Country Oaks Care Center
215 W Pearl St · Pomona, CA · 91768 · 9096221067
81 certified beds For profit - Limited Liability company Chain: David Johnson
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- No federal fines or payment denials in CMS’s 3-year window.
- Inspection results have improved across recent cycles.
The composite number cleared 72 points, but Recommended is gated: inspection record below the Recommended bar. That rule is part of the published method.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 2 times under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 3 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 4.19 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.34 | 0.55–0.75 |
| Weekend hours / resident-day | 3.79 | ≈ weekday level |
| Nursing turnover / year | 53% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (81 in the current record)
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Potential for harm · D April 16, 2026 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected April 22, 2026 · Resident Assessment and Care Planning
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Potential for harm · D March 24, 2026 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected April 15, 2026 · Resident Assessment and Care Planning
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Potential for harm · D July 17, 2025 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected August 7, 2025 · Resident Assessment and Care Planning
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Potential for harm · D July 17, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected August 8, 2025 · Quality of Life and Care
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Potential for harm · E July 17, 2025 · found via complaint
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.
Corrected August 7, 2025 · Nursing and Physician Services
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Potential for harm · D April 16, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 22, 2025 · Quality of Life and Care
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Potential for harm · E April 16, 2025 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected April 23, 2025 · Resident Assessment and Care Planning
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Potential for harm · D April 16, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected April 17, 2025 · Infection Control
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Potential for harm · D March 6, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected March 6, 2025 · Resident Rights
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Potential for harm · D March 6, 2025
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 March 7, 2025 · Resident Rights
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Potential for harm · E March 6, 2025
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.
Corrected March 12, 2025 · Resident Rights
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Potential for harm · D March 6, 2025
Ensure each resident receives an accurate assessment.
Corrected March 14, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 6, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected March 12, 2025 · Resident Assessment and Care Planning
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Potential for harm · D March 6, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 12, 2025 · Quality of Life and Care
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Potential for harm · D March 6, 2025
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected March 12, 2025 · Quality of Life and Care
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Potential for harm · E March 6, 2025
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.
Corrected March 10, 2025 · Quality of Life and Care
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Potential for harm · E March 6, 2025
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected March 12, 2025 · Quality of Life and Care
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Potential for harm · D March 6, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected March 10, 2025 · Quality of Life and Care
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Potential for harm · D March 6, 2025
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.
Corrected March 10, 2025 · Nursing and Physician Services
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Potential for harm · E March 6, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected March 12, 2025 · Pharmacy Service
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Potential for harm · D March 6, 2025
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 March 14, 2025 · Pharmacy Service
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Potential for harm · D March 6, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 12, 2025 · Nutrition and Dietary
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Potential for harm · E March 6, 2025
Provide and implement an infection prevention and control program.
Corrected March 12, 2025 · Infection Control
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Potential for harm · E March 6, 2025
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected March 12, 2025 · Environmental
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No harm found · B March 6, 2025
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected March 14, 2025 · Environmental
Showing the 25 most recent. The Safety Report includes every citation with full findings.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 055247 · certified since November 1, 1971. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.