Las Colinas Post Acute
800 E 5th St, Ontario, CA 91764 · San Bernardino County · 216 certified beds · avg 203 residents/day · certified since Jun 1, 1977
Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)
2/5
Health inspection rating (on-site)
1
Serious findings on record
$70,925
Fines, last 3 years
3.48
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Nov 2, 2023 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 21, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (46)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 5, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| May 5, 2026 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Aug 29, 2025 | F · Potential for harm, facility-wide | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. |
| Aug 29, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 29, 2025 | F · Potential for harm, facility-wide | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Aug 29, 2025 | F · Potential for harm, facility-wide | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Aug 29, 2025 | E · Potential for harm, repeated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Aug 29, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Aug 29, 2025 | B · Minimal risk, repeated | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Aug 29, 2025 | B · Minimal risk, repeated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| May 28, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 14, 2025 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Feb 13, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Dec 4, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Oct 11, 2024 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · from a complaint |
| Jul 18, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jun 25, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 10, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 2, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Sep 8, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for residents with a colostomy, urostomy, or ileostomy — surgical openings in the abdomen that let waste leave the body into a pouch. These require regular, skilled attention to stay clean and healthy. · from a complaint |
| Aug 30, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Aug 30, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Mar 18, 2022 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 18, 2022 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Mar 18, 2022 | D · Potential for harm, one-off | The facility did not notify the appropriate authorities when a resident with a mental disorder or intellectual disability had a significant change in condition. |
| Mar 18, 2022 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Mar 18, 2022 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Mar 18, 2022 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Mar 18, 2022 | B · Minimal risk, repeated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| May 23, 2019 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| May 23, 2019 | F · Potential for harm, facility-wide | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| May 23, 2019 | F · Potential for harm, facility-wide | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| May 23, 2019 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 23, 2019 | F · Potential for harm, facility-wide | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. |
| May 23, 2019 | E · Potential for harm, repeated | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| May 23, 2019 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| May 23, 2019 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| May 23, 2019 | B · Minimal risk, repeated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (7 → 16).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 9 | 0 | F |
| 2022 | 7 | 0 | E |
| 2023 | 4 | 1 | J ▲ |
| 2024 | 5 | 0 | D |
| 2025 | 19 | 0 | F |
| 2026 | 2 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $70,925.
| Date | Type | Amount / length |
|---|---|---|
| Nov 2, 2023 | Fine | $70,925 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.48 | 4.31 | 3.95 | bottom 9% in California; bottom 36% in the U.S. |
| Registered Nurse hours | 0.23 | 0.61 | 0.69 | bottom 3% in California; bottom 4% in the U.S. |
| Weekend total nurse staffing | 3.22 | 3.90 | 3.50 | bottom 11% in California; bottom 43% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.23 | 0.51 | 0.48 | bottom 16% in California; bottom 17% in the U.S. |
| Total nursing staff turnover (%) | 22.9 | 36.7 | 45.8 | top 13% in California; top 5% in the U.S. |
| RN turnover (%) | 44.4 | 38.1 | 42.9 | bottom 36% in California; bottom 45% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.92, RN 0.25, weekend 3.62. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Apt, Frederick | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Etemadian, Ali | Individual | Contracted Managing Employee | NOT APPLICABLE | 01/01/2017 |
| Hancock, Mark | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Jergensen, Joshua | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Lords, Trevor | Individual | W-2 Managing Employee | NOT APPLICABLE | 02/01/2024 |
| Mitchell, John | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "What are your rules for bringing in my family member's favorite foods, and how are they stored?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you inspect and maintain essential equipment, and how quickly are repairs made?"
- "How is pest control handled here, and when was the last treatment or inspection?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Ontario Grove Healthcare & Wellness Centre, LP | 0.3 mi | Ontario, CA | ★★★☆☆ | 4/5 | |
| Heritage Park Nursing Center | 1.2 mi | Upland, CA | ★★★★★ | 5/5 | |
| Upland Rehabilitation and Care Center | 1.3 mi | Upland, CA | ★★★★★ | 4/5 | |
| Villa Mesa Care Center | 1.5 mi | Upland, CA | ★★★☆☆ | 4/5 | |
| Ontario Healthcare Center | 2.7 mi | Ontario, CA | ★★★★★ | 5/5 | |
| Community Extended Care Hospital of Montclair | 2.9 mi | Montclair, CA | ★★★★★ | 5/5 | |
| Montclair Manor Care Center | 3.1 mi | Montclair, CA | ★★★★★ | 4/5 | |
| Inland Christian Home | 3.5 mi | Ontario, CA | ★★★★☆ | 4/5 | |
| Rancho Mesa Care Center | 3.7 mi | Alta Loma, CA | ★★★★☆ | 4/5 | |
| Claremont Heights Post Acute | 4.6 mi | Claremont, CA | ★★☆☆☆ | 2/5 | |
| Trellis Chino | 4.8 mi | Chino, CA | ★★★★★ | 5/5 | |
| Claremont Manor Care Center | 5.3 mi | Claremont, CA | ★★★☆☆ | 3/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 055619.