The Hills Post Acute: Infection Control Failures - CA
The resident, identified in inspection records as Resident 24, had a respiratory infection caused by a multidrug-resistant organism, a category of bacteria and pathogens that have developed resistance to the antibiotics most commonly used to treat them. MDROs spread easily in healthcare settings, particularly among residents with open wounds or devices that penetrate the body, like feeding tubes and urinary catheters. Resident 24 had both.
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See the Derila PillowThe observation took place on March 17, 2025, at 10:03 in the morning. Inspectors watched the nurse, identified as RN 4, troubleshoot the feeding tube, prime the line, and work the machine, all without a gown. When they asked about the orange sticker on the door, she confirmed it was there to signal Enhanced Barrier Precautions. She confirmed she should have put on the gown. Then she said she hadn't realized Resident 24 was on EBP at all.
The physician's order requiring full protective gear for every high-contact care activity had been in place since March 12, five days before the observation. The care plan had been updated two days after that, on March 14, with an explicit intervention to use Enhanced Barrier Precautions. The order listed wounds and an indwelling medical device as the reasons. The sticker was on the door.
None of it registered.
Enhanced Barrier Precautions exist specifically for situations like this one. The approach requires staff to wear both gloves and a gown during any care activity that involves close physical contact, including changing linens, bathing, transferring a resident, adjusting a feeding tube, or performing wound care. The logic is straightforward: MDROs can move from a resident's body to a staff member's clothing and hands, and from there to the next resident the staff member touches. The gown is not a formality.
The facility's own posted signage listed the activities requiring full PPE. Its written infection control policy, revised as recently as March 2024, described the same requirement in nearly identical terms, singling out residents with wounds and indwelling devices as being at especially high risk of acquiring or spreading MDROs.
Resident 24 had no capacity to make decisions for herself, according to a health and physical examination from July 2023. She could not ask the nurse to put on a gown. She could not flag the sticker on the door. She could not do anything but receive whatever care she was given, with whatever precautions the staff chose to take.
Federal inspectors cited the facility for failing to implement its own infection control protocols, noting the deficiency caused minimal harm or the potential for actual harm to a small number of residents. That designation sits near the lower end of the federal harm scale, but it does not mean nothing happened. It means inspectors could not document that a resident was injured as a direct result of what they observed.
Whether Resident 24's MDRO spread, or whether RN 4's unprotected contact with the feeding tube had any consequence beyond that morning, the inspection report does not say. What it says is that a nurse who was responsible for protecting a vulnerable resident from a drug-resistant pathogen did not know the protection was required, and that the order, the care plan, and the warning on the door were not enough to change that.
Resident 24 remained in the facility.
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 12, 2026 · Our methodology
THE HILLS POST ACUTE in SANTA ANA, CA was cited for violations during a health inspection on March 24, 2025.
The observation took place on March 17, 2025, at 10:03 in the morning.
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.