Nursing home report
Sacramento, CA · Medicare-certified · 120 beds
College Oak Nursing and Rehabilitation Center has an overall rating of 3 out of 5 stars, with stronger staffing and quality ratings at 4 out of 5 stars and nurse staffing slightly above the federal benchmark (4.33 vs. 4.1 hours per resident per day). It has had $9,814 in fines in the last 24 months and a recent federal penalty; recent inspection issues included discharge planning, access to vision and hearing services, and food handling standards.
Health inspections
Staffing
4.3272 hrs/resident/day
Quality measures
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 4.3272.
Hours per resident per day.
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
Residents with a fall causing major injury
Residents with pressure ulcers (bedsores)
Residents with a urinary tract infection
Residents who lost too much weight
Residents who were physically restrained
Residents needing more help with daily activities
Residents whose ability to walk got worse
Long-stay residents on antianxiety or sleep medication
Short-stay residents newly given an antipsychotic
Residents with a long-term catheter
Residents with new or worsening incontinence
Residents with depressive symptoms
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
Long-stay residents given the pneumonia vaccine
Short-stay residents given the seasonal flu vaccine
Short-stay residents given the pneumonia vaccine
The home failed to make sure the resident’s transfer or discharge met their needs and preferences and was safe. Cited November 2025 — isolated incident, immediate jeopardy to residents.
F-Tag 627 — 42 CFR §483.15(c) — S/S: J
The nursing home failed to make sure a resident could get needed vision and hearing services. Cited February 2024 — isolated incident, actual harm.
F-Tag 685 — 42 CFR §483.25 — S/S: G
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited April 2026 — widespread issue, potential for harm.
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
The home failed to properly label and securely store medications and biologicals. Cited February 2025 — limited pattern, potential for harm.
F-Tag 761 — 42 CFR §483.45(g) — S/S: E
The home failed to provide pharmacy services and a licensed pharmacist needed to meet each resident’s medication needs. Cited February 2025 — limited pattern, potential for harm.
F-Tag 755 — 42 CFR §483.45 — S/S: E
Reported nurse staffing met or exceeded the federal recommendation.
Health inspection found 1 health deficiency.
Reported nurse staffing met or exceeded the federal recommendation.
Health inspection found 5 health deficiencies.
A federal fine of $9,814 was recorded.
Reported nurse staffing met or exceeded the federal recommendation.
A federal fine of $14,020 was recorded.
Health inspection found 2 health deficiencies.
Health inspection found 10 health deficiencies.
Health inspection found 1 health deficiency.
On record with Medicare: 1 fine · $9,814 in total fines.
Federal fine
Nov 20, 2025
Now operated by College Oaks Nursing and Rehabilitation Center, previously College Oak Nursing and Rehabilitation Center.
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.
