COLLEGE OAK NURSING & REHABILITATION CENTER
Open-data reference.
COLLEGE OAK NURSING & REHABILITATION CENTER is a for profit - limited liability company facility in SACRAMENTO, CA with 120 certified beds and a 4-star overall CMS rating. The facility has 24 deficiency records on file. Total penalties: $14K.
4635 COLLEGE OAK DRIVE, SACRAMENTO, CA 95841
Phone: 9164817434
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 056158
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 120
- Residents
- 110
- In Hospital
- No
- County
- Sacramento
- Last Inspection
- Feb 7, 2025
Staffing Data
- RN Hours
- 0.58 (nat'l avg: 0.68)
- LPN Hours
- 1.28
- CNA Hours
- 2.67
- Total Nursing Hours
- 4.53 (nat'l avg: 3.89)
- PT Hours
- 0.06
- Nursing Turnover
- 45.7%
- RN Turnover
- 54.5%
What the CMS Record Reveals About COLLEGE OAK NURSING & REHABILITATION CENTER
COLLEGE OAK NURSING & REHABILITATION CENTER operates 120 certified beds in SACRAMENTO, CA with approximately 110 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (4★), staffing levels (4★), and quality measures (4★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 24 deficiency records from recent surveys, of which 2 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $14K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 4.53 total nursing hours per resident day (national average 3.89), with RN coverage at 0.58 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, COLLEGE OAK NURSING & REHABILITATION CENTER falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 45.7%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (24 most recent)
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Category: Resident Rights Deficiencies
Corrected: Nov 25, 2025
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Category: Resident Rights Deficiencies
Corrected: Nov 25, 2025
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Feb 28, 2025
Dispose of garbage and refuse properly.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 28, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Feb 28, 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.
Category: Pharmacy Service Deficiencies
Corrected: Feb 28, 2025
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Feb 28, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Feb 28, 2025
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 28, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 28, 2025
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Feb 28, 2025
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Feb 28, 2025
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Category: Nutrition and Dietary Deficiencies
Corrected: Nov 4, 2024
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Sep 10, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Feb 23, 2024
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Feb 23, 2024
Assist a resident in gaining access to vision and hearing services.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 23, 2024
Provide activities to meet all resident's needs.
Category: Quality of Life and Care Deficiencies
Corrected: Feb 23, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Oct 20, 2023
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jun 10, 2021
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Jun 10, 2021
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Category: Pharmacy Service Deficiencies
Corrected: Jun 10, 2021
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Category: Pharmacy Service Deficiencies
Corrected: Jun 10, 2021
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Category: Resident Rights Deficiencies
Corrected: Jun 10, 2021
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 10.0% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 3.4% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.5% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 0.0% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 1.5% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.0% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 99.3% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 92.8% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 0.7% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 17.3% | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 10.7% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 91.3% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 87.9% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 2.6% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 13.2% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 4.2% | Yes |
Penalty History 1 penalties totaling $14K
| Date | Type | Amount |
|---|---|---|
| Nov 20, 2025 | Fine | $14K |
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Frequently Asked Questions
What is the overall CMS rating for COLLEGE OAK NURSING & REHABILITATION CENTER?
What are the staffing levels at COLLEGE OAK NURSING & REHABILITATION CENTER?
How many beds does COLLEGE OAK NURSING & REHABILITATION CENTER have?
Does COLLEGE OAK NURSING & REHABILITATION CENTER have any deficiencies on record?
Has COLLEGE OAK NURSING & REHABILITATION CENTER received any fines or penalties?
Who owns COLLEGE OAK NURSING & REHABILITATION CENTER?
When was COLLEGE OAK NURSING & REHABILITATION CENTER last inspected?
What quality measures are tracked for COLLEGE OAK NURSING & REHABILITATION CENTER?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.