College Oak Nursing And Rehabilitation Center
College Oak Nursing and Rehabilitation Center in Sacramento, CA — inspection on May 29, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
bed-hold policies.
upon transfer to one of three sampled residents (Resident 1).
When Resident 1 was transferred to an
facility's bed hold policy.This failure had the potential for Resident 1 and their RP to not be informed of their rights to return to the facility.A review of Resident 1's progress note dated 5/11/26 indicated, resident was sent to an acute care hospital for treatment via 911 as an emergency transfer.A review of Resident 1's Notice of Transfer/discharge date d 5/11/26 indicated, Resident 1's RP was notified via phone of the transfer.
Notice indicated, [RP name] did not give concent [sic] for bed hold via phone.
Notice indicated, no signature from RP or indication it was sent to RP.
During an interview on 5/29/26, at 12:01 p.m., with the Director of Nursing (DON), DON stated, We did not send a written notification of bed hold for Resident 1's transfer on 5/11/26. DON stated, the facility notified the RP of the bed hold via phone only.
During an interview with Assistant Business Office Manager (ABOM) on 5/29/26, at 12:18 p.m., ABOM stated, the business office is responsible for sending bed hold policy notifications to the residents or the resident's family. ABOM stated, the facility did not send a written notice of the facility's bed hold policy to Resident 1's RP for the transfer on 5/11/26.During a review of the facility's Policy & Procedure (P&P) titled, Transfer or Discharge, Facility-Initiated, dated 2022, the P&P indicated, 5.
Notice of Facility Bed-Hold and return policies are provided to the resident and representative within 24 hours of emergency transfer.During a review of the facility's Policy & Procedure (P&P) titled, Bed-Holds and Returns dated 2022, the P&P indicated, Residents and/or representatives are informed (in writing) of the facility and state (if applicable) bed-hold policies. 1.
All residents/representatives are provided in written information regarding the facility an state bed-hold polices, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave).
Residents regardless of payer source, are provided written notice about these policies at least twice: a.
Notice 1: well in advance of any transfer (e.g., in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours).
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.