Cycle 1
Health 2025-08-29 · Fire 2025-08-29
18 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Ontario, CA
Las Colinas Post Acute
2-star overall rating with 2-star inspections with $70,925 in total fines with 18 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
800 East 5th Street, Ontario, CA
(909) 984-8629
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
216
Certified beds
Average residents
207
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1977-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.28
Registered nurse staffing
LPN hours / resident day
1.42
Licensed practical nurse staffing
Aide hours / resident day
2.38
Nurse aide staffing
Weekend hours
3.58
Weekend nurse staffing
RN turnover
42%
Annual RN turnover
Total nurse turnover
27%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 4.7 |
2.3
2.4 pts worse
|
1.9
2.8 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.6
0.9 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
1.6%
1.2 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 10.1% |
6.8%
3.3 pts worse
|
11.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.2% |
4.1%
3.9 pts better
|
5.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.3% |
13.7%
3.6 pts worse
|
19.6%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 11.8% |
14.2%
2.4 pts better
|
16.7%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.2% |
11.0%
2.8 pts better
|
16.3%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.6% |
10.7%
0.1 pts better
|
14.9%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
1.0%
0.9 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 3.2% |
10.9%
7.7 pts better
|
19.8%
16.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
4.7%
0.3 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.4% |
11.2%
2.8 pts better
|
12.0%
3.6 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.1% |
23.2%
0.1 pts better
|
23.9%
0.8 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-03-18 · Fire 2022-03-18
13 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2019-05-23 · Fire 2019-05-23
16 health deficiencies
Top issue: Nutrition and Dietary (6 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-29
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-08-29
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-09-19
E · Potential for more than minimal harm
2022-03-18
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-04-11
E · Potential for more than minimal harm
2022-03-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-04-11
D · Potential for more than minimal harm
2022-03-18
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-04-11
D · Potential for more than minimal harm
2022-03-18
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2022-04-11
D · Potential for more than minimal harm
2022-03-18
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-04-11
D · Potential for more than minimal harm
2022-03-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-04-11
D · Potential for more than minimal harm
2022-03-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-04-11
D · Potential for more than minimal harm
2022-03-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-04-11
D · Potential for more than minimal harm
2022-03-18
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-04-11
D · Potential for more than minimal harm
2022-03-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-04-11
D · Potential for more than minimal harm
2019-05-23
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2019-08-13
D · Potential for more than minimal harm
2019-05-23
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-08-13
D · Potential for more than minimal harm
2019-05-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2019-08-13
D · Potential for more than minimal harm
2019-05-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-08-13
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-29
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-11-21
F · Potential for more than minimal harm
2025-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-11-21
F · Potential for more than minimal harm
2025-08-29
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-11-21
F · Potential for more than minimal harm
2025-08-29
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-11-21
E · Potential for more than minimal harm
2025-08-29
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 2025-11-21
D · Potential for more than minimal harm
2025-08-29
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-08-29
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-08-29
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 2025-11-21
D · Potential for more than minimal harm
2025-08-29
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-08-29
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-08-29
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-08-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-08-29
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 2025-11-21
D · Potential for more than minimal harm
2025-08-29
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 2025-11-21
B · Minimal harm
2025-08-29
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2025-11-21
B · Minimal harm
2025-08-29
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2025-11-21
D · Potential for more than minimal harm
2025-05-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-03-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-02-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-27
D · Potential for more than minimal harm
2024-12-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-10-11
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-07-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-01
D · Potential for more than minimal harm
2024-06-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-04-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-04-19
J · Immediate jeopardy
2023-11-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-21
D · Potential for more than minimal harm
2023-09-08
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-09-19
D · Potential for more than minimal harm
2023-08-30
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 2023-09-06
D · Potential for more than minimal harm
2023-08-30
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 2023-09-06
D · Potential for more than minimal harm
2023-06-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-22
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2023-05-31
D · Potential for more than minimal harm
2023-04-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-13
E · Potential for more than minimal harm
2022-03-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-04-08
D · Potential for more than minimal harm
2022-03-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-04-08
D · Potential for more than minimal harm
2022-03-18
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2022-04-08
D · Potential for more than minimal harm
2022-03-18
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2022-04-08
D · Potential for more than minimal harm
2022-03-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-04-08
D · Potential for more than minimal harm
2022-03-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-04-08
B · Minimal harm
2022-03-18
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2022-04-08
F · Potential for more than minimal harm
2019-05-23
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2019-06-22
F · Potential for more than minimal harm
2019-05-23
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2019-06-22
F · Potential for more than minimal harm
2019-05-23
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-06-22
F · Potential for more than minimal harm
2019-05-23
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 2019-06-22
F · Potential for more than minimal harm
2019-05-23
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2019-06-22
E · Potential for more than minimal harm
2019-05-23
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 2019-06-22
D · Potential for more than minimal harm
2019-05-23
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-06-22
D · Potential for more than minimal harm
2019-05-23
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2019-06-22
B · Minimal harm
2019-05-23
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2019-06-22
Penalties and ownership
What sits behind the stars
$70,925
2023-11-02
Fine
Fine · fine $70,925
Fine
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Etemadian, Ali
Contracted Managing Employee · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jergensen, Joshua
Corporate Officer · Individual
Lords, Trevor
W-2 Managing Employee · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
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4-star overall rating with 4-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Heritage Park Nursing Center
Upland, CA
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Upland Rehabilitation and Care Center
Upland, CA
5-star overall rating with 4-star inspections with 16 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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