Garfield Neurobehavioral Center

In the surveyor’s words

From the most serious findings on record at Garfield Neurobehavioral Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Aug 1, 2025

  Based 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.An Immediate Jeopardy situation (IJ, a situation in which a facility's actions places one or more residents in jeopardy of being significantly harmed up to the point of possible death if not immediately corrected)… […]

• Actual harm, isolatedF600Feb 21, 2025

  Based 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. Findings: A review of Resident 1's admission record, dated 1/22/25, indicated Resident 1 was admitted to the facility on [DATE] for Huntington's disease (a disease in the brain which results in cognitive and functional decline) and paranoid schizophrenia (psychiatric disease which causes distrust of information and other people). […]

• No harm, potential for more than minimal, patternF759Aug 1, 2025

  Based 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)… […]

• No harm, potential for more than minimal, patternF761Aug 1, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF812Aug 1, 2025

  Based 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. […]