The Hills Post Acute: Drug Log, Medication Failures - CA
The inspection at The Hills Post Acute, a skilled nursing facility at 1800 Old Tustin Avenue, was conducted on March 24, 2025.
The eye drop incident involved Resident 71, a patient with moderate cognitive impairment who had been readmitted to the facility and was prescribed brimonidine tartrate ophthalmic solution 0.2%, one drop in both eyes twice daily, for mild open-angle glaucoma. The prescription dated to January 17, 2025.
On the morning of March 19, inspectors watched LVN 9 administer the drops to Resident 71's eyes. After instilling the solution, LVN 9 told the resident to keep his eyes closed for one minute. Resident 71 opened them immediately and told LVN 9 he wanted sugar. LVN 9 left the room. With no one there to assist him, Resident 71 was observed opening and closing his eyes and wiping them, disrupting absorption of the medication.
The facility's own eye drop administration policy, revised in October 2019, is specific: after instilling the drops, staff should compress the tear duct at the inner corner of the eye for one to two minutes to reduce systemic absorption, or ensure the resident keeps the eye closed for approximately three minutes. Neither happened.
When inspectors interviewed LVN 9 about an hour later, she acknowledged exactly what she had failed to do. She said she should have compressed the inner corner of Resident 71's eyes and stayed with him to make sure they remained closed for a full minute so the medication could absorb properly. She said she would call the physician to ask whether another dose would be needed that morning.
The Director of Nursing was informed of the finding on March 24 and acknowledged it.
The controlled substance log failures were a separate problem, and a broader one. On March 18, inspectors reviewed the logs with LVN 4, who confirmed that multiple licensed nurses' signatures were missing. On March 21, inspectors reviewed the controlled substance logs for Medication Carts 2 and 3 with the Director of Nursing, who verified the same gaps.
The Director of Nursing told inspectors that nurses were supposed to sign the controlled substance log so that medications were accounted for and incoming nurses would know the medications were complete when they arrived for their shift. The missing signatures dated back to at least January 20, 2025, covering the 7-to-3 shift's outgoing nurse. The DON confirmed the nurses should have been signing and had not been.
Controlled substance logs exist precisely because the drugs tracked in them, including opioids and other medications with potential for diversion or misuse, require a documented chain of custody at every shift transition. Gaps in those signatures mean there is no verified record that the medications present at the start of a shift matched what was there at the end.
CMS rated both deficiencies at the level of minimal harm or potential for actual harm, with few residents affected.
Resident 71, whose glaucoma medication may not have absorbed correctly that morning, has moderate cognitive impairment. Whether he received a replacement dose, and whether his physician was ever reached, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Hills Post Acute from 2025-03-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 2, 2026 · Our methodology
THE HILLS POST ACUTE in SANTA ANA, CA was cited for violations during a health inspection on March 24, 2025.
The inspection at The Hills Post Acute, a skilled nursing facility at 1800 Old Tustin Avenue, was conducted on March 24, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.