Garfield Neurobehavioral Center

Nursing Home · Oakland, CA

CMS overall rating 3/5 Abuse citation For profit - Corporation

CMS certification number05A396
This facility was cited for abuse, neglect or exploitation in a recent inspection (CMS abuse icon).

Contact & location

1451 28Th Avenue
Oakland, CA 94601
Alameda County
Phone
(510) 261-9191
ZIP code
94601 – all care providers

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Facility details

Certified beds
96
Residents per day
57.1 (59% occupied)
Ownership
For profit - Corporation
Legal name
Legal Business Name Not Available
Medicare certified since
July 13, 1992
Participates in
Medicaid
Council
Resident council

CMS star ratings

Overall★★★★★ 3/5
State avg 3.2
Health inspections★★★★★ 2/5
State avg 2.8
Staffing★★★★★ 5/5
State avg 3.3
Quality measures★★★★★ 3/5
State avg 4.1
Long-stay quality★★★★★ 3/5
Short-stay qualityNot rated

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
4.58 (state 4.52 · U.S. 3.86)
Registered nurses (RN)
0.61 (state 0.67 · U.S. 0.69)
Licensed practical nurses
0.68 (state 1.20 · U.S. 0.86)
Nurse aides
3.29 (state 2.65 · U.S. 2.32)
Weekend total
4.15 (state 4.09 · U.S. 3.42)
Nursing staff turnover
13.2 (state 36.7 · U.S. 45.8)%
RN turnover
11.1 (state 38.1 · U.S. 42.9)%

Inspections

Last standard inspection
August 1, 2025
Health deficiencies (last cycle)
9.0 (state 15.7 · U.S. 9.3)
From complaints
1
Citations on record (3 years)
18 health · 33 fire safety · includes immediate jeopardy
DateCitationSeverityStatus
2026-07-02 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Deficient, Provider has no plan of correction
2025-08-01 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies		 J
Immediate jeopardy to resident health or safety		 Corrected 2025-08-14
2025-08-01 Ensure medication error rates are not 5 percent or greater.
F0759 · Pharmacy Service Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-08-14
2025-08-01 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.
F0761 · Pharmacy Service Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-08-14
2025-08-01 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-08-14
2025-08-01 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-08-14
2025-08-01 Develop and implement policies and procedures to prevent abuse, neglect, and theft.
F0607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-14
2025-08-01 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
F0609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-14
2025-08-01 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-08-14
2025-02-21 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection		 G
Actual harm		 Corrected 2025-02-28
2024-03-21 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.
F0761 · Pharmacy Service Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-04-06
2024-03-21 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-04-06
2024-03-21 Dispose of garbage and refuse properly.
F0814 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-04-06
2024-03-21 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.
F0584 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-04-06
2024-03-21 Ensure each resident receives an accurate assessment.
F0641 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-04-06
2024-03-18 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F0689 · Quality of Life and Care Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-04-06
2024-03-18 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F0755 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-04-06
2024-03-18 Ensure that residents are free from significant medication errors.
F0760 · Pharmacy Service Deficiencies · complaint inspection		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-04-06

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

No federal fines or payment denials in the last three years.

Ownership & management

NameRoleSince
Ownership Data Not Available

Frequently asked questions

What is the rating of Garfield Neurobehavioral Center?

Garfield Neurobehavioral Center has a 3-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.2-star average in California.

How many beds does Garfield Neurobehavioral Center have?

It has 96 certified beds and cares for about 57 residents per day.

Has Garfield Neurobehavioral Center been fined?

CMS lists no federal fines or payment denials in the last three years.

What is the phone number of Garfield Neurobehavioral Center?

(510) 261-9191. The facility is located at 1451 28Th Avenue, Oakland, CA 94601.

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Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.