Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Garfield Neurobehavioral Center during CMS and state inspections, most recent first.
A CNA witnessed one resident sexually abusing another resident, then closed the door and left the room without intervening. The abused resident had Huntington's Disease, dementia, depression, and a care plan noting risk for victimization, but no active intervention addressing that risk. The other resident had impaired cognition and a care plan noting inappropriate sexual behavior. Staff later confirmed the CNA left because he was scared, and other staff did not immediately assess the resident after learning of the abuse.
Medication Error Rate Exceeded Allowed Threshold: Two medication errors were observed out of 36 opportunities, resulting in a 5.56% error rate. An RN administered only one drop of Systane eye solution in each eye instead of the ordered 2 drops per eye for a resident with chronic dry eyes, and gave a 500 mcg Vitamin B12 tablet instead of the ordered 1000 mcg dose for another resident. The RN stated she misread the eye drop dose and assumed the B12 tablets were 1000 mcg each.
Medication storage and labeling were deficient in the med carts and med refrigerator. An opened OTC eye drop bottle and an opened OTC bisacodyl suppository package were found unlabeled, without resident identifiers, and without dates opened, and two expired Quetiapine bubble cards were stored in a med cart drawer. In Station 3, the med refrigerator thermometer appeared broken, and a box of apple juice was stored in the freezer compartment with medications.
Unsanitary kitchen conditions were observed when a mounted can opener, toaster oven, and knife rack had visible residue and debris, and multiple food items were stored without required open or use-by dates or beyond those dates. The FSM stated the dirty equipment could contaminate food and clean knives, and that unlabeled or expired items should not be stored for use in food served to residents.
Failure to Disinfect Shared Equipment Between Resident Uses: An RN did not sanitize a BP cuff or med tray between uses for multiple residents during med pass. Observation showed the RN used shared equipment for one resident and then another without wiping it down first, despite stating that shared equipment should be disinfected between residents per facility policy.
A CNA witnessed a resident with pants down and his head over another resident’s private area, but left the room to get help instead of staying with the resident and initiating code green. Video confirmed the CNA left the room while the other resident remained inside. The affected resident had Huntington’s disease, non-Alzheimer’s dementia, and depression. The DON stated the CNA was not supposed to leave during the incident, and the facility’s abuse policy required staff to intervene and correct suspected abuse situations.
The facility failed to follow its abuse reporting policy when a sexual abuse allegation involving two residents was not reported to law enforcement within the required timeframe. Staff observed one resident with his pants down and the other resident with the first resident’s private area in his mouth, and a CNA reported the incident right away. The CD and DON acknowledged the delay, and facility records showed the report was not sent to law enforcement until several hours later, despite policy and AFL requirements for prompt reporting.
Failure to Maintain an Active Epistaxis Care Plan: A resident with chronic nosebleeds and Eliquis use had repeated epistaxis episodes documented, including bleeding that required pressure, cold compresses, nasal spray, ice chips, and temporary holds of anticoagulation per MD orders. Although staff stated the resident was being monitored and had previously had a short-term care plan, the comprehensive care plan did not contain an active epistaxis/nosebleed plan when the issue remained ongoing.
A resident with cognitive impairments and dependent on staff for care was sexually abused by a CNA, who was later arrested after evidence was found in their online storage. The facility identified the resident in the videos and confirmed the CNA's employment, violating the resident's right to be free from abuse.
Failure to Protect a Resident from Sexual Abuse
Penalty
Summary
The facility failed to keep a resident free from sexual abuse when a CNA witnessed another resident sexually abusing the resident and then closed the door and left the room without intervening. The resident involved had been admitted to the facility in December 2018 and had diagnoses including Huntington's Disease, non-Alzheimer's dementia, and depression. The resident's care plan identified the resident as being at risk for victimization, but it did not show an active intervention addressing that risk. The incident occurred when the CNA opened the resident's room door and saw another resident with his pants down and his mouth on the resident's private area. The CNA stated he left the room to get help because he was scared. Video footage showed the other resident entering the room, the door closing, the CNA opening the door, stepping in, then closing the door and walking away, leaving the other resident inside the room. Staff later confirmed that the CNA closed the door and left the other resident in the room. The other resident involved had diagnoses including impaired cognitive functions and awareness and had a care plan noting risk for physical altercations, property destruction, and inappropriate sexual behavior. Staff interviews showed that the expected response was to stay with the resident and call a code green, but the CNA did not do so. Additional staff stated they did not immediately check on the resident after learning of the abuse. The facility policy stated staff are required to intervene, identify, and correct situations where abuse or suspected crimes may occur.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less when 2 medication errors were observed out of 36 opportunities, resulting in a 5.56% error rate. One error involved a resident with chronic dry eyes whose physician order dated 12/17/2024 directed staff to instill 2 drops of Systane Ophthalmic Solution in both eyes twice daily. During observation, RN 1 placed one drop in the resident’s right eye and one drop in the left eye, and later confirmed the order but stated, "I thought I gave two." The second error involved a resident whose physician order dated 03/01/2024 directed Vitamin B12 Oral Tablet Extended Release 1000 mcg, 1 tablet by mouth daily as a supplement. During observation, RN 1 administered Vitamin B12 Oral Tablet Extended Release 500 mcg. During interview, RN 1 stated she was supposed to give two tablets to equal the ordered dose and explained she assumed the tablets in the bottle were 1000 mcg each, when they were 500 mcg. The facility’s Medication Administration policy stated the medication label should be read three times: when pulling the medication, when the dose is prepared, and before administration.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Medication storage and labeling were not maintained in accordance with facility policy and accepted principles. In Station 2 medication cart, an opened bottle of OTC Artificial Tears was found unlabeled, without a resident identifier, and without a date opened. In the same cart, two expired bubble packaging cards of Quetiapine 50 mg dated 02/25/25 were found in the second drawer. LVN 1 stated the eye drops had been opened that day and that it is important to label medications to prevent medication errors; she also stated the second drawer was for extra medications and that nurses should check expiration dates before administration. In Station 3, the medication refrigerator thermometer appeared broken and could not be read, although RN 5 stated the silver thermometer holder could be used to read it and reported the refrigerator temperature was 40 degrees F. A boxed apple juice was also found in the freezer compartment of the medication refrigerator, and RN 5 stated it had been there for years. In addition, an opened OTC Bisacodyl suppository package was found in the Station 3 medication refrigerator unlabeled, without a resident identifier, and without a date opened. Facility policy required refrigerated medications to be kept with a thermometer for temperature monitoring, outdated medications to be immediately removed from stock, refrigerated medications to be kept in closed and labeled containers separated from foods, and nurses to place a date-opened sticker on medications when one is not provided.
Unsanitary kitchen equipment and improperly labeled food storage
Penalty
Summary
The facility failed to store, prepare, and serve food under sanitary conditions when a mounted can opener was observed dirty with yellow/orange and black residue buildup and a peeling blade coating, a countertop toaster oven was dirty with white, brown, and black debris inside the compartment and conveyor, and a stainless steel wall-mounted knife rack was dirty with sticky white residue where clean knives were stored. During the kitchen observation, the Food Service Manager stated the can opener needed replacement because rust on the blade could get residents sick, the toaster had not been cleaned and debris could contaminate food residents consume, and the dirty knife rack could contaminate clean knives used for food preparation. The facility also had multiple food storage issues, including opened dairy products and other items without open or use-by dates, tofu with a prepared date of 7/22/25 and use-by date of 7/25/25, and seasonings/spices stored beyond their use-by dates such as ground white pepper, cumin seed, and ground turmeric. Additional opened food items, including waffle fries, French toast, and an egg frittata, were not labeled with open and/or use-by dates. The FSM stated that food items labeled beyond use-by should not be stored because they could be used in cooking food served to residents, and that all food items should be labeled so staff know when they should be discarded. Facility policy required can openers to be cleaned after each use and sanitized daily, toasters to be cleaned after each use, knives to be cleaned and sanitized after each use, frozen food to be labeled with the date placed in the freezer, and recommended maximum storage periods for spices of 6-12 months.
Failure to Disinfect Shared Equipment Between Resident Uses
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed when RN 1 did not sanitize a blood pressure cuff between use for Resident 27 and Resident 37, and did not sanitize a medication tray between uses during the morning medication pass for Residents 36, 27, 37, 44, 30, and 5. During observation on 07/29/2025 at 08:31 AM, RN 1 did not sanitize the blood pressure cuff or medication tray after use for Resident 27 and before use for Resident 37. During a later observation at 08:43 AM, RN 1 again used the blood pressure cuff and medication tray for Resident 37 without sanitizing them after use by Resident 27. In interview, RN 1 stated shared equipment such as a vital sign machine, blood pressure cuff, and medication tray should be sanitized between each resident and stated the facility policy required shared equipment to be wiped down with a germicidal wipe and allowed to air dry for three minutes. Record review of the facility’s policy and procedure for cleaning and non-critical reusable equipment stated reusable equipment and medical devices are to be reprocessed through cleaning followed by disinfection between individuals served.
Failure to Follow Abuse Reporting and Intervention Policy During Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to implement its abuse prevention and reporting policy for one sampled resident when a CNA witnessed another resident with his pants pulled down in the resident’s room and his head positioned over the resident’s private area. The CNA stated he saw the resident’s penis showing, but he left the room to get help and later confirmed he closed the door and left the other resident inside because he was scared. The DON stated the CNA was not supposed to leave the resident when witnessing abuse and was expected to stay with the resident and initiate code green to alert other staff. Resident 47’s record showed diagnoses including Huntington’s disease, non-Alzheimer’s dementia, and depression. Video review confirmed Resident 2 entered Resident 47’s room, the door closed, the CNA looked into the room and then left, and Resident 2 exited the room shortly afterward. The facility’s abuse policy defined sexual abuse and required staff to intervene, identify, and correct situations where abuse or suspected crimes may occur, and its change-in-status policy stated a licensed nurse would assess involved individuals without delay in suspected physical abuse.
Failure to Timely Report Sexual Abuse Allegation
Penalty
Summary
The facility failed to implement its abuse policy and procedure when it did not report a sexual abuse incident involving two residents to law enforcement within the required timeframe. The report states that on 7/26/25 staff observed one resident with his pants down and the other resident with the first resident’s private area in his mouth. A CNA later stated he saw one resident with his pants pulled down to his legs and his head on the other resident’s private part, and he reported it right away. Resident 47’s records showed diagnoses including Huntington’s disease, non-Alzheimer’s dementia, and depression. Resident 2’s records showed diagnoses including unspecified symptoms and signs involving cognitive functions and awareness. Nursing progress notes documented the sexual abuse allegation for both residents on 7/26/25, and the Clinical Director stated she initiated the investigation but did not notify law enforcement right away. She stated the incident occurred at 2:25 p.m. but law enforcement was not called until 6:25 p.m., and she explained that it was "a lot going." The Director of Nursing stated she was aware of a two-hour reporting requirement if there was significant injury, and said the incident was not reported within two hours because Resident 47 did not have significant injury. She also stated she was notified at 2:29 p.m. and instructed the Clinical Director to call law enforcement after 4:00 p.m. Facility communication records showed the SOC 341 was submitted to the State Agency at 6:19 p.m., to the Long Term Care Ombudsman at 6:20 p.m., and to local law enforcement at 6:23 p.m. The facility policy and CDPH AFL 21-26 both required immediate reporting to law enforcement, with written reporting to the appropriate agencies within the required timeframe.
Failure to Maintain an Active Epistaxis Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive epistaxis care plan for Resident 5. The resident had a history of recurrent nosebleeds and was taking Eliquis, with physician orders to monitor for signs and symptoms of bleeding and notify the MD if any occurred. The record also showed an ENT visit for chronic nosebleeds over the past year, with notes that the bleeding seemed to come from both sides of the nose and that nasal precautions and Vaseline were discussed. The resident experienced multiple nosebleed events documented in the record, including episodes on 4/11/25, 4/27/25, 5/1/25, 6/3/25, and 7/20/25. These events included blood dripping from the nose, bleeding that took from 5 to 30 minutes to stop, and interventions such as applying pressure, cold compresses, nasal spray, ice chips, and holding Eliquis for a period of time per MD orders. One note also documented an ENT appointment related to a deviated septum and a scab near the nasal septum. At the time of survey review, the comprehensive care plan did not contain an active epistaxis or nosebleed care plan. RN 3 stated the resident was being monitored for nosebleeds and that a nosebleed care plan should be initiated because it serves as a guide for care. The DON and MDS stated a nosebleed care plan had been initiated earlier but was resolved after they believed the issue had stopped, and they stated they were not aware of the later nosebleed on 7/29/25. They also stated the resident should have an active nosebleed care plan because the issue was ongoing.
Failure to Protect Resident from Sexual Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a Certified Nursing Assistant (CNA). The incident involved a resident who was non-verbal, cognitively impaired, and dependent on staff for all aspects of care due to Huntington's disease and paranoid schizophrenia. The resident was unable to make safe decisions and was conserved by family. On the day of the incident, the CNA was assigned to the resident and worked the evening shift. The abuse was discovered when the police informed the facility that they had arrested the CNA after finding evidence of the abuse in the CNA's online storage account. The police report detailed that the CNA had taken two videos of the resident, where the CNA manipulated the resident's genitals. The facility was able to identify the resident in the videos through specific room features and confirmed the CNA's employment. The CNA was charged with Lewd Acts on a Dependent Adult by a Caretaker. The facility's policy on Resident's Rights, which includes the right to be free from abuse, was not upheld in this instance.
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Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oakland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fruitvale Healthcare Center | 0.1 mi | ★★★★★ | 1 | 0 |
| Mercy Retirement & Care Center | 0.6 mi | ★★★★★ | 3 | 0 |
| Oakland Heights Nursing And Rehabilitation | 1 mi | ★★★★★ | 0 | 0 |
| Bellaken Skilled Nursing Center | 1.1 mi | ★★★★★ | 1 | 0 |
| Bay Marina Post Acute | 1.1 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.