The Hills Post Acute: Oxygen Given Without Orders - CA
Federal inspectors visited the facility on March 18, 2025, and found the oxygen concentrator running adjacent to Resident 123's bed. The device had been set to administer continuous oxygen since the resident was readmitted to the facility following a hospitalization. A January 25 hospital record showed she had been diagnosed with pneumonia.
When inspectors reviewed her chart with a licensed vocational nurse identified in the report as LVN 1, the nurse confirmed the resident had been receiving the oxygen throughout her shift that day, and from the time of readmission. Then LVN 1 looked through the physician's orders and confirmed what wasn't there: no order authorizing the oxygen therapy. None.
The facility had also failed to develop a care plan for the oxygen use. A care plan is the document that tells staff how to manage a specific treatment for a specific resident, what the goals are, what to watch for, how to respond if something changes. Without one, every nurse and aide coming onto a shift had no formal guidance on how to handle Resident 123's oxygen. Whether to adjust it. Whether to remove it. What symptoms should prompt concern.
The director of nursing reviewed the medical record with inspectors the following day, on March 19. She confirmed the care plan had not been initiated. She said it should have been started when Resident 123 was readmitted and when she first began receiving the oxygen therapy.
That statement acknowledged two separate failures at the same moment: the missing order and the missing plan. Both were preventable. Both were apparently unnoticed until a federal inspector walked in.
Oxygen therapy is not a neutral intervention. At two liters per minute delivered continuously through a nasal cannula, it is a medical treatment with a specific clinical purpose. It requires a physician to assess the patient, determine the appropriate flow rate, and document an order. For a resident recovering from pneumonia, the decision about when to continue oxygen, when to wean it, and when to discontinue it requires clinical judgment grounded in the individual patient's condition. That judgment is supposed to be recorded. It is supposed to guide the staff caring for her.
None of that existed for Resident 123.
Inspectors classified the violation as having the potential for minimal harm, the lowest level on the federal scale. The deficiency was cited under the regulatory tag governing comprehensive care plans.
The Hills Post Acute is located at 1800 Old Tustin Avenue in Santa Ana. The inspection was completed March 24, 2025.
What the report does not answer is how long the oxygen had been running without an order before inspectors arrived. LVN 1 said the resident had received it from the time of readmission. The readmission date is redacted in the public version of the report. It could have been days. The record does not say.
Resident 123 was still in her bed when inspectors observed her on March 18, the oxygen concentrator beside her, the tubing and cannula attached, the machine running.
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.
Federal inspectors visited the facility on March 18, 2025, and found the oxygen concentrator running adjacent to Resident 123's bed.
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.