Garfield Neurobehavioral Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of four sampled residents (Resident 1) from physical abuse when Resident 1 was hit on the head and arms by Resident 2 during an altercation on 8/16/25. This failure resulted in Resident 1 suffering facial pain and a headache. During a review of Resident 1's facility document admission Record (AD), printed on 7/2/26, the AD indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a general term for a group of conditions that affect the brain. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep one resident, Resident 47, free from sexual abuse when Certified Nursing Assistant (CNA) 1 witnessed Resident 47 being sexually abused by Resident 2 and then closed the door without intervening, leaving Resident 47 at risk for further abuse by Resident 2. This failure resulted in Resident 47 being sexually abused and had the potential for psychosocial harm. Furthermore, this failure had the potential to result in further sexual abuse towards Resident 47 and/or other vulnerable residents in the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a medication error rate of 5% (%: percent, a unit of measure) or less when two medication errors were observed out of 36 opportunities: Resident 44 did not receive two drops of Systane Eye Solution in each eye, per physicians order. Resident 30 did not receive Vitamin B12 Oral Tablet Extended Release 1000mcg (Cyanocobalamin), per physicians order. This failure resulted in a medication error rate of 5.56% and placed Resident 44 and Resident 30 at risk for receiving a subtherapeutic dose and compromised effects of the medications.1. A record review of Resident 44's physician orders dated 12/17/2024, indicated to instill 2 drops of Systane Ophthalmic (Eye) Solution 0.4-0.3 % (PolyethyleneGlycol-Propylene Glycol) in both eyes two times a day for chronic dry eyes (when tears are unable to lubricate eyes). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate storage and labeling of medications when the following occurred:Medication refrigerator in Station 3 medication room did not have a working thermometer to allow for accurate temperature monitoring. Mutli-use over the counter (OTC) Artificial Tears (Lubricating Eye Drops; for relief of dry eyes) was opened and unlabeled without Resident identifier, and undated with first use/open date in Station 2 medication cart. Two expired Antipsychotic medication bubble packaging cards found were in Station 2 medication cart. An Apple Juice box was found in Station 3 medication freezer where other medications were stored. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when:a. A mounted can opener was dirtyb. A toaster oven was dirtyc. A knife rack was dirtyd. Multiple food items were stored beyond the use by date. e. Food items stored in the freezer were unlabeled There failures placed the facility's 56 residents, who received food from the kitchen, at risk for foodborne illnesses. During the initial kitchen observation on 7/28/25 at 9:30 a.m. with Food Service Manager (FSM), the following was observed: (a) mounted can opener was dirty with yellow/orange and black residue build up and the blade coating was peeling off(b) countertop toaster oven was dirty with white/brown/black debris inside the compartment and the conveyor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were implemented when the following was observed:Registered nurse (RN) 1 did not sanitize (disinfect; removal of bacteria, etc.) a blood pressure cuff between use for Resident 27 and Resident 37. RN 1 did not sanitize a medication tray between uses during morning medication pass between each Residents observed (Resident 36, Resident 27, Resident 37, Resident 44, Resident 30, and Resident 5). This failure placed facility residents at risk for contracting community infections. During an observation on 07/29/2025 at 08:31 AM RN1 did not sanitize a blood pressure cuff or medication tray after use for Resident 27 and before use for Resident 37. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure their abuse policy and procedure was implemented for one of one sampled Residents (Resident 47). This failure resulted in Resident 47 being sexually abused and had the potential for other residents to be unprotected against abuse. During a review of Resident 47's admission Record dated 7/29/25, the admission record showed Resident 47 was admitted to the facility on [DATE]. During a review of Resident 47's Quarterly Minimum Data Set (MDS - an assessment tool used to guide care), dated 6/5/25, MDS showed resident 47 had multiple diagnoses that included Huntington's Disease (brain disorder that causes involuntary movements cognitive decline, and behavioral changes), non-Alzheimer's dementia (a condition that causes decline in cognitive abilities such as thinking), and depression. During an interview on 7/29/25 at 1:15 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement its abuse Policy and Procedure (P&P) when the facility did not report an incident of sexual abuse to law enforcement for two of two Residents (Residents 47 and 2) within two hours of the incident occurring. This failure had the potential to put other residents at risk of further abuse. During a review of Resident 47's admission Record dated 7/29/25, the admission record showed Resident 47 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive epistaxis (nosebleed) care plan for Resident 5 to address medical needs. This failure placed Resident 5 at risk for potential harm from bleeding. During record review of admission record, printed on 8/01/25, Resident 5 was admitted on [DATE]. During record review of Resident 5's Minimum Data Set (MDS, an assessment used to guide care) dated 7/17/25, indicated Resident 5's Brief Interview for Mental Status (BIMS, an assessment used to assess mental status) score was 09 out of 15, indicated Resident was mildly impaired. During record review on 07/29/2025 at 4:30 PM of Resident 5's 'Post Assessment Form Part 1,' dated 4/11/25 at 02:38 AM indicated in the hallway, Resident noted blood dripping on his nose and took 5 mins to stop the bleeding, denies he pick his nose. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from abuse when Certified Nursing Assistant 1 (CNA 1) sexually abused Resident 1 twice in one day. This failure resulted in Resident 1 being sexually abused and had the potential for psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure controlled medications (substances that have an accepted medical use, medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V, and have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence) in emergency kits (e-kit, a box with emergency medications) were stored appropriately when: 1. two e-kits containing controlled substances were found in locked boxes that were not permanently affixed to the refrigerator in Med room [ROOM NUMBER] and Med room [ROOM NUMBER] 2. an e-kit containing controlled substances was found unsecured on a shelf in Med room [ROOM NUMBER] 3. an e-kit containing controlled substances was found unsecured in the refrigerator in Med room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards of food and safety when: 1. Freezer and refrigerator: - Inside Freezer 1, a large, half full, opened bag of frozen potato wedges was without a used-by date. - Inside the three-door paneled refrigerator, three cups of individually scooped protein pudding had no label and used-by date. 2. Equipment: - Ice machine scoop holder was unclean. - An unclean bread knife was stored in the knife rack. - Single-door freezer 3 had ice build-up on the top shelf, directly below the freezer fan. - Dietary staff did not sanitize the thermometer in between use. 3. Food Service Worker 1's (FSW 1) hair was not completely secured to the hairnet. 4. Environment: - Kitchen entrance sink had a leaky faucet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of two garbage dumpster bins located outside the facility grounds had lids that tightly closed. This failure had the potential to attract pests to the facility and lead to pest-related disease for 60 residents out of a facility census of 60.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide one of four sampled residents (Resident 17), routine housekeeping and maintenance services to maintain a clean, sanitized wheelchair/recliner for resident's daily use. This failure resulted in an undignified and unclean wheelchair for Resident 17's use.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set Assessment (MDS a standardized resident assessment tool) was accurate for one of 22 sample residents (Resident 46). For Resident 46, the facility failed to accurately code a fall with major injury (rib fracture) on Resident 46's MDS. Failure to accurately capture fall data may impact care planning and fall interventions for Resident 46.

Inspectors wroteBased on observation and interview, the facility failed to provide adequate supervision to prevent a physical altercation for two of two sampled residents (Resident 1 and Resident 2) when assigned staff members did not closely monitor the residents who were dining during dinnertime in the large dining room. This failure resulted in an unwitnessed altercation between Resident 1 and Resident 2 wherein Resident 2 hit Resident 1 with his right-hand ?st. This created a red discoloration underneath Resident 1 ' s left eye and had the potential to cause Resident 1 emotional and/or psychological distress, as well as place all the other residents eating in the large dining room at safety risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received medication according to the physician orders for Quinidine (a medication used to treat fast or irregular heartbeat [arrythmia]). The facility also failed to notify Resident 1 ' s physician of the missed medications in a timely manner. This failure to inform the physician of Resident 1's missed medications prevented the physician from prescribing a change in treatment or monitoring and had contributed to Resident 1 receiving 10 shocks, from the Cardiology Clinic to his defibrillator (a device that provide electric shock to the heart to restore a normal heartbeat) on 5/21/22 and was sent out to acute hospital via 911 for evaluation and further treatment on 5/23/22.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from medication error when Quinidine (a medication used to treat fast or irregular heartbeat [arrythmia]) was not administered as ordered by the physician. This failure contributed to Resident 1 receiving 10 shocks, from the Cardiology Clinic to his defibrillator (a device that provide electric shock to the heart to restore a normal heartbeat) on 5/21/22 and sent out to acute hospital via 911 for evaluation and further treatment on 5/23/22.