College Oak Nursing and Rehabilitation Center
4635 College Oak Drive · Sacramento, CA · 95841 · 9164817434
120 certified beds For profit - Limited Liability company Chain: Cypress Healthcare Group
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Staffing hours comfortably above national benchmarks.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 3 of 5 Staffing: 4 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 4.45 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.76 | 0.55–0.75 |
| Weekend hours / resident-day | 3.99 | ≈ weekday level |
| Nursing turnover / year | 43% | median 45% |
| Fines (3-yr window) | 1 · $14,020 |
Inspection citations (24 in the current record)
-
Potential for harm · D April 9, 2026
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected April 24, 2026 · Resident Rights
-
Potential for harm · D April 9, 2026
Provide safe, appropriate pain management for a resident who requires such services.
Corrected April 24, 2026 · Quality of Life and Care
-
Potential for harm · D April 9, 2026
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.
Corrected April 24, 2026 · Pharmacy Service
-
Potential for harm · F April 9, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected April 24, 2026 · Nutrition and Dietary
-
Potential for harm · D April 9, 2026
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected April 24, 2026 · Resident Assessment and Care Planning
-
Immediate jeopardy · J November 20, 2025 · found via complaint
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected November 25, 2025 · Resident Rights
-
Potential for harm · D November 20, 2025 · found via complaint
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected November 25, 2025 · Resident Rights
-
Potential for harm · D February 7, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected February 28, 2025 · Resident Rights
-
Potential for harm · D February 7, 2025
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected February 28, 2025 · Resident Assessment and Care Planning
-
Potential for harm · D February 7, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected February 28, 2025 · Resident Assessment and Care Planning
-
Potential for harm · D February 7, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected February 28, 2025 · Resident Assessment and Care Planning
-
Potential for harm · E February 7, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected February 28, 2025 · Pharmacy Service
-
Potential for harm · E February 7, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected February 28, 2025 · Pharmacy Service
-
Potential for harm · E February 7, 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 locked compartments, separately locked, compartments for controlled drugs.
Corrected February 28, 2025 · Pharmacy Service
-
Potential for harm · E February 7, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected February 28, 2025 · Nutrition and Dietary
-
Potential for harm · E February 7, 2025
Dispose of garbage and refuse properly.
Corrected February 28, 2025 · Nutrition and Dietary
-
Potential for harm · E February 7, 2025
Provide and implement an infection prevention and control program.
Corrected February 28, 2025 · Infection Control
-
Potential for harm · D October 24, 2024 · found via complaint
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected November 4, 2024 · Nutrition and Dietary
-
Potential for harm · D August 6, 2024 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected September 10, 2024 · Resident Assessment and Care Planning
-
Actual harm · G February 9, 2024
Assist a resident in gaining access to vision and hearing services.
Corrected February 23, 2024 · Quality of Life and Care
-
Potential for harm · D February 9, 2024
Provide activities to meet all resident's needs.
Corrected February 23, 2024 · Quality of Life and Care
-
Potential for harm · D February 9, 2024
Ensure medication error rates are not 5 percent or greater.
Corrected February 23, 2024 · Pharmacy Service
-
Potential for harm · D February 9, 2024
Provide and implement an infection prevention and control program.
Corrected February 23, 2024 · Infection Control
-
Potential for harm · D October 5, 2023 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 20, 2023 · Quality of Life and Care
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| November 20, 2025 | Fine | $14,020 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 056158 · certified since February 16, 1970. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.