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Garfield Neurobehavioral Center
1451 28th Avenue, Oakland, CA 94601 (opens Google Maps) · Alameda County · (510) 261-9191· 96 certified beds · avg 57 residents/day · certified since Jul 13, 1992 · Medicaid only — not Medicare certified
Certified for Medicaid only. It cannot bill Medicare, so a short post-hospital rehabilitation stay would not be covered the usual way here. Who pays for nursing home care →
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
2/5
Health inspection rating (on-site)
inspected Aug 1, 2025
2
Serious findings on record
most recent Aug 1, 2025
$0
Fines, last 3 years
6.39
Nurse hours/resident/day (adjusted)
Every record stays on this page.
What health inspectors found (on-site government inspections — the most independent evidence available)
New to these records? How to read an inspection report →
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5 · how star ratings work →
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and quality measures from resident assessments and claims.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, isolated · Aug 1, 2025 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
▲ Immediate jeopardy, isolated · Aug 1, 2025 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Aug 14, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · Feb 21, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
▲ Actual harm, isolated · Feb 21, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Feb 28, 2025 (Deficient, Provider has date of correction)
Inspection findings in the public record
Showing the latest 3 of 18 inspection findings. Open the full record below to read every finding.
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. F-0600
The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. F-0759
View all 18 inspection findingsShow only the latest 3 findings
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 2, 2026 | D · Potential for more than minimal harm, isolated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint · F-0600 |
| Aug 1, 2025 | ▲ J · Immediate jeopardy, isolated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · F-0600 |
| Aug 1, 2025 | E · Potential for more than minimal harm, pattern | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · F-0759 |
| Aug 1, 2025 | E · Potential for more than minimal harm, pattern | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · F-0761 |
| Aug 1, 2025 | E · Potential for more than minimal harm, pattern | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Aug 1, 2025 | E · Potential for more than minimal harm, pattern | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880 |
| Aug 1, 2025 | D · Potential for more than minimal harm, isolated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. · F-0607 |
| Aug 1, 2025 | D · Potential for more than minimal harm, isolated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · F-0609 |
| Aug 1, 2025 | D · Potential for more than minimal harm, isolated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · F-0656 |
| Feb 21, 2025 | ▲ G · Actual harm, isolated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint · F-0600 |
| Mar 21, 2024 | E · Potential for more than minimal harm, pattern | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · F-0761 |
| Mar 21, 2024 | E · Potential for more than minimal harm, pattern | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Mar 21, 2024 | E · Potential for more than minimal harm, pattern | The facility did not dispose of garbage and refuse properly. · F-0814 |
| Mar 21, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · F-0584 |
| Mar 21, 2024 | D · Potential for more than minimal harm, isolated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641 |
| Mar 18, 2024 | D · Potential for more than minimal harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689 |
| Mar 18, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint · F-0755 |
| Mar 18, 2024 | D · Potential for more than minimal harm, isolated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint · F-0760 |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (5 → 8).
All citationsSerious citations (G–L)
2024
All citations: 8
Serious citations (G–L): 0
2025
All citations: 9
Serious citations (G–L): 2
2026
All citations: 1
Serious citations (G–L): 0
All bars start at zero. Exact values and supporting details remain below.
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 8 | 0 | E |
| 2025 | 9 | 2 | J ▲ |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
Nurse staffing (from payroll records, adjusted for how much care residents need)
What these staffing numbers mean →
This facilityCalifornia averageU.S. average
Total nurse staffing (hours per resident per day)
This facility: 6.39
California average: 4.31
U.S. average: 3.95
Registered Nurse hours
This facility: 0.85
California average: 0.61
U.S. average: 0.69
Weekend total nurse staffing
This facility: 5.79
California average: 3.90
U.S. average: 3.50
All bars start at zero. Exact values and supporting details remain below.
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 6.39 | 4.31 | 3.95 | top 4% in California; top 3% in the U.S. |
| Registered Nurse hours | 0.85 | 0.61 | 0.69 | top 15% in California; top 24% in the U.S. |
| Weekend total nurse staffing | 5.79 | 3.90 | 3.50 | top 3% in California; top 2% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.65 | 0.51 | 0.48 | top 18% in California; top 19% in the U.S. |
| Total nursing staff turnover (%) | 13.2 | 36.7 | 45.8 | top 2% in California; top 1% in the U.S. |
| RN turnover (%) | 11.1 | 38.1 | 42.9 | top 6% in California; top 4% in the U.S. |
Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.58, RN 0.61, weekend 4.15.Comparing with Medicare Care Compare? Care Compare shows the raw figure (4.58 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 5/5.
Quality measures: assessments & claims
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5
Costs & payment
Price evidence · separate from quality
No verified facility-specific private-pay price is available in our data for Garfield Neurobehavioral Center. CMS inspection and staffing records do not tell us what this home will charge you.
Calculate a stay from a quote you receive
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Before you compare prices
- Request the room type, effective date and itemized daily rate in writing.
- Ask about therapy, medicines, supplies, care-level charges, deposits, refunds and annual increases.
- Confirm insurance or Medicaid eligibility and bed availability directly; certification alone does not guarantee either.
Understand who pays for care · How we handle price evidence · Report an incorrect price
Who owns this facility
How to read ownership records →
Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ownership Data Not Available |
All 1 owning or managing party CMS has on file are shown — none excluded.
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What specific steps do you take to prevent abuse and neglect, and how are staff trained on them?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
Also worth asking anywhere
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the plan of correction for the findings in your most recent state inspection?"
- "CMS reports 13% total nursing staff turnover here — who on the care team has been with you longest?"
- "Can I visit again unannounced, at a mealtime or on a weekend?"
Nearby facilities (12 closest of 113 within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Fruitvale Healthcare Center | 0.1 mi | Oakland, CA | ★★★★★ | 5/5 | |
| Mercy Retirement & Care Center | 0.6 mi | Oakland, CA | ★★★★☆ | 4/5 | |
| Oakland Heights Nursing and Rehabilitation | 1.0 mi | Oakland, CA | ★★★★★ | 4/5 | |
| Bellaken Skilled Nursing Center | 1.1 mi | Oakland, CA | ★★★★★ | 5/5 | |
| Bay Marina Post Acute | 1.1 mi | Oakland, CA | ★★★☆☆ | 2/5 | |
| Marina Garden Nursing Center | 1.2 mi | Alameda, CA | ★★★★★ | 5/5 | |
| Bay Area Healthcare Center | 1.5 mi | Oakland, CA | ★★★★★ | 5/5 | |
| Alameda Hospital D/P SNF | 1.6 mi | Alameda, CA | ★★★☆☆ | 2/5 | abuse |
| Excell Health Care Center | 1.7 mi | Oakland, CA | ★★★★★ | 5/5 | |
| Redwood Healthcare Center LLC | 1.7 mi | Oakland, CA | ★★★★☆ | 4/5 | |
| Princeton Manor Healthcare Center, LLC | 1.8 mi | Oakland, CA | ★★★☆☆ | 3/5 | |
| Bay View Rehabilitation Hospital, LLC | 1.8 mi | Alameda, CA | ★☆☆☆☆ | 1/5 | abuse |
Compare this facility with the 3 closest →
Other facilities in the same county
CMS records place this facility in Alameda, CA — 69 certified facilities there. These are outside the 20-mile list above, or far enough down it not to appear.
- Golden Harbor Healthcare Center — Hayward, CA · overall 2/5
- Hayward Gardens Post Acute — Hayward, CA · overall 5/5
- Hayward Healthcare & Wellness Center — Hayward, CA · overall 2/5
- Hayward Hills Health Care Center — Hayward, CA · overall 3/5
- Hayward Post Acute — Hayward, CA · overall 4/5
- Jones Convalescent Hospital — San Leandro, CA · overall 4/5
- Kyakameena Care Center — Berkeley, CA · overall 3/5
- Lake Merritt Healthcare Center LLC — Oakland, CA · overall 2/5
Listed by facility name — not a ranking. Homes already in the table above are not repeated here.
Facility data as of CMS processing date 2026-08-01. CCN 05A396.