and that the age-adjusted fall death rate among older adults rose 21 percent, from 64.7 per 100,000 in 2018 to 78.4 per 100,000 in 2024.
What CareGuard does
Safety reviews
A structured review of a facility across a defined set of categories — the physical plant and environment, memory care, restraint reduction, resident rights, ongoing monitoring and facility-wide compliance among them.
A reporting channel
Staff, families and visitors can report what they see, and the report travels to facility ownership and the attorneys ownership has designated — rather than stopping at the shift supervisor.
Federal protection
Information that meets the statutory definition of patient safety work product is privileged and confidential under federal law. That protection is what makes candid reporting possible at all.
The listing
| PSO name | CareGuard |
| AHRQ-assigned PSO number | P0268 |
| Listed effective | November 22, 2024 |
| Listing period | Three years, to November 21, 2027 |
| Listed by | The Secretary of the U.S. Department of Health and Human Services, through AHRQ |
| Parent organization | Sevadar Foundation Inc. |
The listing is a matter of public record and appears in AHRQ’s listed-PSO directory. What being listed does and does not mean →
Veterans conduct the physical-plant reviews
The part of a review that covers the building — corridors, handrails, exits, floors, call systems — is conducted by veterans. That is a deliberate choice about who is good at reading a building for the way a plan fails. How the review program works →
Go deeper
What a Patient Safety Organization is
The statute, the protection, and why the protection is the mechanism rather than a legal footnote.
Facility safety reviews
What a review covers and how a finding travels to someone who can act on it.
CareGuard is not a regulator. A listed PSO is a private organization operating under a federal statute. It does not conduct state survey, issue citations, levy fines or revoke licenses. If you need a regulator, CareGuard’s own site points you at the official routes: emergencies and official routes. In an emergency, call 911.
Sources
Every figure on this page is traceable. Where a source is a government report, the year the data describe is named alongside it, because it is usually not the year of publication.
- U.S. Congress. Patient Safety and Quality Improvement Act of 2005, Public Law 109–41, enacted July 29, 2005; 119 Stat. 424. Codified at 42 U.S.C. §§ 299b–21 to 299b–26. govinfo.gov
- U.S. Department of Health and Human Services. Patient Safety and Quality Improvement; Final Rule, 73 Fed. Reg. 70732 (November 21, 2008). Codified at 42 C.F.R. Part 3, “Patient Safety Organizations and Patient Safety Work Product.” govinfo.gov
- Agency for Healthcare Research and Quality, Center for Quality Improvement and Patient Safety. Letter listing CareGuard PSO as a Patient Safety Organization, November 22, 2024 — PSO number P0268, listing effective November 22, 2024 for three years, to November 21, 2027. Document on file with Sevadar Foundation.
- Agency for Healthcare Research and Quality. Listed PSO directory entry for CareGuard, PSO P0268. pso.ahrq.gov/pso/careguard
- U.S. Department of Health and Human Services, Office of Inspector General. Adverse Events in Skilled Nursing Facilities: National Incidence Among Medicare Beneficiaries. Report OEI-06-11-00370, February 27, 2014. Data describe a sample of Medicare SNF stays in August 2011. oig.hhs.gov
- Centers for Disease Control and Prevention. Facts About Falls and Older Adult Falls Data, Older Adult Fall Prevention, pages dated January 27, 2026 and February 26, 2026. cdc.gov