Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Las Colinas Post Acute during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was not provided with a dental assessment within ninety days of admission, as required by facility policy. Both the resident and the DON confirmed that no dental services had been provided since admission, and record review supported this finding.
A resident was found with blanchable redness on the face after a shower, following complaints from the resident's wife about hot water and rough scrubbing by a CNA. Despite the facility's policy to report such incidents, the DON and Administrator did not report it to the CDPH, as they did not perceive it as abuse due to a lack of malicious intent. The IDT reviewed the incident but did not include the resident or the resident's wife in the meeting.
A facility failed to maintain an accurate MAR for a resident with liver failure and ESRD. An LVN did not sign the MAR for a scheduled dose of Lactulose, a medication to reduce ammonia levels, potentially leading to the resident's hospital readmission. The DON confirmed that unsigned medications are considered not given, and the LVN admitted to not signing the MAR despite believing she administered the medication.
A resident with a foley catheter was not monitored per shift as ordered, with missing documentation for multiple shifts. The resident, with a history of hemiplegia, epilepsy, COPD, and UTIs, was sent to an acute hospital after a change in condition. The facility's policies on documentation were not followed, as revealed by interviews with the ADON and an LVN.
The facility did not follow its policies for providing ADLs and timely response to call lights for two residents. One resident with chronic respiratory failure and other conditions reported delays in assistance, while another with respiratory failure and diabetes experienced similar issues. The facility's policies require prompt response to call lights and care to maintain residents' abilities, which were not adhered to.
A resident admitted without wounds developed a stage 4 pressure injury and multiple blisters while under care, despite being at high risk for skin breakdown. The facility's interventions, such as protective lotion and pressure-reducing mattresses, were insufficient, leading to significant skin deterioration. Staff acknowledged the resident's poor circulation and immunocompromised state but admitted the wounds could have been prevented.
Two residents in the facility experienced significant delays in response to their call lights, impacting their care. One resident, with cerebral ataxia and hypothyroidism, reported waiting up to two hours for assistance, particularly during the PM shift. Another resident, with heart failure, also faced excessive delays, sometimes using a phone to contact the desk for quicker help. Both residents' care plans required prompt response to call lights due to their medical conditions and deficits in activities of daily living.
A resident was discharged with four medication packs not prescribed to them, resulting from a failure to follow the facility's medication verification process. The resident's post-discharge plan of care did not match the medication orders, and a critical medication was missing.
Failure to Provide Timely Dental Assessment
Penalty
Summary
The facility failed to provide a dental assessment to a resident within ninety days of admission, as required by its own policy. The resident, who was admitted with multiple diagnoses including intervertebral disc degeneration, type 2 diabetes mellitus, muscle wasting and atrophy, obstructive and reflux uropathy, acute kidney failure, and hypertension, did not receive any dental services after admission. This was confirmed through interviews with both the resident and the Director of Nursing (DON), as well as a review of the resident's admission record. The DON acknowledged that the resident should have been seen by the facility's dental consultant within ninety days of admission, in accordance with the facility's policy dated April 2007. The policy specifically states that a consultant dentist is responsible for providing a dental assessment to each resident within this timeframe. The lack of a dental assessment for this resident was verified through record review and staff interviews.
Failure to Report Suspected Abuse
Penalty
Summary
The facility failed to report a suspected case of abuse involving a resident who was noted to have blanchable redness on the left side of the face near the left eye. The incident occurred after the resident's wife reported that the resident complained about the water being too hot during a shower given by a CNA, and that the resident's face was scrubbed too hard. The Licensed Vocational Nurse (LVN 1) received this complaint and reported it to the Front Desk LVN (LVN 2) and the Registered Nurse (RN 1). The RN conducted an assessment and confirmed the redness but deemed it blanchable. Despite the complaint and the physical evidence, the Director of Nursing (DON) and the Administrator did not report the incident to the California Department of Public Health (CDPH), as they did not perceive it as abuse due to a lack of malicious intent. The facility's policy requires all reports of resident abuse, including injuries of unknown origin, to be reported to local, state, and federal agencies. However, the facility's Interdisciplinary Team (IDT) reviewed the incident and concluded there was no intent to harm, thus deciding not to report it. The IDT's review included interviews with staff involved in the resident's care, but neither the resident nor the resident's wife was included in the meeting. The Administrator confirmed that the decision not to report was based on the belief that no abuse occurred, despite the facility's policy and procedure requirements.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to maintain an accurate medication administration record (MAR) for a resident diagnosed with liver failure and end-stage renal disease (ESRD). On January 25, 2025, at 9:00 PM, a Licensed Vocational Nurse (LVN) did not sign the MAR to confirm the administration of Lactulose, a medication prescribed to reduce ammonia levels in the blood. The resident's orders specified that Lactulose should be administered orally three times a day, but the MAR only showed administration at 9:00 AM and 1:00 PM on that day. During interviews, the Director of Nursing (DON) confirmed that if a medication is not signed on the MAR, it is considered not given. The LVN involved stated that she believed she administered the medication but acknowledged her mistake in not signing the MAR. The facility's policy requires the individual administering medication to initial the MAR after giving each medication. This oversight potentially resulted in the resident's readmission to the hospital with elevated ammonia levels.
Failure to Document Foley Catheter Monitoring
Penalty
Summary
The facility failed to ensure that a resident with a foley catheter had documented monitoring per shift as ordered. This deficiency was identified during a review of the resident's medical records, which revealed missing electronic signatures for catheter monitoring on multiple shifts. The resident, who had a history of hemiplegia, epilepsy, chronic obstructive pulmonary disease, and urinary tract infections, was admitted to the facility with specific orders to monitor the catheter for changes in urine character and proper placement every shift. However, there were missing signatures from both the PM and NOC shifts, indicating a lack of documentation for the required monitoring. The deficiency was further highlighted when the resident experienced a change in condition, including tachycardia and altered level of consciousness, leading to a doctor's order to send the resident to an acute hospital for further evaluation. Interviews with the Assistant Director of Nursing and a Licensed Vocational Nurse revealed that the missing documentation was identified after an Ombudsman request, and the nurses attested to performing the assessments but failed to document them timely. The facility's policies on charting and documentation emphasize the importance of accurate and timely record-keeping, which was not adhered to in this case.
Failure to Respond to Call Lights and Provide ADLs
Penalty
Summary
The facility failed to adhere to its policy and procedure for providing Activities of Daily Living Services (ADLs) and ensuring timely response to call lights for two of the three sampled residents. Resident 1, who was admitted with chronic respiratory failure, morbid obesity, heart failure, and muscle wasting and atrophy, reported that staff took a long time to respond to call lights when assistance was needed. Similarly, Resident 3, with diagnoses including respiratory failure, type 2 diabetes mellitus, epilepsy, and muscle wasting and atrophy, also expressed that there were delays in answering call lights. The facility's policy, titled 'Answering the Call Light,' mandates that call lights should be answered as soon as possible, and the policy on 'Activities of Daily Living' requires that residents receive appropriate care to maintain or improve their abilities unless clinical conditions make it unavoidable. Interviews with the Administrator and the Director of Nursing confirmed that staff did not follow these policies, as they acknowledged the expectation for staff to respond to call lights and attend to residents' needs promptly.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to provide appropriate care to prevent the development of pressure ulcers in a resident, leading to a stage 4 pressure injury on the coccyx and multiple blisters on various parts of the body. The resident, who was admitted without any wounds, developed these injuries while under the facility's care. The resident had a high risk for skin breakdown due to decreased mobility, anemia, and other health conditions, as indicated in the care plan initiated upon admission. Despite the implementation of interventions such as applying protective lotion, using a pressure-reducing mattress, and providing frequent skin care, the resident developed a coccyx wound and heel blister shortly after admission. The facility's records show that the resident's skin was intact upon admission, but a comprehensive skin evaluation later revealed significant skin breakdown, including a stage 4 pressure injury and other blisters. The facility's policy on pressure ulcer prevention was not effectively followed, as the resident's condition deteriorated, leading to the development of multiple wounds. Interviews with the facility's staff, including the Treatment Nurse, ADON, and DON, confirmed that the resident did not have wounds upon admission and that the wounds developed during the resident's stay. The staff acknowledged the resident's poor circulation and immunocompromised state but indicated that the wounds could have been prevented. The facility's failure to adhere to its own policies and procedures for pressure ulcer prevention contributed to the resident's skin breakdown and subsequent transfer to a hospital for further evaluation.
Delayed Response to Call Lights for Two Residents
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the timely response to call lights, impacting two residents. Resident 1, who was admitted with cerebral ataxia and hypothyroidism, expressed dissatisfaction with the response time to call lights, particularly during the PM shift after 9:00 PM. The resident reported waiting for assistance for up to two hours. Resident 1's care plan indicated a need for prompt response to call lights due to deficits in activities of daily living related to their medical conditions. Similarly, Resident 2, admitted with heart failure, also reported excessive delays in response to call lights, sometimes resorting to using a telephone to contact the desk for quicker assistance. Resident 2 experienced delays while soiled, with response times extending up to two hours. The care plan for Resident 2 highlighted the need for assistance with activities of daily living due to mobility decline. The facility's policy, revised in October 2010, emphasized the importance of responding to residents' requests and needs promptly.
Resident Discharged with Incorrect Medications
Penalty
Summary
The facility failed to ensure that a resident was discharged home with the correct medication packs as ordered by the physician. This failure resulted in the resident being discharged with four medication packs that were not prescribed to them and belonged to another resident. The resident had been admitted with diagnoses including heart failure, hypothyroidism, and acute kidney failure. During the review of the resident's medical records, it was found that the post-discharge plan of care did not match the medication orders, and a critical medication for hypothyroidism was missing. The Licensed Vocational Nurse (LVN) and the Assistant Director of Nursing (ADON) acknowledged the discrepancy and confirmed that the resident received another resident's medication packs, which should not have happened. The normal discharge process involves explaining the medications to the resident or their responsible party, checking the medication list against the resident's wristband, and having multiple nurses verify the medications. However, in this case, the process was not followed correctly. The Director of Nursing (DON) also confirmed that the medications should be verified against the physician's orders and that the resident should agree with the medications and sign off on them. The facility's policy on discharge medications requires reconciliation of pre-discharge and post-discharge medications, which was not adhered to in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ontario
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ontario Grove Healthcare & Wellness Centre, Lp | 0.3 mi | — | 1 | 0 |
| Heritage Park Nursing Center | 1.2 mi | — | 0 | 0 |
| Upland Rehabilitation And Care Center | 1.3 mi | — | 1 | 0 |
| Villa Mesa Care Center | 1.5 mi | — | 19 | 0 |
| Ontario Healthcare Center | 2.7 mi | — | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.