The Hills Post Acute: Care Plan Failures for Psychosis - CA
The resident, identified in inspection records as Resident 70, had been prescribed Seroquel, an antipsychotic medication. For months, his care plan described his psychosis one way. His physician's orders described it another. Nobody reconciled the two.
The gap wasn't subtle. His care plans, written in June 2024, described his psychosis as persecutory delusions, specifically the belief that people were trying to shoot him. By August 4, 2024, the behavior recorded in his physician's orders had changed. He was now experiencing visual hallucinations, seeing objects that were not there. The Seroquel dose, 37.5 milligrams, was ordered to address this new manifestation, with instructions to monitor the episodes every shift.
The care plan was never revised to reflect it.
That meant the document guiding Resident 70's day-to-day care still described a man gripped by paranoid fears of being shot, while the orders his nurses were following addressed something else entirely: a man seeing things that weren't in the room with him. The two conditions are both psychosis, but they are not the same experience, and a care plan that doesn't reflect what a resident is actually going through isn't guiding care so much as describing someone who no longer exists.
On March 21, 2025, inspectors sat down with the facility's MDS Coordinator and went through Resident 70's records together. The MDS Coordinator confirmed what the documents showed: the care plan did not reflect the current behavior manifestation. The coordinator said the nurse who had updated the behavior in the physician's order should have updated the care plan right away.
Should have. Didn't.
Later that same day, inspectors spoke with the Director of Nursing. The Director of Nursing confirmed it directly: there was no revision of the care plan after the change in Resident 70's behavior manifestation.
The facility's own leadership, in two separate conversations on the same afternoon, acknowledged the failure without dispute.
Care plans in nursing homes are not paperwork for its own sake. They are the operational record of who a resident is and what they need. When a nurse comes on shift, when a new aide is assigned, when a physician stops by, the care plan is what tells them what they're walking into. A care plan that describes behavior from eight months ago is not a care plan. It's a historical document being used as a current one.
For Resident 70, that meant staff working from a description of paranoid delusions while his orders tracked visual hallucinations. Whether those two things overlapped in his daily experience, whether he was still having both, whether the shift in documented symptoms reflected a meaningful change in his condition, none of that is answered in the inspection report. What is answered is that nobody updated the plan.
CMS rated the harm from this deficiency as minimal, or potential for actual harm, affecting few residents.
Inspectors completed their review on March 24, 2025. The Hills Post Acute is a post-acute care facility licensed in California and certified under Medicare and Medicaid.
Resident 70's care plan, as of the inspection, still said people were trying to shoot him.
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 2, 2026 · Our methodology
THE HILLS POST ACUTE in SANTA ANA, CA was cited for violations during a health inspection on March 24, 2025.
The resident, identified in inspection records as Resident 70, had been prescribed Seroquel, an antipsychotic medication.
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.