College Oak Nursing & Rehabilitation Center

F 0627 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Note: The nursing home is disputing this citation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

College Oak Nursing & Rehabilitation Center

4635 College Oak Drive Sacramento, CA 95841

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

hell; their intention was to get rid of me and they did. Resident 1 indicated her discharge plan was to find placement in transitional housing and confirmed she is still unhoused. Resident 1 confirmed the facility did not give her written notification or discharge instructions at the time of her discharge and stated she was unaware of her right to appeal the decision or who to contact for support or guidance. During a concurrent

interview and record review on [DATE REDACTED] at 4:01 p.m. with the Social Services Director (SSD), Resident 1's medical record was reviewed from [DATE REDACTED] through [DATE REDACTED]. 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 REDACTED] 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 REDACTED] 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 REDACTED] 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.

Event ID:

Facility ID:

If continuation sheet