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Nursing HomeMedicaid

Garfield Neurobehavioral Center

Meets baseline Medicare standards with room for improvement. A tour and talking to current residents' families is the best next step.

1451 28th Avenue, San Antonio · Oakland, CA 9460196 bedsLicensed & Active
3/5
Medicare
Inspection
Quality
Staffing
Google rating
4.5/5

based on 2 Google reviews

Garfield Neurobehavioral Center Nursing Home in Oakland, CA — Street View
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What this means for your family

Garfield Neurobehavioral Center falls in the middle range of Medicare quality ratings. This means baseline standards are met, but there is room for improvement. A personal tour and conversation with current residents' families will give you the best picture of daily life here.

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.80hrs
OK
Registered nurses for medical care
Total Nursing
5.06hrs
OK
All nurses + aides combined
Staff Turnover
14%
Lower is better (< 30% = good)
RN Turnover
0%
Lower is better (< 30% = good)

This facility meets the national staffing benchmarks. Higher staffing is linked to fewer falls and better day-to-day care.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 14 measures

Medicare Rating
4/ 5
Better Than Avg

7

measures

Worse Than Avg

4

measures

Mixed Results

3

measures

Long-Stay Residents
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility83.3%
Worse than Avg
Here
83.3%
US
15.4%
CA
11.6%
Alameda
11.5%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility40.5%
Worse than Avg
Here
40.5%
US
19.5%
CA
13.7%
Alameda
9.0%
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
12.1%
CA
7.0%
Alameda
3.8%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility9.6%
Mixed vs Avgs
Here
9.6%
US
19.4%
CA
10.7%
Alameda
7.6%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility7.6%
Better than Avg
Here
7.6%
US
15.3%
CA
10.5%
Alameda
9.1%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
CA
98.6%
Alameda
97.6%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

8deficiencies
Near state avg (15.4)
4 complaint-triggered

This facility has concerning recurring issues with abuse protection appearing across multiple surveys including family complaint reports, alongside persistent problems with medication management and fire safety systems. Recent inspections show continued deficiencies in preventing resident abuse, medication error rates, and fire safety equipment maintenance, though all violations have correction dates indicating the facility is addressing identified problems.

Aug 1, 2025Routine
15
0600Immediate jeopardy · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

0039Potential for harm · WidespreadCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0759Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0880Potential for harm · PatternCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0161Potential for harm · IsolatedCorrected

Construction Deficiencies

Use approved construction type or materials.

0293Potential for harm · IsolatedCorrected

Egress Deficiencies

Have properly located and lighted "Exit" signs.

0919Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0607Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0353Minimal · WidespreadCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Feb 21, 2025Complaint
1
0600Actual harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Mar 21, 2024Routine
17
0711Potential for harm · WidespreadCorrected

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

0161Potential for harm · PatternCorrected

Construction Deficiencies

Use approved construction type or materials.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0814Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

0026Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

Establish roles under a Waiver declared by secretary.

0039Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

0321Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0324Potential for harm · IsolatedCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0345Potential for harm · IsolatedCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0363Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0919Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

0920Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

0584Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Mar 18, 2024Complaint
3
0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0760Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Jan 6, 2022Routine
14
0032Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

Provide primary/alternate means for communication.

0023Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

Establish policies and procedures for medical documentation.

0030Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

0031Potential for harm · IsolatedCorrected

Emergency Preparedness Deficiencies

Provide emergency officials' contact information.

0211Potential for harm · IsolatedCorrected

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

0321Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0324Potential for harm · IsolatedCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

0353Potential for harm · IsolatedCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0363Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0711Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

0712Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

0918Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0923Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Ownership & Operations

Who Operates This Facility

Owner / Operator

Garfield Neurobehavioral Center

Organization Type

for profit

Ownership & Management

Owners

Undisclosed

Ownership Data Not Available · Organization

Source: Medicare provider data

Contact

Get in Touch

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References & Resources

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