Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
8’24
9’25
1’26
18 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Jul 2, 2026 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Aug 1, 2025 | J · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Routine |
| Aug 1, 2025 | D · potential | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Routine |
| Aug 1, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Routine |
| Aug 1, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Aug 1, 2025 | E · potential | Ensure medication error rates are not 5 percent or greater. | Routine |
| Aug 1, 2025 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Aug 1, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Aug 1, 2025 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Feb 21, 2025 | G · harm | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Mar 21, 2024 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Mar 21, 2024 | D · potential | Ensure each resident receives an accurate assessment. | Routine |
| Mar 21, 2024 | E · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Routine |
| Mar 21, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Mar 21, 2024 | E · potential | Dispose of garbage and refuse properly. | Routine |
| Mar 18, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Mar 18, 2024 | D · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Mar 18, 2024 | D · potential | Ensure that residents are free from significant medication errors. | Complaint |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Garfield Neurobehavioral Center
1451 28th Avenue, Oakland, CA 94601 · (510) 261-9191
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 05A396
- Certified beds
- 96
- Legal owner
- Legal Business Name Not Available
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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