Federal inspectors found that Resident 162, who received dialysis three times weekly, was given Benazepril hydrochloride on December 22, 24, 29, and 31, 2024 — all days when the resident was scheduled for or attended dialysis treatments. A physician's order dated December 29 explicitly stated to hold the antihypertensive medication "on dialysis days."
When confronted with medication administration records during the March inspection, the facility's Director of Nursing acknowledged the violations. "The DON verified that on 12/22, 12/24, 12/29, and 12/31/24, the resident went out for the dialysis, and the blood pressure medication should have been held as per the physician's order," inspectors wrote.
The medication errors weren't isolated incidents. Inspectors documented systemic problems with oxygen equipment, controlled substance tracking, and basic infection control practices at the 160-bed facility on Old Tustin Avenue.
During the initial facility tour, inspectors found Resident 815 using oxygen tubing without any date label and not stored in a sanitary plastic bag. The tubing was observed "rolled and tucked in the oxygen concentrator's handle" when not in use, creating potential for contamination and respiratory infections.
LVN 1 told inspectors the oxygen tubing should be labeled with the date it was first used and kept inside a plastic bag "to avoid the buildup of residue in the tubing and for infection control measure." The nurse verified the tubing for Resident 815 was neither labeled nor kept in sanitary condition, and said she would dispose of it and replace it with new equipment.
The facility's Infection Prevention coordinator explained the risks of contaminated oxygen equipment. "If the oxygen tubing was on the floor or had touched any of the resident's surroundings, it had to be replaced because it had been contaminated and if it was used again, it could cause respiratory infection or illness," the IP told inspectors.
Similar labeling problems affected another resident's oxygen equipment. Resident 695, who required continuous oxygen at 2-5 liters per minute to maintain 92% oxygen saturation, had unlabeled nasal cannula and humidifier bottle. LVN 2 acknowledged "the nasal cannula and humidifier bottle should be labeled with the date for the staff to know when the nasal cannula and humidifier bottle should be changed."
The facility's dialysis care failures extended beyond medication errors. Resident 816, who received dialysis Monday, Wednesday and Friday, had an AV shunt access site that showed concerning signs but generated no physician notifications despite facility policy requiring immediate contact for complications.
Medication administration records showed Resident 816's AV shunt repeatedly tested negative for thrill and bruit — blood flow indicators that signal proper function. The records also documented presence of "redness, bleeding, skin breakdown and edema" at the access site on multiple dates in March.
LVN 10 confirmed the significance of these findings. "The positive sign + meant there was present, while the negative sign - and X meant there was none, or absent referring to the bruit and thrill noted from the resident's access site," she explained. "The Y meant there was presence of redness, bleeding, skin breakdown or edema and those could be a sign of infection."
Despite facility policy requiring immediate physician notification for such changes, no documentation showed doctors were contacted about the deteriorating access site.
Controlled substance tracking showed equally concerning gaps. Medication Cart 2's narcotic log was missing nurse signatures on November 16, November 20, January 31, and March 15. Cart 3 had missing signatures on January 12, January 20, and January 21.
"The nurses should have signed the controlled log so that the medication were accounted, and the nurses knew the medications were complete when they come to work," the Director of Nursing told inspectors after reviewing the incomplete logs.
LVN 3 explained the security implications: "The Controlled Substance Log should be signed or initialed by the nurses to account for the narcotic medications to avoid possible drug diversion."
Basic infection control practices broke down in multiple areas. During morning rounds, inspectors found Resident 139's urinal containing approximately 200 ml of urine stored directly next to a water pitcher and two juice cups on the bedside table.
The MDS Coordinator acknowledged "there was a potential for contamination of the drinks" when shown the setup during a follow-up observation.
Hand hygiene violations occurred during medication administration. LVN 5 was observed giving medication through a gastrostomy tube to Resident 50, but after checking tube placement with gloved hands, she pulled a privacy curtain with the same gloves and continued the procedure without changing gloves or performing hand hygiene.
"LVN 5 acknowledged the findings" when confronted about the infection control breach, inspectors noted.
The facility failed to follow its own enhanced barrier precautions for a resident with multidrug-resistant organisms. Resident 24, who had physician orders requiring personal protective equipment for high-contact care activities, received gastrostomy tube care from RN 4 who wore only gloves — no gown or mask despite the posted precaution sign.
"RN 4 verified she should have donned PPE, and did not realize Resident 24 was on EBP," according to the inspection report.
Kitchen sanitation problems created additional infection risks for the 151 residents who consumed facility-prepared food. The hood over the stove contained "black, dirt residue," and multiple cooking utensils had partially melted handles or were covered with "dry, crusted residue" and "cloudy film."
Cutting boards used for food preparation were "heavily marred and had deep groves," while the chest freezer used for ice cream storage had no thermometer to monitor temperature. Milk served to residents measured 49.1 degrees Fahrenheit during test observations, exceeding the facility's own 45-degree standard.
Medical record keeping showed systematic problems across multiple residents. Resident 123's medication administration record failed to document whether tuberculosis testing was completed as ordered, and showed no evidence of required monitoring for sleep patterns, medication side effects, or pain levels on multiple shifts.
Resident 20's Physician Orders for Life-Sustaining Treatment form remained incomplete for six months, with blank fields for the physician's name, telephone number, license number, and signature.
"The POLST should have been accurately completed and filled out completely," the Director of Nursing acknowledged when shown the incomplete document.
The facility also failed to provide basic accommodations for residents' needs. Resident 34, whose diet card clearly documented dislikes for cabbage and shredded carrots, was served both items for lunch and "expressed feeling upset because despite informing the staff of her food dislikes, some of these items were still being served to her."
Resident 27, who had physician orders for a sippy cup to promote independence with self-feeding, was served lunch with regular cups instead of the prescribed adaptive equipment.
The Hills Post Acute received citations for violations affecting medication safety, infection control, food service, dialysis care, and medical record keeping. The facility must submit a plan of correction addressing each deficiency identified during the March inspection.
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.
