All states › California › Oakland › Garfield Neurobehavioral Center
1451 28th Avenue Oakland, CA 94601 · Alameda County
All 18 nursing homes in Oakland, CA (16 take Medicaid)
CMS certification number 05A396 · See this home on Medicare Care Compare
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.
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.
About this nursing home
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.
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.
EEnsure medication error rates are not 5 percent or greater.
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.
EProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
EProvide and implement an infection prevention and control program.
DDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
DTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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.
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.
EProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
EDispose of garbage and refuse properly.
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.
DEnsure each resident receives an accurate assessment.
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.
DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
DEnsure that residents are free from significant medication errors.
Questions to ask on a tour of Garfield Neurobehavioral Center
- 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?
- CMS cited the home under its abuse and neglect rules on July 2, 2026. How are staff trained, and how are concerns reported?
- Do you have a Medicaid bed open now, and will you admit someone whose Medicaid application is still pending?
- 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 month | Overall | Inspection | Staffing | Quality |
|---|---|---|---|---|
| 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.
- 0.8 mi
-
1.3 mi
Highland Hospital OaklandEmergency room ★☆☆☆☆ Medicare overall 1 of 5Median ER visit 3h 2m for patients treated and sent home
-
1.8 mi
Alameda Hospital AlamedaEmergency room ★★★★☆ Medicare overall 4 of 5Median ER visit 2h 33m for patients treated and sent home
Hospital ratings, ER visit times and more at Hospitals In Each State
Source: CMS Care Compare. Distances are approximate.
Nearby nursing homes
More nursing homes near Garfield Neurobehavioral Center › All nursing homes in Oakland ›
Compare Garfield Neurobehavioral Center with the 3 closest homes side by side ›
Higher-rated nursing homes within 10 miles
- Fruitvale Healthcare Center · Oakland · 5 stars · 0.1 mi
- Mercy Retirement & Care Center · Oakland · 5 stars · 0.6 mi
- Oakland Heights Nursing and Rehabilitation · Oakland · 5 stars · 1.0 mi
- Bellaken Skilled Nursing Center · Oakland · 5 stars · 1.1 mi
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.