Garfield Neurobehavioral Center

Nursing home in Oakland, CA

Medicaid-certified3★ overall (CMS)CMS abuse icon

Call (510) 261-9191 Send a message Map ↗

Public-record details

Address: 1451 28th Avenue, Oakland, CA 94601
Phone: (510) 261-9191
Listed under: For-profit, No fines in 3 years
Medicare CCN: 05A396
Overall star rating: 3 of 5 ★★★☆☆
Health inspection rating: 2 of 5
Staffing rating: 5 of 5
Quality measures rating: 3 of 5
Certified beds: 96
Average residents per day: 57
Ownership: For-profit, corporation
Legal business name: Legal Business Name Not Available
Certified for: Medicaid
First approved by Medicare/Medicaid: Jul 13, 1992
Changed ownership in last 12 months: No
Continuing care retirement community: No
Located inside a hospital: No
Resident or family council: Resident council
Sprinklers in all required areas: Yes

CMS certification number 05A396. Source: CMS Nursing Home Provider Information, Health Deficiencies and Penalties (record). Data as of 2026-09-30.

Inspection record

Most recent standard health inspection: Aug 1, 2025. CMS lists 18 health citations for this facility across its last three standard inspection cycles and complaint inspections (Mar 18, 2024 to Jul 2, 2026): 5 from complaint inspections, 2 at the “actual harm” level or higher, including 1 at “immediate jeopardy”. CMS shows its abuse icon for this facility, which it uses for nursing homes cited for abuse at the harm level recently or at the potential-harm level in each of the last two years.

Inspection	Citation	Severity
Jul 2, 2026	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation · complaint inspection	D Potential for more than minimal harm, isolated
Aug 1, 2025	Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation	D Potential for more than minimal harm, isolated
Aug 1, 2025	Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation	D Potential for more than minimal harm, isolated
Aug 1, 2025	Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning	D Potential for more than minimal harm, isolated
Aug 1, 2025	Ensure medication error rates are not 5 percent or greater. Pharmacy Service	E Potential for more than minimal harm, pattern
Aug 1, 2025	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… Pharmacy Service	E Potential for more than minimal harm, pattern
Aug 1, 2025	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary	E Potential for more than minimal harm, pattern
Aug 1, 2025	Provide and implement an infection prevention and control program. Infection Control	E Potential for more than minimal harm, pattern
Aug 1, 2025	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation	J Immediate jeopardy, isolated
Feb 21, 2025	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation · complaint inspection	G Actual harm, isolated
Mar 21, 2024	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. Resident Rights	D Potential for more than minimal harm, isolated
Mar 21, 2024	Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning	D Potential for more than minimal harm, isolated

Showing the 12 most recent of 18. Full inspection reports are on Medicare Care Compare.

Severity letters follow CMS's scope-and-severity grid: A–C potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, J–L immediate jeopardy. Most citations are corrected; a citation is what inspectors found on that date. Source: CMS Health Deficiencies file, processed Aug 1, 2026.

Fines and payment denials

CMS records no fines or payment denials for this facility in the last three years.

Source: CMS Penalties file, processed Aug 1, 2026. Amounts are as CMS reports them and may reflect later reductions or appeals.

Staffing

Total nurse staffing per resident per day: 4.58 hours
Registered nurse (RN) time per resident per day: 0.61 hours
Nurse aide time per resident per day: 3.29 hours
Total nurse staffing on weekends: 4.15 hours
Nursing staff turnover (yearly): 13%
RN turnover (yearly): 11%

From payroll-based staffing data the facility submits to CMS. Hours are per resident per day.

A citation is what inspectors found on one date; most are corrected within weeks. Look for patterns — the same problem cited in several inspections — and for anything at the G–L level (actual harm or immediate jeopardy). The full inspection narrative (Form CMS-2567) is linked from Medicare Care Compare, and your state long-term care ombudsman can tell you about complaints.

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