Facility WatchInspection records for every certified US nursing home
Country Oaks Care Center
215 W Pearl ST Pomona, CA 91768 (909) 622-1067
CCN
055247
Certified beds
81
Ownership
For profit - Limited Liability company
Chain
David Johnson
Nurse staffing
4.07
Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.33 hours per resident per day
Nursing staff turnover: 53% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected April 16, 2026
1 citation · from a complaint investigation · Health
D
F0842No actual harm with potential for more than minimal harm · Isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected April 22, 2026
Inspected March 24, 2026
1 citation · from a complaint investigation · Health
D
F0842No actual harm with potential for more than minimal harm · Isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected April 15, 2026
Inspected July 17, 2025
3 citations · from a complaint investigation · Health
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected August 7, 2025
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected August 8, 2025
E
F0726No actual harm with potential for more than minimal harm · Pattern
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Deficient, Provider has date of correction · corrected August 7, 2025
Inspected April 16, 2025
3 citations · from a complaint investigation · Health
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected April 22, 2025
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected April 17, 2025
E
F0842No actual harm with potential for more than minimal harm · Pattern
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected April 23, 2025
Inspected March 6, 2025
17 citations · Health
B
F0912No actual harm with potential for minimal harm · Pattern
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Deficient, Provider has date of correction · corrected March 14, 2025
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected March 6, 2025
D
F0578No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected March 7, 2025
D
F0641No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected March 14, 2025
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected March 12, 2025
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected March 12, 2025
D
F0690No actual harm with potential for more than minimal harm · Isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected March 12, 2025
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected March 10, 2025
D
F0726No actual harm with potential for more than minimal harm · Isolated
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Deficient, Provider has date of correction · corrected March 10, 2025
D
F0758No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected March 14, 2025
D
F0812No actual harm with potential for more than minimal harm · Isolated
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected March 12, 2025
E
F0584No actual harm with potential for more than minimal harm · Pattern
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Deficient, Provider has date of correction · corrected March 12, 2025
E
F0693No actual harm with potential for more than minimal harm · Pattern
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Deficient, Provider has date of correction · corrected March 10, 2025
E
F0694No actual harm with potential for more than minimal harm · Pattern
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Deficient, Provider has date of correction · corrected March 12, 2025
E
F0755No actual harm with potential for more than minimal harm · Pattern
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected March 12, 2025
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected March 12, 2025
E
F0921No actual harm with potential for more than minimal harm · Pattern
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected March 12, 2025
Inspected February 19, 2025
2 citations · from a complaint investigation · Health
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected March 13, 2025
D
F0921No actual harm with potential for more than minimal harm · Isolated
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected February 26, 2025
Inspected October 29, 2024
1 citation · from a complaint investigation · Health
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected November 4, 2024
Inspected October 23, 2024
1 citation · from a complaint investigation · Health
D
F0776No actual harm with potential for more than minimal harm · Isolated
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Deficient, Provider has date of correction · corrected November 12, 2024
Inspected September 25, 2024
1 citation · from a complaint investigation · Health
E
F0726No actual harm with potential for more than minimal harm · Pattern
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Deficient, Provider has date of correction · corrected October 24, 2024
Inspected August 28, 2024
3 citations · from a complaint investigation · Health
D
F0732No actual harm with potential for more than minimal harm · Isolated
Post nurse staffing information every day.
Deficient, Provider has date of correction · corrected August 29, 2024
E
F0690No actual harm with potential for more than minimal harm · Pattern
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected August 29, 2024
E
F0725No actual harm with potential for more than minimal harm · Pattern
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Deficient, Provider has date of correction · corrected August 29, 2024
Inspected August 12, 2024
1 citation · from a complaint investigation · Health
E
F0689No actual harm with potential for more than minimal harm · Pattern
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected August 26, 2024
Inspected August 1, 2024
1 citation · from a complaint investigation · Health
D
F0607No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Deficient, Provider has date of correction · corrected August 2, 2024
Inspected July 27, 2024
1 citation · from a complaint investigation · Health
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected July 29, 2024
Inspected July 15, 2024
3 citations · from a complaint investigation · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected July 31, 2024
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected July 28, 2024
E
F0584No actual harm with potential for more than minimal harm · Pattern
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Deficient, Provider has date of correction · corrected July 15, 2024
Inspected June 11, 2024
1 citation · from a complaint investigation · Health
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected July 9, 2024
Inspected May 7, 2024
1 citation · from a complaint investigation · Health
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected May 31, 2024
Inspected April 17, 2024
2 citations · from a complaint investigation · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected May 16, 2024
E
F0690No actual harm with potential for more than minimal harm · Pattern
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected May 16, 2024
Inspected March 19, 2024
2 citations · from a complaint investigation · Health
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected March 20, 2024
E
F0842No actual harm with potential for more than minimal harm · Pattern
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected March 21, 2024
Inspected March 7, 2024
1 citation · from a complaint investigation · Health
E
F0657No actual harm with potential for more than minimal harm · Pattern
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected April 2, 2024
Inspected February 23, 2024
14 citations · from a complaint investigation · Health
B
F0912No actual harm with potential for minimal harm · Pattern
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Waiver has been granted · corrected March 18, 2024
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected March 18, 2024
D
F0690No actual harm with potential for more than minimal harm · Isolated
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Deficient, Provider has date of correction · corrected March 18, 2024
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected March 18, 2024
D
F0756No actual harm with potential for more than minimal harm · Isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected March 18, 2024
D
F0758No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected March 18, 2024
D
F0919No actual harm with potential for more than minimal harm · Isolated
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected March 18, 2024
D
F0921No actual harm with potential for more than minimal harm · Isolated
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected March 18, 2024
E
F0656No actual harm with potential for more than minimal harm · Pattern
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected March 18, 2024
E
F0684No actual harm with potential for more than minimal harm · Pattern
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected March 18, 2024
E
F0686No actual harm with potential for more than minimal harm · Pattern
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected March 18, 2024
E
F0692No actual harm with potential for more than minimal harm · Pattern
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected March 18, 2024
E
F0838No actual harm with potential for more than minimal harm · Pattern
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Deficient, Provider has date of correction · corrected March 18, 2024
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected March 18, 2024
Inspected December 26, 2023
2 citations · from a complaint investigation · Health
D
F0808No actual harm with potential for more than minimal harm · Isolated
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Deficient, Provider has date of correction · corrected January 18, 2024
D
F0812No actual harm with potential for more than minimal harm · Isolated
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected January 17, 2024
Inspected February 24, 2023
19 citations · Health
B
F0888No actual harm with potential for minimal harm · Pattern
Ensure staff are vaccinated for COVID-19
Deficient, Provider has date of correction · corrected March 17, 2023
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected March 17, 2023
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected March 17, 2023
D
F0584No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Deficient, Provider has date of correction · corrected March 17, 2023
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected March 17, 2023
D
F0676No actual harm with potential for more than minimal harm · Isolated
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Deficient, Provider has date of correction · corrected March 17, 2023
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected March 17, 2023
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected March 17, 2023
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected March 17, 2023
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected March 17, 2023
D
F0808No actual harm with potential for more than minimal harm · Isolated
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Deficient, Provider has date of correction · corrected March 17, 2023
D
F0881No actual harm with potential for more than minimal harm · Isolated
Implement a program that monitors antibiotic use.
Deficient, Provider has date of correction · corrected March 17, 2023
D
F0921No actual harm with potential for more than minimal harm · Isolated
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Deficient, Provider has date of correction · corrected March 17, 2023
E
F0565No actual harm with potential for more than minimal harm · Pattern
Honor the resident's right to organize and participate in resident/family groups in the facility.
Deficient, Provider has date of correction · corrected March 17, 2023
E
F0695No actual harm with potential for more than minimal harm · Pattern
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected March 17, 2023
E
F0698No actual harm with potential for more than minimal harm · Pattern
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected March 17, 2023
E
F0759No actual harm with potential for more than minimal harm · Pattern
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected March 17, 2023
E
F0761No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected March 17, 2023
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected March 17, 2023