facebook tracking Garfield Neurobehavioral Center, Oakland CA: CMS Ratings
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Garfield Neurobehavioral Center

All states › California › Oakland › Garfield Neurobehavioral Center

1451 28th Avenue Oakland, CA 94601 · Alameda County

(510) 261-9191

All 18 nursing homes in Oakland, CA (16 take Medicaid)

Cited for abuse Accepts Medicaid 96 certified beds For profit

CMS certification number 05A396 · See this home on Medicare Care Compare

CMS abuse icon CMS marks this nursing home with its abuse icon. CMS shows the icon for homes with abuse citations in recent inspections: an abuse citation where residents were harmed (scope and severity G or higher) within the past year, or abuse citations at D or higher (potential for harm) in each of the last two years. Shown as of October 2026. Details on Care Compare.

Ratings come from CMS and are updated monthly; these are from October 2026. Check the latest inspection report and visit in person before you decide.

Is Garfield Neurobehavioral Center a good nursing home? Reviews, ratings and inspection record

There are no official resident reviews of nursing homes: Medicare's Care Compare publishes inspections, staffing and quality data instead. Here is what that record shows for Garfield Neurobehavioral Center as of October 2026.

CMS rates it 3 out of 5 stars overall, about the same as the California average of 3.2. Inspectors issued 18 citations in the last three years. CMS reports no fines or payment denials in that time. CMS currently shows its abuse icon for this home (see above).

Online reviews from families and residents are on Google Maps and other sites; they reflect individual experiences and aren't checked by CMS. The full inspection reports, including what inspectors observed, are on Medicare Care Compare.

Staffing

Nursing staff spend about 4.59 hours per resident per day at Garfield Neurobehavioral Center, above the California median of 4.27 (US median: 3.72). About 0.79 of those hours are from registered nurses. On weekends it falls to 4.10 hours, 11% below its all-week average. 10.2% of nursing staff left within a year (California median 36%). That is lower than most homes in California, a sign of a steadier team.

Nursing care per resident per day 4.59 hours
Above the California median of 4.27 Registered nurses, licensed practical nurses and aides combined, from payroll records.
Registered nurse hours 0.79 per resident a day RNs handle assessments, medications and changes in condition.
Weekend nursing care 4.10 hours Per resident a day. A big drop from weekdays can mean thin weekend staffing.
Nursing staff turnover 10.2% a year Share of nursing staff who left over a year. Lower usually means steadier care.
Registered nurse turnover 22.2% a year Share of registered nurses who left over a year.
Administrators who left — Frequent leadership changes are worth asking about on a visit.

About this nursing home

Certified beds96
Residents per day 59 About 62% of beds filled, on average
OwnershipFor profit - Corporation
Payment acceptedMedicaid
Certified sinceJuly 1992
Legal business nameLegal Business Name Not Available

Paying for care at Garfield Neurobehavioral Center: Medicare and Medicaid

Garfield Neurobehavioral Center is certified for Medicaid but not Medicare, so Medicare won't pay for a rehab stay here after a hospital discharge. It can serve long-term residents covered by California Medicaid.

Health inspections

The most recent standard inspection was on August 1, 2025 and found 8 deficiencies, plus 1 from complaint inspections in the same period. In total, inspectors issued 18 citations in the last three years.

Each citation has a scope and severity letter from A to L. A–C: potential for minimal harm. D–F: potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy to resident health or safety.

What the inspections found

Over the last three years, inspectors issued 18 citations at Garfield Neurobehavioral Center across 5 inspection dates, 5 of them from complaint investigations. 1 was at the immediate-jeopardy level (J–L), CMS's most serious category, most recently on August 1, 2025. The most common areas cited were freedom from abuse, neglect, and exploitation (5) and pharmacy service (5). The most serious was cited under the CMS rule to "protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody" (tag F0600, level J, August 1, 2025). 5 citations were under CMS's abuse, neglect and exploitation rules.

July 2, 2026 · 1 citation · includes complaint inspection

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

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Complaint inspection · Deficient, Provider has date of correction (Jul 31, 2026)

August 1, 2025 · 8 citations, includes immediate jeopardy

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

Immediate jeopardy · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Deficient, Provider has date of correction (Aug 14, 2025)

EEnsure medication error rates are not 5 percent or greater.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0759 · Deficient, Provider has date of correction (Aug 14, 2025)

EEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (Aug 14, 2025)

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

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Aug 14, 2025)

EProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Aug 14, 2025)

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

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0607 · Deficient, Provider has date of correction (Aug 14, 2025)

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

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 · Deficient, Provider has date of correction (Aug 14, 2025)

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

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Deficient, Provider has date of correction (Aug 14, 2025)

February 21, 2025 · 1 citation, includes actual harm · includes complaint inspection

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

Actual harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0600 · Complaint inspection · Deficient, Provider has date of correction (Feb 28, 2025)

March 21, 2024 · 5 citations

EEnsure 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.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (Apr 6, 2024)

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

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Apr 6, 2024)

EDispose of garbage and refuse properly.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0814 · Deficient, Provider has date of correction (Apr 6, 2024)

DHonor 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.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Deficient, Provider has date of correction (Apr 6, 2024)

DEnsure each resident receives an accurate assessment.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0641 · Deficient, Provider has date of correction (Apr 6, 2024)

March 18, 2024 · 3 citations · includes complaint inspection

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

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Apr 6, 2024)

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

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Apr 6, 2024)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Complaint inspection · Deficient, Provider has date of correction (Apr 6, 2024)

Questions to ask on a tour of Garfield Neurobehavioral Center

  1. Inspectors cited the home at the immediate-jeopardy level on August 1, 2025 under the rule on freedom from abuse, neglect, and exploitation. What changed afterwards, and can I see the plan of correction?
  2. CMS cited the home under its abuse and neglect rules on July 2, 2026. How are staff trained, and how are concerns reported?
  3. Do you have a Medicaid bed open now, and will you admit someone whose Medicaid application is still pending?
  4. When is the first care-plan meeting, and can family attend?

Questions come from this home's CMS data: its inspections, staffing and ownership record.

Fines and payment denials

CMS reports no fines or payment denials for this home in the last three years.

Rating history

CMS monthOverallInspectionStaffingQuality
October 2026 3/5 2/5 5/5 3/5
August 2026 3/5 2/5 5/5 3/5
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Location

Hospitals near Garfield Neurobehavioral Center

The Medicare-certified hospitals closest to this nursing home, with their CMS data. Ask the home which hospital it usually sends residents to.

Hospital ratings, ER visit times and more at Hospitals In Each State
Source: CMS Care Compare. Distances are approximate.

Nearby nursing homes

Fruitvale Healthcare Center Oakland · 0.1 mi away ★★★★★ Inspection 5/5 · Staffing 4/5 140 beds · Medicaid
Mercy Retirement & Care Center Oakland · 0.6 mi away ★★★★★ Inspection 4/5 · Staffing 3/5 59 beds · Medicaid
Oakland Heights Nursing and Rehabilitation Oakland · 1.0 mi away ★★★★★ Inspection 4/5 · Staffing 4/5 48 beds · Medicaid
Bellaken Skilled Nursing Center Oakland · 1.1 mi away ★★★★★ Inspection 5/5 · Staffing 4/5 61 beds · Medicaid
Bay Marina Post Acute Oakland · 1.1 mi away ★★★☆☆ Inspection 2/5 · Staffing 3/5 94 beds · Medicaid

More nursing homes near Garfield Neurobehavioral Center ›   All nursing homes in Oakland ›

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Source: CMS Provider Data Catalog (provider information, health deficiencies, penalties), October 2026. Inspection citations and penalties cover the last three years. Nursing Homes In Each State is independent and not affiliated with CMS or Medicare. About the data · Report a problem with this listing. Is this your nursing home? Feature it here.

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https://www.nursinghomesineachstate.com/california/oakland/garfield-neurobehavioral-center/ · Data: CMS, October 2026 · Nursing Homes In Each State, not affiliated with CMS or Medicare.