College Oak Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at College Oak Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF627Nov 20, 2025

  Based on interview and record review, the facility failed to ensure a safe and appropriate discharge was provided to one of three sampled residents (Resident 1), when Resident 1 was not permitted admission to the facility upon return from a day leave and was discharged to her car.This failure resulted in Resident 1's unanticipated discharge and homelessness with no resources, medical care, or information on how to file an appeal.On 10/23/25 at 1:52 p.m. an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Administrator (Admin). […]

• Actual harm, isolatedF685Feb 9, 2024

  Based on interviews, record review, facility document review, and facility policy review, the facility failed to ensure 1 (Resident #72) of 2 residents reviewed for vision services received treatment to maintain vision abilities. Specifically, the facility failed to obtain an ophthalmology appointment for the treatment of cataracts for Resident #72, who requested multiple times to be seen by a specialist for treatment. This failure resulted in Resident #72's vision worsening. Findings included: A review of a facility policy titled Referrals, Social Services, revised in December 2008, revealed, Social services personnel shall coordinate most resident referrals with outside agencies. The policy revealed, 3. […]

• No harm, potential for more than minimal, widespreadF812Apr 9, 2026

  Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and served in a sanitary manner for a census of 112 when:1.Three bags of food were found unsealed in the freezer, and 2.There was a large buildup of black residue on the inside door jam of the walk-in refrigerator .These failures present a potential risk of foodborne illnesses for residents eating facility prepared meals.Findings:1.During a concurrent observation and interview on 4/6/26 at 8:12 a.m. […]

• No harm, potential for more than minimal, patternF755Feb 7, 2025

  Based on observation, interview and record review the facility failed to ensure accurate accountability of controlled medication when: 1. There was a discrepancy between the Controlled Drug Record (CDR-inventory sheet that keeps record of the usage of controlled medications) and medication blister card (medcard-a type of medication packaging) for Resident 76, Resident 151 and Resident 17. 2. A bottle of morphine sulfate solution (controlled medication [medication with high potential for abuse or addiction] to relieve pain) was not reconciled properly. These failures resulted in the facility not having an accurate accountability of controlled medications, and the potential for abuse or misuse of these medications. Findings: 1. […]

• No harm, potential for more than minimal, patternF759Feb 7, 2025

  Based on observation, interview and record review, the facility failed to ensure medication error rate was not less than 5% when the error rate was 17.86% based on five medication errors out of 28 opportunities observed during a medication pass observation for three out of six residents (Resident 7, Resident 204 and Resident 351). This failure resulted in medications not given in accordance with the prescriber's orders or manufacturer's specifications and had the potential to affect the resident's clinical conditions. Findings: 1. During a concurrent medication observation and interview on 2/5/25 at 7:29 a.m. […]