The Hills Post Acute: Missing Adaptive Equipment - CA
Inspectors observed Resident 27 at 12:20 p.m. on March 17, 2025. He had already finished a cup of nectar milk and was three-quarters of the way through a cup of nectar cranberry juice, both served in standard cups. The sippy cup his doctor ordered on February 7 was nowhere on the tray.
The nursing assistant standing with him, identified in inspection records as CNA 4, confirmed it immediately. The resident did not have a sippy cup. The kitchen should have sent one. LVN 8 had checked the food tray before it reached the resident.
Ten minutes later, inspectors spoke with LVN 8 directly. She said Resident 27 should have been provided with a sippy cup. She verified the findings.
That was the extent of any explanation the facility offered.
The order itself had a clear paper trail. A nutritionist's evaluation from October 2024 noted the resident should have a "magic cup" at lunch and dinner. By February 2025, a physician had formalized the need, writing an order that the resident "may benefit from a sippy cup to promote independence with self-feeding." The facility's own diet card, reviewed by inspectors on March 20, listed the sippy cup as required adaptive equipment for breakfast, lunch, and dinner, all three meals, every day.
On at least this one afternoon, none of that translated into action.
The violation was cited at the lowest level of harm under federal inspection standards, meaning inspectors found minimal harm or potential for actual harm rather than an injury that had already occurred. But the purpose of the equipment speaks to something larger than a missed cup. Adaptive feeding tools exist to preserve a resident's ability to do something for themselves. When that equipment doesn't arrive, the resident either struggles with a container not designed for their needs or depends on staff to help with something they were capable of managing alone. Either way, independence erodes.
The Hills Post Acute is a post-acute and rehabilitation facility at 1800 Old Tustin Avenue in Santa Ana. The inspection was completed March 24, 2025.
Inspectors reviewed 33 residents as part of the survey. Resident 27 was the only one found to have this particular problem. That narrowness does not make the lapse routine. A physician's order, a nutritionist's recommendation, and a diet card all pointed to the same thing. A licensed nurse checked the tray. The cup was still missing.
CNA 4's explanation pointed to the kitchen as the source of the failure. But the diet card existed precisely so that the right equipment would travel with the right meal to the right resident. Somewhere between the paperwork and the tray, the system broke down, and the nurse who reviewed the food before it reached the resident did not catch it.
Resident 27 managed. He drank his juice. He finished his milk. What he did not get was the equipment his care team had decided, months before, that he needed to maintain whatever degree of self-sufficiency he still had.
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.
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Last verified: November 3, 2026 · Our methodology
THE HILLS POST ACUTE in SANTA ANA, CA was cited for violations during a health inspection on March 24, 2025.
Inspectors observed Resident 27 at 12:20 p.m.
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.