nursing home in Oakland, CA
Garfield Neurobehavioral Center
1451 28th Avenue, Oakland, CA 94601 · (510) 261-9191
★★★★★3
Average
CMS overall star rating
CMS overall star rating
- Health inspections★★★★★2
- Staffing★★★★★5
- Quality measures★★★★★3
- Abuse citation
Source: Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. We refresh our information from this source. About our data
Garfield Neurobehavioral Center at a glance
Garfield Neurobehavioral Center is a 96-bed for-profit nursing home in Oakland, California (Alameda County).
CMS gives it 3 out of 5 stars on its overall star rating, close to the California average of 3.2.
Residents receive about 4.6 hours of nursing care per day (0.6 of them from registered nurses), close to the state average of 4.5 hours.
Its most recent standard health inspection (August 1, 2025) found 9 health citations. The California average is 15.5.
It has not received a federal fine in the past three years.
Nursing staff turnover is 13.2% per year (state average 36.7%).
Facility details
- Type
- Nursing home
- Ownership
- For Profit - Corporation
- Beds
- 96
- Certified for
- Medicaid
- Medicare-certified since
- July 13, 1992
- Resident/family council
- Resident
- County
- Alameda County
- CMS Certification Number
- 05A396
Ratings
| Measure | This facility | California avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Overall star rating ⓘ (higher is better) | 3 / 5 | 3.2 / 5 | 3 / 5 | Average |
| Health inspection rating ⓘ (higher is better) | 2 / 5 | 2.8 / 5 | 2.8 / 5 | Worse |
| Staffing rating ⓘ (higher is better) | 5 / 5 | 3.3 / 5 | 2.9 / 5 | Better |
| Quality measures rating ⓘ (higher is better) | 3 / 5 | 4.1 / 5 | 3.6 / 5 | Worse |
| Long-stay quality rating (higher is better) | 3 / 5 | 4.4 / 5 | 3.8 / 5 | Worse |
Staffing
| Measure | This facility | California avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Total nurse staff hours per resident per day ⓘ (higher is better) | 4.58 hrs | 4.52 hrs | 3.86 hrs | Better |
| Registered nurse hours per resident per day (higher is better) | 0.61 hrs | 0.67 hrs | 0.69 hrs | Worse |
| Nurse aide hours per resident per day (higher is better) | 3.29 hrs | 2.65 hrs | 2.32 hrs | Better |
| Weekend nurse staff hours per resident per day (higher is better) | 4.15 hrs | 4.09 hrs | 3.42 hrs | Better |
| Nursing staff turnover (yearly) (lower is better) | 13.2% | 36.7% | 45.8% | Better |
| Registered nurse turnover (yearly) (lower is better) | 11.1% | 38.1% | 42.9% | Better |
Inspections
| Measure | This facility | California avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Health citations in the most recent inspection (lower is better) | 9 | 16 | 9 | Average |
| Citations from complaint investigations (latest cycle) (lower is better) | 1 | 4 | 3 | Better |
| Weighted health inspection score ⓘ (lower is better) | 108.3 | 105.8 | 80.6 | Worse |
Penalties
| Measure | This facility | California avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Fines in the past 3 years (lower is better) | 0 | 1 | 1 | Better |
| Total fines in the past 3 years (lower is better) | $0 | $23,986 | $30,972 | Better |
| All federal penalties in the past 3 years (lower is better) | 0 | 1 | 1 | Better |
Size
| Measure | This facility | California avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Certified beds | 96 | 99 | 107 | |
| Average residents per day | 57 | 88 | 86 | |
| Occupancy | 59.5% | 88.4% | 80.9% |
Long-stay residents
| Measure | This facility | California avg. | U.S. avg. | vs. U.S. |
|---|---|---|---|---|
| Long-stay residents with a fall causing major injury (lower is better) | 1.3% | 1.6% | 3.2% | Better |
| Long-stay residents with pressure ulcers (lower is better) | 1.5% | 4.3% | 4.6% | Better |
| Long-stay residents given antipsychotic medication (lower is better) | 82.5% | 12% | 15.4% | Worse |
| Long-stay residents with a urinary tract infection (lower is better) | 3.6% | 1.2% | 1.6% | Worse |
| Long-stay residents with a catheter left in the bladder (lower is better) | 1.7% | 0.8% | 0.8% | Worse |
| Long-stay residents needing more help with daily activities (lower is better) | 10.4% | 10.2% | 13.9% | Better |
| Long-stay residents whose walking worsened (lower is better) | 8.3% | 9.8% | 14.1% | Better |
| Long-stay residents who lose too much weight (lower is better) | 4.6% | 4% | 5.2% | Better |
| Long-stay residents with depressive symptoms (lower is better) | 0% | 7.3% | 12.8% | Better |
| Long-stay residents who were physically restrained (lower is better) | 0% | 0.4% | 0.1% | Better |
| Long-stay residents given anti-anxiety or sleep medication (lower is better) | 40.4% | 13.7% | 19.5% | Worse |
| Long-stay residents with new or worse incontinence (lower is better) | 7.7% | 10.2% | 19% | Better |
| Long-stay residents given a flu vaccine (higher is better) | 100% | 98.2% | 95.5% | Average |
| Long-stay residents given a pneumonia vaccine (higher is better) | 100% | 98.6% | 93.6% | Better |
Inspection citations
State inspectors cited this home for 18 health deficiencies and 33 fire safety deficiencies in the inspection records CMS currently publishes. 2 citations involved actual harm, including 1 rated "immediate jeopardy".
| Date | Citation | Severity | Status |
|---|---|---|---|
| July 2, 2026 Complaint | 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 Deficiencies · Tag F0600 | D Potential harm, isolated | Corrected July 31, 2026 |
| August 1, 2025 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | F Potential harm, widespread | Corrected August 18, 2025 |
| August 1, 2025 Fire safety | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Tag E0039 | F Potential harm, widespread | Corrected August 13, 2025 |
| August 1, 2025 Fire safety | Use approved construction type or materials. Construction Deficiencies · Tag K0161 | D Potential harm, isolated | Corrected August 6, 2025 |
| August 1, 2025 Fire safety | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0919 | D Potential harm, isolated | Corrected August 6, 2025 |
| August 1, 2025 Fire safety | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0920 | D Potential harm, isolated | Corrected August 6, 2025 |
| August 1, 2025 Fire safety | Have properly located and lighted "Exit" signs. Egress Deficiencies · Tag K0293 | D Potential harm, isolated | Corrected August 6, 2025 |
| August 1, 2025 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | C No harm, widespread | Corrected August 6, 2025 |
| August 1, 2025 Standard | 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 Deficiencies · Tag F0600 | J Immediate jeopardy, isolated | Corrected August 14, 2025 |
| August 1, 2025 Standard | 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. Pharmacy Service Deficiencies · Tag F0761 | E Potential harm, pattern | Corrected August 14, 2025 |
| August 1, 2025 Standard | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Tag F0880 | E Potential harm, pattern | Corrected August 14, 2025 |
| August 1, 2025 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | E Potential harm, pattern | Corrected August 14, 2025 |
| August 1, 2025 Standard | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · Tag F0759 | E Potential harm, pattern | Corrected August 14, 2025 |
| August 1, 2025 Standard | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0609 | D Potential harm, isolated | Corrected August 14, 2025 |
| August 1, 2025 Standard | 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 Deficiencies · Tag F0656 | D Potential harm, isolated | Corrected August 14, 2025 |
| August 1, 2025 Standard | Develop and implement policies and procedures to prevent abuse, neglect, and theft. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0607 | D Potential harm, isolated | Corrected August 14, 2025 |
| February 21, 2025 Complaint | 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 Deficiencies · Tag F0600 | G Actual harm, isolated | Corrected February 28, 2025 |
| March 21, 2024 Fire safety | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Tag K0711 | F Potential harm, widespread | Corrected April 5, 2024 |
| March 21, 2024 Fire safety | Use approved construction type or materials. Construction Deficiencies · Tag K0161 | E Potential harm, pattern | Corrected April 5, 2024 |
| March 21, 2024 Fire safety | Ensure proper usage of power strips and extension cords. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0920 | D Potential harm, isolated | Corrected April 5, 2024 |
| March 21, 2024 Fire safety | Establish roles under a Waiver declared by secretary. Emergency Preparedness Deficiencies · Tag E0026 | D Potential harm, isolated | Corrected April 5, 2024 |
| March 21, 2024 Fire safety | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Tag E0039 | D Potential harm, isolated | Corrected April 5, 2024 |
| March 21, 2024 Fire safety | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Tag K0321 | D Potential harm, isolated | Corrected April 5, 2024 |
| March 21, 2024 Fire safety | Provide properly protected cooking facilities. Smoke Deficiencies · Tag K0324 | D Potential harm, isolated | Corrected April 5, 2024 |
| March 21, 2024 Fire safety | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Tag K0345 | D Potential harm, isolated | Corrected April 5, 2024 |
| March 21, 2024 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | D Potential harm, isolated | Corrected April 5, 2024 |
| March 21, 2024 Fire safety | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Tag K0355 | D Potential harm, isolated | Corrected April 5, 2024 |
| March 21, 2024 Fire safety | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Tag K0363 | D Potential harm, isolated | Corrected April 5, 2024 |
| March 21, 2024 Fire safety | Meet requirements for the use of electrical equipment. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0919 | D Potential harm, isolated | Corrected April 5, 2024 |
| March 21, 2024 Standard | Dispose of garbage and refuse properly. Nutrition and Dietary Deficiencies · Tag F0814 | E Potential harm, pattern | Corrected April 6, 2024 |
| March 21, 2024 Standard | 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. Pharmacy Service Deficiencies · Tag F0761 | E Potential harm, pattern | Corrected April 6, 2024 |
| March 21, 2024 Standard | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Tag F0812 | E Potential harm, pattern | Corrected April 6, 2024 |
| March 21, 2024 Standard | 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 Deficiencies · Tag F0584 | D Potential harm, isolated | Corrected April 6, 2024 |
| March 21, 2024 Standard | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Tag F0641 | D Potential harm, isolated | Corrected April 6, 2024 |
| March 18, 2024 Complaint | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Tag F0755 | D Potential harm, isolated | Corrected April 6, 2024 |
| March 18, 2024 Complaint | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Tag F0689 | D Potential harm, isolated | Corrected April 6, 2024 |
| March 18, 2024 Complaint | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Tag F0760 | D Potential harm, isolated | Corrected April 6, 2024 |
| January 6, 2022 Fire safety | Provide properly protected cooking facilities. Smoke Deficiencies · Tag K0324 | D Potential harm, isolated | Corrected February 2, 2022 |
| January 6, 2022 Fire safety | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Tag K0321 | D Potential harm, isolated | Corrected February 2, 2022 |
| January 6, 2022 Fire safety | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Tag K0211 | D Potential harm, isolated | Corrected February 2, 2022 |
| January 6, 2022 Fire safety | Provide primary/alternate means for communication. Emergency Preparedness Deficiencies · Tag E0032 | D Potential harm, isolated | Corrected February 2, 2022 |
| January 6, 2022 Fire safety | Provide emergency officials' contact information. Emergency Preparedness Deficiencies · Tag E0031 | D Potential harm, isolated | Corrected February 2, 2022 |
| January 6, 2022 Fire safety | Establish policies and procedures for medical documentation. Emergency Preparedness Deficiencies · Tag E0023 | D Potential harm, isolated | Corrected February 2, 2022 |
| January 6, 2022 Fire safety | List the names and contact information of those in the facility. Emergency Preparedness Deficiencies · Tag E0030 | D Potential harm, isolated | Corrected February 2, 2022 |
| January 6, 2022 Fire safety | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0923 | D Potential harm, isolated | Corrected February 2, 2022 |
| January 6, 2022 Fire safety | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Tag K0918 | D Potential harm, isolated | Corrected February 2, 2022 |
| January 6, 2022 Fire safety | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Tag K0712 | D Potential harm, isolated | Corrected February 2, 2022 |
| January 6, 2022 Fire safety | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Tag K0711 | D Potential harm, isolated | Corrected February 2, 2022 |
| January 6, 2022 Fire safety | Install corridor and hallway doors that block smoke. Smoke Deficiencies · Tag K0363 | D Potential harm, isolated | Corrected February 2, 2022 |
| January 6, 2022 Fire safety | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Tag K0355 | D Potential harm, isolated | Corrected February 2, 2022 |
| January 6, 2022 Fire safety | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Tag K0353 | D Potential harm, isolated | Corrected February 2, 2022 |
Severity letters follow the CMS scope-and-severity grid: A–C no actual harm with 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. How to read inspection citations.
Fines and payment denials
CMS reports no federal fines or payment denials in the past three years.
Owners and managers
Individuals and organizations reported to CMS as owning or operating this nursing home.
| Name | Role | Share | Since |
|---|---|---|---|
| ownership data not available |
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Frequently asked questions
What is Garfield Neurobehavioral Center's rating?
Garfield Neurobehavioral Center has 3 out of 5 stars on the CMS overall star rating. The average for California nursing homes is 3.2 stars.
How many inspection citations did Garfield Neurobehavioral Center receive?
Its most recent standard health inspection found 9 citations, compared with a California average of 15.5. Every citation is listed on this page with its severity.
Does Garfield Neurobehavioral Center accept Medicare and Medicaid?
CMS lists it as certified for: Medicaid. Call the facility to confirm bed availability and whether it accepts your specific plan.
Who owns Garfield Neurobehavioral Center?
It is for profit - corporation. The ownership section on this page lists the owners and managers reported to CMS.
Where is Garfield Neurobehavioral Center and how do I contact it?
Garfield Neurobehavioral Center is at 1451 28th Avenue, Oakland, CA 94601. Phone: (510) 261-9191.
About this data
Ratings and measures come from the Centers for Medicare & Medicaid Services (CMS), Medicare Care Compare. They're based on state inspections, patient surveys and facility reports, and they describe the past. Facilities change, so visit in person and confirm details directly. About our data · Spotted an error? Let us know.