Cycle 1
Health 2025-02-07 · Fire 2025-02-07
12 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Sacramento, CA
College Oak Nursing & Rehabilitation Center
4-star overall rating with 4-star inspections with $14,020 in total fines with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
4635 College Oak Drive, Sacramento, CA
(916) 481-7434
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
110
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cypress Healthcare Group
Operator or chain grouping
Approved since
1970-02-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.28
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.67
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.53
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.86
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.15
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
4.38
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,445
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.37
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.70
Baseline 20.71% · Performance 21.11% · Measure score 0.70 · Achievement 0.70 · Improvement 0
Healthcare-associated infections
3.35
Baseline 6.04% · Performance 6.83% · Measure score 3.35 · Achievement 3.35 · Improvement 0
Total nurse turnover
0.75
Baseline 55.36% · Performance 60.63% · Measure score 0.75 · Achievement 0.75 · Improvement 0
Adjusted total nurse staffing
3.35
Baseline 4.14 hours · Performance 4.03 hours · Measure score 3.35 · Achievement 3.35 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.42% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 286 · Observed rate 13.29% · Lower 95% interval 9% |
| Discharge to community | 57.85% |
50.57%
7.3 pts better
|
Better than the National Rate · Eligible stays 289 · Observed rate 51.21% · Lower 95% interval 51.29% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 99.42% |
95.27%
4.2 pts better
|
Numerator 172 · Denominator 173 |
| Falls with major injury | 1.73% |
0.77%
1 pts worse
|
Numerator 3 · Denominator 173 |
| Discharge self-care score | 44.66% |
53.69%
9 pts worse
|
Numerator 46 · Denominator 103 |
| Discharge mobility score | 55.34% |
50.94%
4.4 pts better
|
Numerator 57 · Denominator 103 |
| Pressure ulcers or injuries, new or worsened | 1.16% |
2.29%
1.1 pts better
|
Numerator 2 · Denominator 173 · Adjusted rate 1.19% |
| Healthcare-associated infections requiring hospitalization | 6.83% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 170 · Observed rate 6.47% · Lower 95% interval 3.9% |
| Staff COVID-19 vaccination coverage | 21.38% |
8.2%
13.2 pts better
|
Numerator 31 · Denominator 145 |
| Staff flu vaccination coverage | 65.93% |
42%
23.9 pts better
|
Numerator 149 · Denominator 226 |
| Discharge function score | 50.49% |
56.45%
6 pts worse
|
Numerator 52 · Denominator 103 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 45 · Denominator 45 |
| Transfer of health information to patient | 92.86% |
96.28%
3.4 pts worse
|
Numerator 91 · Denominator 98 |
| Resident COVID-19 vaccinations up to date | 27.16% |
25.2%
2 pts better
|
Numerator 22 · Denominator 81 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.3
0.1 pts better
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.8 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.6
About the same
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
98.5%
0.8 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 100.0% · Q3 100.0% · Q4 98.7% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.2% |
98.2%
7 pts worse
|
95.5%
4.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
1.6%
1.4 pts worse
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.5% · Q3 2.8% · Q4 0.0% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
6.8%
5.3 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.5% · Q3 1.5% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
4.1%
0.7 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 6.3% · Q3 1.5% · Q4 2.7% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.7% |
13.7%
3 pts better
|
19.6%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 9.2% · Q3 12.1% · Q4 11.0% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.2% |
14.2%
10 pts better
|
16.7%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 0.0% · Q3 5.5% · Q4 3.4% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.3% |
11.0%
6.3 pts worse
|
16.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.0% |
10.7%
0.7 pts better
|
14.9%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 12.5% · Q3 5.0% · Q4 7.8% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
1.0%
0.5 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 1.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 13.2% |
10.9%
2.3 pts worse
|
19.8%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 17.2% · Q3 9.1% · Q4 8.1% · 4Q avg 13.2% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.7%
2.1 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 4.0% · Q3 2.2% · Q4 1.7% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.8% |
94.0%
1.2 pts worse
|
81.7%
11.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.1% · Q2 92.4% · Q3 96.0% · Q4 90.6% · 4Q avg 92.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
11.2%
0.6 pts worse
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 12.0% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.5% · Q2 0.5% · Q3 0.9% · Q4 0.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.9% |
93.2%
5.3 pts worse
|
79.7%
8.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.8% |
23.2%
6.6 pts worse
|
23.9%
5.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.8% · Observed 31.6% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-09 · Fire 2024-02-09
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-05-13 · Fire 2021-05-13
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-02-07
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-02-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-02-07
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-02-21
D · Potential for more than minimal harm
2025-02-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-21
F · Potential for more than minimal harm
2024-02-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-02-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-27
D · Potential for more than minimal harm
2024-02-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-27
D · Potential for more than minimal harm
2021-05-13
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2021-06-02
D · Potential for more than minimal harm
2021-05-13
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-06-02
D · Potential for more than minimal harm
2021-05-13
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2021-06-02
D · Potential for more than minimal harm
2021-05-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-02
D · Potential for more than minimal harm
2021-05-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-06-02
D · Potential for more than minimal harm
2021-05-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-06-02
Inspection history
Recent health citations
J · Immediate jeopardy
2025-11-20
F627 · Resident Rights Deficiencies
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2025-11-25
D · Potential for more than minimal harm
2025-11-20
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-11-25
E · Potential for more than minimal harm
2025-02-07
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-02-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-02-07
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-02-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-02-07
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-02-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-07
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-07
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-28
D · Potential for more than minimal harm
2025-02-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-10-24
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-11-04
D · Potential for more than minimal harm
2024-08-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-10
G · Actual harm
2024-02-09
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-02-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-02-09
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-02-23
D · Potential for more than minimal harm
2024-02-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-23
D · Potential for more than minimal harm
2023-10-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-20
D · Potential for more than minimal harm
2021-05-13
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2021-06-10
D · Potential for more than minimal harm
2021-05-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2021-06-10
D · Potential for more than minimal harm
2021-05-13
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2021-06-10
D · Potential for more than minimal harm
2021-05-13
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-06-10
D · Potential for more than minimal harm
2021-05-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-10
Penalties and ownership
What sits behind the stars
$14,020
2025-11-20
Fine
Fine · fine $14,020
Fine
Ownership
Cypress Healthcare Group LLC
5% Or Greater Direct Ownership Interest · Organization
Jackson, Matthew
5% Or Greater Indirect Ownership Interest · Individual
Jackson, Robert
5% Or Greater Indirect Ownership Interest · Individual
Sanofsky, Jack
5% Or Greater Indirect Ownership Interest · Individual
Jackson, Matthew
Corporate Director · Individual
Jackson, Robert
Corporate Director · Individual
Kaplow, Trina
W-2 Managing Employee · Individual
Sanofsky, Jack
Corporate Director · Individual
Nearby options
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5-star overall rating with 3-star inspections with 11 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
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Sacramento, CA
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
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5-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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