College Oak Nursing & Rehabilitation Center
COLLEGE OAK NURSING & REHABILITATION CENTER in SACRAMENTO, CA — inspection on November 20, 2025.
Found 2 citations. 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
continues to worry about the colder weather and rain. Resident 1 stated she will need to relocate to a different parking lot, since her current location was prone to flooding. Resident 1 confirmed her last entry in the LOA binder was 9/24/25 at 10:30 a.m. and when she had returned to the facility at 4 p.m. she expressed that she wanted to be permitted to return.During a review of the facility's policy and procedure (P&P) titled, Resident Leave of Absence, dated 8/2006, the P&P indicated, Each resident leaving the premises (excluding transfers/discharged /appointments) must obtain an MD order for approved leave of absence (LOA).During a review of the facility's P&P titled, Discharging a Resident Without a Physician Approval revised October 2022, the P&P indicated, A physician's order is obtained for discharges, unless a resident or representative is discharging himself or herself against medical advice. 1.
Should a resident. request an immediate discharge, the resident's attending physician is promptly notified. 4. If a resident wishes to be discharged to a setting that does not appear to meet his or her post-discharge needs, or appears unsafe, the facility will. a) discuss with the resident.and document the implications and/or risks of being discharged to a location that is not equipped to meet his/her needs and attempt to ascertain why the resident is choosing that location; b) document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed; c) document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings; and d) determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect is necessary.
The referral should be made at the time of discharge.During a review of the facility's P&P titled, Transfer or Discharge, Resident Initiated, dated 10/2022, the P&P indicated, 3. a.
Therapeutic leave is a type of resident-initiated transfer.
However, if the facility makes a determination to not allow the resident to return, the transfer becomes a facility-initiated discharge.For resident-initiated discharges, the medical record contains: e. documentation or evidence of the resident's or resident representative's verbal or written notice of intent to leave the facility; f. a discharge care plan; and g. documented discussions with the resident, or if appropriate, his/her representative, containing details of discharge planning and arrangements for post-discharge care. 2.
The comprehensive care plan contains the resident's goals for admission and desired outcomes, which will be in alignment with the discharge if it is resident-initiated.During a review of the facility's P&P titled, Transfer or Discharge Notices, dated 3/2025, the P&P indicated, Residents (or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing.A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman.
Notice of Transfer or Discharge (Anticipated): 1.
The resident and his or her representative are provided with a written notice of impending transfer or discharge at least 30 days prior to the transfer or discharge. 3.
The resident and representative are notified in writing of the following information: a.
The specific reason for the transfer or discharge, including the basis under S483.15(c)(1)(i)(A)-(F); b.
The effective date of the transfer or discharge; c.
The specific location (such as the name of the new provider, description, and/or address if the location is a residence) to which the resident is being transferred or discharged ; d. An explanation of the resident's rights to appeal the transfer or discharge to the state, including: (1) the name, address, email, and telephone number of the entity which receives such appeal hearing requests; (2) information about how to obtain an appeal form; and (3) how to get assistance in completing and submitting the appeal hearing request; e.
The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; f.
The Notice of Facility Bed-Hold and policies.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/20/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
College Oak Nursing & Rehabilitation Center
4635 College Oak Drive Sacramento, CA 95841
SUMMARY STATEMENT OF DEFICIENCIES
During a concurrent interview and record review on [DATE] at 4:01 p.m. with the Social Services Director (SSD), Resident 1's medical record was reviewed from [DATE] through [DATE].
The SSD indicated a Notice of Transfer or Discharge form, which included information on how to file an appeal if the resident did not agree with the transfer or discharge, was provided to the resident at least 30 days prior to the transfer or discharge, and a copy of the notice was sent to the local Ombudsman office.
The SSD confirmed there was no documentation in Resident 1's medical record that indicated Resident 1 had been provided with the Notice of Transfer or Discharge form, prior to or on the day of her discharge.
The SSD confirmed Resident 1 was not given the required notices.
During an interview on [DATE] at 11:37 a.m. with the Director of Nursing (DON) the DON acknowledged the Notice of Transfer or Discharge form was provided to residents prior to their transfer or discharge from the facility and a copy of the notice was sent to the Ombudsman office.
The DON confirmed the Notice of Transfer or Discharge was required under federal and state guidelines.
During a follow-up telephone interview on [DATE] at 3:19 p.m. with the Ombudsman, the Ombudsman indicated he has not received any recent notifications regarding discharges from the facility and further stated, I have not received any [transfer or discharge] notifications from [the facility].
During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge Notices, revised 3/2025, the P&P indicated, Residents (or resident representatives) are notified of an impending transfer or discharge and the reasons for the move in writing and in a language and manner they understand. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman. 1.the resident and his or her representative are provided with a written notice of an impending transfer or discharge at least 30 days prior to the transfer or discharge. 3.
The resident and representative are notified in writing of the following information: a.
The specific reason for the transfer or discharge, including the basis under S483.15(c)(1)(i)(A)-(F); b.
The effective date of the transfer or discharge; c.
The specific location (such as the name of the new provider, description, and/or address if the location is a residence) to which the resident is being transferred or discharged ; d. An explanation of the resident's rights to appeal the transfer or discharge to the state, including: (1) the name, address, email, and telephone number of the entity which receives such appeal hearing requests; (2) information about how to obtain an appeal form; and (3) how to get assistance in completing and submitting the appeal hearing request; e.
The name, address, and telephone number of the Office of the State Long-term Care Ombudsman; f.
The Notice of Facility Bed-Hold and policies. 4. A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.
During a review of the facility's P&P titled, Transfer of Discharge, Resident-Initiated, dated [DATE] the P&P indicated, . 3.
Resident-initiated transfer or discharge means the resident.has provided verbal or written notice of intent to leave the facility. a.
Therapeutic leave is a type of resident-initiate transfer.
However, if the facility makes a determination to not allow the resident to return, the transfer becomes a facility-initiated discharge.
Facility ID: