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Nursing HomeMedicaid Investigative

Las Colinas Post Acute

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

800 East 5th Street, Ontario, CA 91764216 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
3.3/5

based on 135 Google reviews

5
4
3
2
1
Las Colinas Post Acute Nursing Home in Ontario, CA — Street View
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4/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (2/5 stars)
  • Low staffing rating (2/5 stars)
  • Above-median deficiencies (18 vs median 13.0)

Below average in CA · Critically understaffed (RN) · Low staff turnover (stable workforce) · Below chain average · $70,925 in fines

Source: Medicare data

What this means for your family

This facility offers excellent rehabilitation therapy and high-quality dining, which can be great for short-term recovery. However, families must be extremely vigilant about overnight care, as there is a documented pattern of delayed responses to call lights and inadequate hygiene maintenance during night shifts.

Google Reviews

Google Reviews

135 reviews analyzed
Families considering Las Colinas Post Acute will find a polarizing environment. While many long-term residents and their families praise the compassionate nursing staff, high-quality rehabilitation therapy, and excellent food, there are frequent and serious allegations regarding neglect, specifically involving delayed response to call lights and inadequate hygiene care during overnight shifts.

Quality Themes

Tap a score for details
Food8.0Staff4.0Clean4.0Activities5.0Meds2.0MemoryN/AComms2.0ValueN/A

Strengths

  • Compassionate and attentive nursing staff
  • High-quality rehabilitation and physical therapy
  • Outstanding food variety and quality
  • Clean and well-maintained facility

Concerns

  • Slow response to call buttons and neglect during night shifts (mentioned by 7 reviewers)
  • Inadequate hygiene and failure to change incontinence products (mentioned by 4 reviewers)
  • Difficulty communicating with management and doctors (mentioned by 5 reviewers)
  • Issues with medication administration delays (mentioned by 3 reviewers)

Rating Trends

Tap a year to see what changed

234'16(3)'18(16)'20(12)'22(20)'24(9)'26(9)

Distribution

5
50
4
3
3
1
2
2
1
52

How They Respond to Reviews

100%response rate
Good

The owner provides highly personalized, name-dropping responses to 5-star reviews, often celebrating specific staff members. For 1-star reviews, they use a consistent template of acknowledging concerns and directing the reviewer to contact the administrator via a specific phone number.

Questions for Your Tour

  • 1We've heard wonderful things about the variety and quality of the food here; could you tell us more about the daily meal menus?
  • 2How do you ensure that call buttons are answered promptly, especially during the overnight hours?
  • 3What specific protocols are in place to ensure medication is administered accurately and on a strict schedule?
  • 4Can you describe your process for communicating important medical updates or changes in condition from doctors to the family?
  • 5How does the nursing team manage routine hygiene and personal care tasks to ensure every resident's comfort is maintained?
  • 6What kind of daily activities or social programs are available to keep residents engaged and active?

Personalized based on this facility's data


Key Review Excerpts

The food is outstanding. Management is always there for help. The nurses are super friendly!

Long-term resident's family · 2026★★★★★

The nurses leave you in your waste overnight. The nurses sleep on graveyard. They don’t answer the call button for over 45mins.

Patient · 2026☆☆☆☆

The rehab department has been really great and Saul Gomez has been outstanding with my rehabilitation. I highly recommend him.

Rehab patient · 2025★★★★★
Source: 135 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.28hrs
37%
Registered nurses for medical care
Total Nursing
4.08hrs
99%
All nurses + aides combined
Staff Turnover
27%
Lower is better (< 30% = good)
RN Turnover
42%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
3/ 5
Better Than Avg

11

measures

Worse Than Avg

1

measures

Mixed Results

5

measures

Long-Stay Residents
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility4.5%
Better than Avg
Here
4.5%
US
19.4%
CA
10.7%
San bernardino
8.6%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility8.3%
Better than Avg
Here
8.3%
US
15.3%
CA
10.5%
San bernardino
10.7%
💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
93.4%
CA
98.6%
San bernardino
98.8%
💊

Residents on antipsychotic medication

↓ Lower is better
This Facility14.3%
Mixed vs Avgs
Here
14.3%
US
15.4%
CA
11.6%
San bernardino
8.8%
😔

Residents with depression symptoms

↓ Lower is better
This Facility12.5%
Worse than Avg
Here
12.5%
US
12.1%
CA
7.0%
San bernardino
10.7%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility18.5%
Mixed vs Avgs
Here
18.5%
US
19.5%
CA
13.7%
San bernardino
16.9%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
79.7%
CA
93.2%
San bernardino
94.0%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility100.0%
Better than Avg
Here
100.0%
US
81.8%
CA
94.2%
San bernardino
97.2%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility1.4%
Mixed vs Avgs
Here
1.4%
US
1.6%
CA
1.5%
San bernardino
1.2%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

18deficiencies
1penalties
Above state avg (15.4)
16 complaint-triggered
$70,925 in fines

Families have filed complaints triggering 15 deficiencies, highlighting serious concerns about treatment and care quality. Recurring problems include inadequate treatment according to resident care plans, medication management issues, nutrition and dietary services, and infection control. While the facility has corrected cited deficiencies, the pattern of complaints suggests ongoing care quality challenges that warrant careful consideration during any visit.

Aug 29, 2025Routine
19
0813ModerateCorrected

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

0880ModerateCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0908ModerateCorrected

Environmental Deficiencies

Keep all essential equipment working safely.

0925ModerateCorrected

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

0006ModerateCorrected

Emergency Preparedness Deficiencies

Conduct risk assessment and an All-Hazards approach.

0030ModerateCorrected

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

0578ModerateCorrected

Resident Rights Deficiencies

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.

0363MinorCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0605MinorCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

0636MinorCorrected

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

0656MinorCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0657MinorCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0676MinorCorrected

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

0685MinorCorrected

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

0695MinorCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0755MinorCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0761MinorCorrected

Pharmacy Service Deficiencies

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.

0577MinorCorrected

Resident Rights Deficiencies

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

0912MinorCorrected

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

May 28, 2025Complaint
1
0684MinorCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Mar 14, 2025Complaint
1
0609MinorCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Feb 13, 2025Complaint
1
0684MinorCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Dec 4, 2024Complaint
1
0684MinorCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Oct 11, 2024Complaint
1
0676MinorCorrected

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Federal Penalties

Fine

Nov 2, 2023

$70,925

Ownership & Operations

Who Operates This Facility

Owner / Operator

Las Colinas Post Acute

Organization Type

for profit

Chain Affiliation

Chain Name

Pacs Group

Chain Size

264 facilities nationwide

Chain avg rating: 2.9/5 · Rank 205 of 260

Ownership & Management

Key personnel

Etemadian, AliContracted Managing EmployeeLords, TrevorW-2 Managing EmployeeApt, FrederickOfficer / DirectorHancock, MarkOfficer / DirectorJergensen, JoshuaOfficer / Director
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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