Nursing home

Garfield Neurobehavioral Center

1451 28TH Avenue, Oakland, CA 94601

★★★★★Overall Medicare rating
★★★★★Health inspections
★★★★★Staffing
★★★★★Quality measures

Medicare rates every nursing home from 1 to 5 stars. 5 is much above average, 1 is much below.

Findings, latest cycle9
Findings with harm or immediate jeopardy, 3 cycles2
Fines, 3 years$0
Beds96
Medicare has flagged this home for abuse: an inspection found that a resident was harmed by abuse, or there were repeated findings of possible abuse. Open this home on Medicare.gov

Inspection findings

Inspectors recorded 18 findings in the last three inspection cycles.

1 Immediate jeopardy1 Actual harm to a resident16 No harm, but a risk of harm

Each entry below is a requirement that inspectors found the home did not meet on that date, in the regulator's own English wording.

Inspection dateAreaRequirement the home did not meet (official wording, in English)SeverityCorrected
Jul 2, 2026Abuse, neglect and exploitationProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600)No harm, but a risk of harm
isolated · from a complaint
Corrected: Jul 31, 2026
Aug 1, 2025Infection controlProvide and implement an infection prevention and control program. (F0880)No harm, but a risk of harm
pattern
Corrected: Aug 14, 2025
Aug 1, 2025Food and nutritionProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812)No harm, but a risk of harm
pattern
Corrected: Aug 14, 2025
Aug 1, 2025Pharmacy and medicationsEnsure 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)No harm, but a risk of harm
pattern
Corrected: Aug 14, 2025
Aug 1, 2025Pharmacy and medicationsEnsure medication error rates are not 5 percent or greater. (F0759)No harm, but a risk of harm
pattern
Corrected: Aug 14, 2025
Aug 1, 2025Resident assessment and care planningDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F0656)No harm, but a risk of harm
isolated
Corrected: Aug 14, 2025
Aug 1, 2025Abuse, neglect and exploitationTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F0609)No harm, but a risk of harm
isolated
Corrected: Aug 14, 2025
Aug 1, 2025Abuse, neglect and exploitationDevelop and implement policies and procedures to prevent abuse, neglect, and theft. (F0607)No harm, but a risk of harm
isolated
Corrected: Aug 14, 2025
Aug 1, 2025Abuse, neglect and exploitationProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600)Immediate jeopardy
isolated
Corrected: Aug 14, 2025
Feb 21, 2025Abuse, neglect and exploitationProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (F0600)Actual harm to a resident
isolated · from a complaint
Corrected: Feb 28, 2025
Earlier inspections (8)
Inspection dateAreaRequirement the home did not meet (official wording, in English)SeverityCorrected
Mar 21, 2024Food and nutritionDispose of garbage and refuse properly. (F0814)No harm, but a risk of harm
pattern
Corrected: Apr 6, 2024
Mar 21, 2024Food and nutritionProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F0812)No harm, but a risk of harm
pattern
Corrected: Apr 6, 2024
Mar 21, 2024Pharmacy and medicationsEnsure 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)No harm, but a risk of harm
pattern
Corrected: Apr 6, 2024
Mar 21, 2024Resident assessment and care planningEnsure each resident receives an accurate assessment. (F0641)No harm, but a risk of harm
isolated
Corrected: Apr 6, 2024
Mar 21, 2024Resident rightsHonor 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)No harm, but a risk of harm
isolated
Corrected: Apr 6, 2024
Mar 18, 2024Pharmacy and medicationsEnsure that residents are free from significant medication errors. (F0760)No harm, but a risk of harm
isolated · from a complaint
Corrected: Apr 6, 2024
Mar 18, 2024Pharmacy and medicationsProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F0755)No harm, but a risk of harm
isolated · from a complaint
Corrected: Apr 6, 2024
Mar 18, 2024Quality of life and careEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F0689)No harm, but a risk of harm
isolated · from a complaint
Corrected: Apr 6, 2024

Fines and payment denials

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

Staffing

Nurse staff hours per resident per day4.59California median: 4.27
Registered nurse hours per resident per day0.79California median: 0.52
Nurse staff hours on weekends4.10California median: 3.85
Nursing staff who left within a year10.2%California median: 36.0%

About this home

Beds96
Residents per day, average59.3
OwnershipFor-profit, corporation
In Medicare/Medicaid sinceJul 13, 1992

Questions to ask when you call

Source. Medicare Care Compare (CMS Provider Data), data dated Oct 1, 2026. Open this home on Medicare.gov · Report an error

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