Garfield Neurobehavioral Center
1451 28th Avenue, Oakland, CA 94601
Garfield Neurobehavioral Center is a nursing home in Oakland, California. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
CMS star ratings
- 3 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 5 of 5CMS staffing star rating
- 3 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (510) 261-9191
- Last standard health inspection
- August 1, 2025 (1 year ago)
- Certified beds
- 96
- Residents per day, on average
- 59.3
- Ownership type
- For profit - Corporation
- Legal business name
- Legal Business Name Not Available
- Chain
- Not listed by CMS
- Takes part in
- Medicaid
Fewer health citations than the California average (18 vs 50).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
1 citation
Health inspection on July 2, 2026
CMS lists this as a complaint inspection.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on July 31, 2026.
CMS has cited this home for F0600 3 times since 2025.
CMS update of February 25, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
8 citations
Health inspection on August 1, 2025
CMS lists this as a standard inspection.
Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.
86 of 1,165 California homes (7%) got a citation at the immediate jeopardy level in 2025.
Citation F0600. Severity J: immediate jeopardy, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on August 14, 2025.
Citation F0759. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on August 14, 2025.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on August 14, 2025.
CMS has cited this home for F0761 2 times since 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on August 14, 2025.
CMS has cited this home for F0812 2 times since 2024.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on August 14, 2025.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on August 14, 2025.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on August 14, 2025.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on August 14, 2025.
7 citations
Fire safety inspection on August 1, 2025
CMS lists this as a standard inspection.
Citation E0039. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on August 13, 2025.
CMS has cited this home for E0039 2 times since 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on August 18, 2025.
CMS has cited this home for K0918 2 times since 2022.
Citation K0161. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on August 6, 2025.
CMS has cited this home for K0161 2 times since 2024.
Citation K0293. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on August 6, 2025.
Citation K0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on August 6, 2025.
CMS has cited this home for K0919 2 times since 2024.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on August 6, 2025.
CMS has cited this home for K0920 2 times since 2024.
Citation K0353. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on August 6, 2025.
CMS has cited this home for K0353 3 times since 2022.
CMS update of July 30, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
CMS update of May 28, 2025
Star rating
The CMS overall star rating changed from 5 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 5 of 5 to 2 of 5.
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of April 30, 2025
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 5 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
1 citation
Health inspection on February 21, 2025
CMS lists this as a complaint inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
227 of 1,165 California homes (19%) got a citation at the actual harm level in 2025.
Citation F0600. Severity G: actual harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on February 28, 2025.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
5 citations
Health inspection on March 21, 2024
CMS lists this as a standard inspection.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 6, 2024.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 6, 2024.
Citation F0814. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Dispose of garbage and refuse properly.
CMS lists it as corrected on April 6, 2024.
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on April 6, 2024.
Citation F0641. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure each resident receives an accurate assessment.
CMS lists it as corrected on April 6, 2024.
12 citations
Fire safety inspection on March 21, 2024
CMS lists this as a standard inspection.
Citation K0711. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on April 5, 2024.
CMS has cited this home for K0711 2 times since 2022.
Citation K0161. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on April 5, 2024.
Citation E0026. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Establish roles under a Waiver declared by secretary.
CMS lists it as corrected on April 5, 2024.
Citation E0039. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Conduct testing and exercise requirements.
CMS lists it as corrected on April 5, 2024.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on April 5, 2024.
CMS has cited this home for K0321 2 times since 2022.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on April 5, 2024.
CMS has cited this home for K0324 2 times since 2022.
Citation K0345. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on April 5, 2024.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 5, 2024.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on April 5, 2024.
CMS has cited this home for K0355 2 times since 2022.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on April 5, 2024.
CMS has cited this home for K0363 2 times since 2022.
Citation K0919. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the use of electrical equipment.
CMS lists it as corrected on April 5, 2024.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on April 5, 2024.
3 citations
Health inspection on March 18, 2024
CMS lists this as a complaint inspection.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on April 6, 2024.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on April 6, 2024.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on April 6, 2024.
14 citations
Fire safety inspection on January 6, 2022
CMS lists this as a standard inspection.
Citation E0023. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Establish policies and procedures for medical documentation.
CMS lists it as corrected on February 2, 2022.
Citation E0030. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
List the names and contact information of those in the facility.
CMS lists it as corrected on February 2, 2022.
Citation E0031. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide emergency officials' contact information.
CMS lists it as corrected on February 2, 2022.
Citation E0032. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide primary/alternate means for communication.
CMS lists it as corrected on February 2, 2022.
Citation K0211. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on February 2, 2022.
Citation K0321. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on February 2, 2022.
Citation K0324. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide properly protected cooking facilities.
CMS lists it as corrected on February 2, 2022.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on February 2, 2022.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on February 2, 2022.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on February 2, 2022.
Citation K0711. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on February 2, 2022.
Citation K0712. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on February 2, 2022.
Citation K0918. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on February 2, 2022.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on February 2, 2022.
Questions
When was Garfield Neurobehavioral Center last inspected?
CMS lists August 1, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Garfield Neurobehavioral Center have?
CMS lists 18 health citations since March 18, 2024. CMS also calls these deficiencies.
Has Garfield Neurobehavioral Center been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Garfield Neurobehavioral Center?
Its CMS overall star rating is 3 of 5.
Is Garfield Neurobehavioral Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.