The Hills Post Acute: Fluid Order Ignored for Days - CA
The inspection, completed March 24, 2025, found that Resident 15 had a physician's order for 360 milliliters of fluid with each meal. She wasn't getting it. The registered dietitian confirmed to inspectors that the shortfall had been going on since at least March 12. The dietitian also confirmed there was no documentation that the physician had ever been notified.
Nobody had called the doctor. Nobody had written it down.
When inspectors asked the dietitian how long the resident had gone without the ordered fluids, the dietitian didn't dispute the timeline. She said she would speak with the resident about her preferences and then provide an additional 120 milliliters with meals going forward, bringing the total to the ordered amount.
That conversation happened on March 20, with inspectors present. Resident 15 told the dietitian directly that she wanted 360 milliliters with her meals, exactly as her doctor had ordered. She also said she had preferences: apple juice, cranberry juice, water, milk, chocolate milk. She had options. She had a preference. She had a physician's order. None of it had translated into what ended up on her tray.
The dietitian told inspectors she would begin providing the correct amount immediately.
What the report does not contain is any explanation for why it took an inspection to make that happen. There is no documentation of staff identifying the gap, no record of an internal correction, no note to the physician explaining that his or her order had gone unfulfilled for nearly two weeks. The correction came because inspectors were in the building and asked.
Resident 15 is described in the report as one of a few residents affected. The level of harm is listed as minimal harm or potential for actual harm, the lower end of the federal scale. But the classification reflects what inspectors could document, not necessarily what the resident experienced over those twelve days. Adequate hydration is not a comfort preference. It affects kidney function, medication metabolism, skin integrity, cognition, and blood pressure. Twelve days is not an oversight that resolves itself.
The facility is located at 1800 Old Tustin Avenue in Santa Ana. The inspection was conducted by the California Department of Public Health on behalf of the Centers for Medicare and Medicaid Services.
The deficiency is cross-referenced in the report to a separate finding under F657, which covers care plan revisions. That connection suggests the fluid order failure was not an isolated lapse in meal service but part of a broader pattern the inspectors documented involving how the facility updates and follows care plans when a resident's needs or orders change.
The dietitian's response, once inspectors sat down with her and the resident together, was immediate. She agreed to the correct amount. She noted the resident's preferences. She said she would start that day.
Resident 15 had to tell a staff member, in front of federal inspectors, that she wanted what her doctor had prescribed.
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 4, 2026 · Our methodology
THE HILLS POST ACUTE in SANTA ANA, CA was cited for violations during a health inspection on March 24, 2025.
The inspection, completed March 24, 2025, found that Resident 15 had a physician's order for 360 milliliters of fluid with each meal.
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.