The Hills Post Acute: Oxygen Equipment Dating Failure - CA
An inspector visited the room on the morning of March 17, 2025, with LVN 2 present at Resident 695's side. The nurse looked at the equipment and confirmed what the inspector had already seen. There was no label. No date. Nothing to tell the next nurse, or the one after that, when the equipment had been put in place or when it needed to come out.
"The nasal cannula and humidifier bottle should be labeled with the date," LVN 2 said, "for the staff to know when the nasal cannula and humidifier bottle should be changed."
The humidifier bottle is the small water-filled chamber that sits between the oxygen source and the tubing running to a resident's nose. It keeps the oxygen from drying out the airway. It also holds standing water, which, left too long, can become a source of bacterial growth. The nasal cannula, the two-pronged plastic tube that sits directly inside a resident's nostrils, carries the same risk the longer it goes unchanged.
The point of dating the equipment is simple: without a label, there is no way to enforce a change schedule. Without a change schedule, there is no reliable way to prevent infection. The nurse standing at the bedside understood this. The equipment still had no date on it.
The director of nursing was interviewed the following afternoon, on March 18. She was shown the findings. She did not dispute them.
"It was important to put the date on the nasal cannula and humidifier bottle," the DON said, "so they would know when to change them to prevent infection."
The director of nursing confirmed the risk in plain terms. The equipment serving Resident 695 had been in use without any mechanism for tracking how long it had been there.
Inspectors classified the violation as causing minimal harm or the potential for actual harm, affecting a small number of residents. It was a single finding in a short inspection cycle, not a cascade of failures. But the circumstances it revealed are worth sitting with. A licensed nurse at the bedside, responsible for the care of a resident on supplemental oxygen, had not labeled the equipment. The system that should have caught that, a supervisor, a charge nurse, a routine check, had not caught it either. The director of nursing, when told, agreed immediately that it mattered.
That agreement came the day after the inspector found it.
The Hills Post Acute is a post-acute care and rehabilitation facility at 1800 Old Tustin Avenue in Santa Ana. The inspection was conducted on March 24, 2025, and the deficiency was documented under the federal statement of deficiencies process administered by the Centers for Medicare and Medicaid Services.
Resident 695 was on oxygen. The equipment helping them breathe had no date on it, and no one on the floor had flagged it. The director of nursing, once informed, said immediately that she understood why it mattered. What she did not explain was why the label had never been there in the first place.
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 2, 2026 · Our methodology
THE HILLS POST ACUTE in SANTA ANA, CA was cited for violations during a health inspection on March 24, 2025.
An inspector visited the room on the morning of March 17, 2025, with LVN 2 present at Resident 695's side.
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.