The Hills Post Acute
THE HILLS POST ACUTE in SANTA ANA, CA — inspection on March 24, 2025.
Found 17 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the facility's Resident Council Meeting Minutes was initiated on 3/24/25.
The minutes for January to March 2025 showed concerns with the noise level of staff talking loudly during the 2300 - 0700 hours shift change, and the kitchen and dining room doors were getting slammed at nighttime.
- Medical record review for Resident 70 was initiated on 3/17/25. Resident 70 was admitted to the
facility on [DATE].
On 3/17/25 at 1600 hours, an observation and concurrent interview as conducted with Resident 70. Resident 70 was observed in his room (Room A) lying in his bed.
The wall adjacent to Resident 70's bed was observed in disrepair, with scratches and chipped paint. Resident 70 stated the facility had recently repaired the wall adjacent to the entrance to his room; however, the facility had yet to repair the wall adjacent to his bed. Resident 70 stated he would like the wall adjacent to his bed repaired as he spent a lot of time inside of his room.
On 3/24/25 at 1600 hours, an interview was conducted with the Administrator.
The Administrator acknowledged the findings and stated the facility was in the process of repairing Resident 70's room.
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The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705
Review of Resident 123's Acute Care Hospital 1 H&P examination dated 1/25/25, showed Resident 123 was diagnosed with pneumonia.
On 3/18/25 at 1143 hours, an observation was conducted of Resident 123. Resident 123 was observed lying in bed. An oxygen concentrator was observed adjacent to Resident 123's bed.
The oxygen concentrator was set to administer a continuous oxygen at a rate of 2 liters per minute.
The oxygen tubing and nasal cannula were observed attached to the oxygen concentrator.
On 3/18/25 at 1145 hours, an observation, interview, and concurrent medical record review was conducted with LVN 1. LVN 1 stated Resident 123 was recently readmitted to the facility from the acute care hospital. LVN 1 stated Resident 123 had received the oxygen therapy from the time she was readmitted to the facility. LVN 1 stated Resident 123 had received the continuous oxygen at a rate of 2 liters per minute throughout her shift today. LVN 1 reviewed Resident 123's physician's orders and verified Resident 123 did not have a physician's order for the oxygen therapy.
On 3/19/25 at 1041 hours, an interview and concurrent medical record review was conducted with the DON.
The DON reviewed Resident 123's medical record and verified a care plan was not initiated for Resident 123's use of the oxygen.
The DON stated a care plan for the use of the oxygen therapy should have been initiated after Resident 123 was readmitted to the facility and at the time Resident 123 first received the oxygen therapy.
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The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705
Review of Resident 70's Care Plan initiated on 3/26/24, showed a care plan problem was developed
persecutory delusions (type of paranoia) thinking people are trying to shoot him.
The goal included for Resident 70 to have fewer episodes of psychosis manifested by persecutory delusions thinking people are trying to shoot him.
Review of Resident 70's Care Plan initiated on 6/17/24, showed a care plan problem was developed to address Resident 70's Seroquel use for psychosis m/b persecutory delusion thinking people are trying to shoot him.
Further review of Resident 70's Care Plan failed to show the care plan was revised when there was a change of the the behavior manifestation for the Seroquel medication use on 8/4/24.
On 3/21/25 at 1100 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator on Resident 70's comprehensive care plans.
The MDS Coordinator verified the care failed to show the current behavior manifestation of seeing objects that were not there as indicated in the physician's order for the use of the Seroquel medication.
The MDS Coordinator stated the nurse who updated the behavior in the physician's order should have updated the care plan right away.
On 3/21/25 at 1320 hours, an interview was conducted with the DON.
The DON verified there was no revision of the care plan after a change in Resident 70's behavior manifestation.
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The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705
care need and should be followed. LVN 9 verified Resident 2's fingernails were long and sharp which
fingernails should be kept short to prevent harm and infection to the resident. LVN 9 further stated Resident 2 was dependent with ADL care and the staff should assist Resident 2 with hygiene and grooming which included the trimming of the nails.
On 3/24/25 at 1615 hours, an interview was conducted with the DON.
The DON was notified and acknowledged the above findings.
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The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705
The RD also verified there was no documentation Resident 15's physician was notified Resident 15
replied from at least 3/12/25.
The RD stated she would speak to Resident 15 regarding fluid
accordance with the physician's order.
On 3/20/25 at 1506 hours, an interview was conducted with Resident 15 and the RD. Resident 15 stated she wanted 360 ml of fluid with her meals, in accordance with her physician's order. Resident 15 stated she liked several types of fluids which included, juice (apple and cranberry), water, milk, and chocolate milk.
The RD stated she would start to provide Resident 15 with 360 ml of fluids with her meals, in accordance with Resident 15's fluid preferences and the physician's order.
Cross reference to F-F657, example #1.
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The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705
Review of Resident 145's H&P examination dated 2/19/25, showed the resident was alert and oriented to name, place, location, and time.
Review of Resident 145's MDS dated [DATE], showed the resident had a BIMS score of 15, indicating the resident had intact cognition.
Review of Resident 145's Order Summary Report dated 3/18/25, showed the following physician's order: - dated 3/15/25, to administer Ertapenem Sodium Solution (antibiotic) 1 gm intravenously one time a day for infection prevention status post procedure for 7 days until finished, and - dated 3/17/25, for maintenance, to flush with 10 ml of NS at least every 12 hours and PRN.
Review of Resident 145's Progress Notes showed the nursing note completed by LVN 7 dated 3/14/25, showed the resident returned from his appointment with an IV line to the right hand, and the dressing was clean, dry, and intact.
On 3/24/25 at 1026 hours, an interview and concurrent record review for Resident 145 was conducted with the DON.
The DON was informed and verified there was no physician's order for the care and maintenance of the peripheral IV line, and no plan of care was developed for the use of the IV site on 3/14/25.
The DON stated the physician's order for the IV maintenance and plan of care should have been initiated on 3/14/25, when Resident 145 had the peripheral IV line.
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The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705
cannula and humidifier bottle. LVN 2 stated the nasal cannula and humidifier bottle should be labeled
On 3/18/25 at 1425 hours, an interview was conducted with the DON.
The DON was informed and verify the above findings.
The DON stated it was important to put the date on the nasal cannula and humidifier bottle so they would know when to change them to prevent infection.
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The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705
on 3/12 and 3/14/25 for the PM shift; and 3/11, 3/12, and 3/14/25 for the noc shift.
AV shunt was assessed with absence or negative for thrill and bruit, and for the presence of redness,
On 3/20/25 at 1120 hours, an interview and concurrent medical record review was conducted with LVN 10. LVN 10 verified Resident 816 had the left upper arm AV shunt.
When asked about the assessment of the dialysis access site per shift as documented in the MAR, LVN 10 stated the positive sign + meant there was present, while the negative sign - and X meant there was none, or absent referring to the bruit and thrill noted from the resident's access site. LVN 10 stated the Y meant there was presence of redness, bleeding, skin breakdown or edema and those could be a sign of infection. LVN 10 verified Resident 816's AV shunt was assessed without thrill and bruit, and with presence of redness, bleeding, skin breakdown and edema as recorded in the MAR but there was no documentation of the physician being notified. LVN 10 stated the licensed staff should have notified the physician because it was a change in condition if the AV shunt was assessed without thrill and bruit and with the presence of redness, bleeding, skin breakdown and edema.
On 3/20/25 at 1415 hours, an interview was conducted with RN 1. RN 1 stated it was necessary to assess the dialysis access site properly to determine if there was change in condition. RN 1 stated the physician was needed to be notified as soon as possible if there was absence of bruit and thrill, and for the presence of redness, edema, bleeding and skin breakdown to implement the proper interventions per the physician's order.
On 3/24/25 at 1615 hours, an interview was conducted with the DON.
The DON was informed and acknowledged the above findings.
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The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705
Review of the facility's P&P titled IIB5: Eye Drop Administration revised 10/2019 showed to administer ophthalmic solution/suspension into the eye in a safe, accurate, and effective manner.
While the eye is closed, use one finger to compress the tear duct in the inner corner of the eye for one to two minutes.
This reduces systemic absorption of the medication.
Alternatively, the resident may keep his/her eyes closed for approximately three minutes.
On 3/19/25 at 0908 hours, a medication administration observation was conducted with LVN 9. LVN 9 administered the brimonidine tartrate ophthalmic solution (an eye drop medication for glaucoma), one drop in both eyes of Resident 71.
After instilling the eye drop solution to Resident 71's eyes, LVN 9 instructed the resident to close his eyes for one minute.
However, Resident 9 opened his eyes immediately and started talking to LVN 9 informing LVN 9 that he wanted some sugar. LVN 9 left Resident 71's room to get the requested sugar. Resident 71 was observed opening and closing his eyes intermittently and wiped his eyes.
Medical record review of Resident 71 was initiated on 3/19/25. Resident 71 was readmitted to the facility on [DATE].
Review of Resident 71's MDS assessment dated [DATE], showed Resident 71 had moderate cognitive impairment.
Review of Resident 71's Order Summary Report for March 2024 showed a physician's order dated 1/17/25, to instill brimonidine tartrate ophthalmic solution 0.2% one drop in both eyes two times a day for mild open-angle glaucoma.
On 3/19/25 at 1007 hours, an interview was conducted with LVN 9. LVN 9 stated she should have compressed the inner corner of the eyes of Resident 71 and stayed with the resident to make sure the eyes were closed for one full minute and the eye drop medication could have been absorbed fully. LVN 9 stated she would call Resident 71's physician and ask if another dose of the eye drop medication would be needed for the morning since she did not observe Resident 71's eyes were closed for one full minute.
On 3/24/25 at 1615 hours, an interview was conducted with the DON.
The DON was informed and acknowledged the above findings.
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The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705
pharmacy/registered pharmacist can modify, change, or attach prescription labels.
Using professional
the medication container and all other labeling recommendations.
On 3/18/25 at 1408 hours, an inspection of Treatment Cart 2 and concurrent interview was conducted with LVN 8.
The following findings were verified with LVN 8: - Santyl collagenase ointment ( a topical enzyme medication used for wound management) 30 grams 250 units/gram with an expiration date of 1/31/25, was written on a yellow label with initial; and - Santyl collagenase ointment 30 grams 250 units/gram with an expiration date of 2/8/25, was written on a yellow label with initial.
LVN 8 further stated they should follow the date written if there was a label with a specific expiration date. LVN 8 stated any expired medications or medical supplies should be disposed.
On 3/24/25 at 1615 hours, an interview was conducted with the DON.
The DON was informed and acknowledged the above findings.
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The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705
Review of Resident 34's care plan dated 2/24/25, showed a care plan for nutrition related to hyperlipidemia, asthma, anxiety, and risk for weight loss or gain.
The interventions included honoring the resident's rights to make personal dietary choices and providing dietary education as needed.
Review of Resident 34's Nutrition Evaluation and RD Nutrition Review dated 3/1/25, showed Resident 34 disliked the bacon, pork, mushrooms, spinach, olives, cabbage, and shredded carrots.
Review of Resident 34's Diet Card dated 3/20/25, showed for breakfast, lunch, and dinner, Resident 34 disliked the bacon, pork, mushrooms, spinach, olives, cabbage, and shredded carrots.
On 3/17/25 at 0730 hours, an observation and concurrent interview was conducted with Resident 34. Resident 34 was observed sitting upright in bed. Resident 34 expressed feeling upset because despite informing the staff of her food dislikes, some of these items were still being served to her.
On 3/17/25 at 1140 hours, Resident 34 was observed sitting upright in bed. Resident 34 was served cabbage and carrots for lunch despite her diet card clearly noting her dislikes for the cabbage and shredded carrots.
On 3/17/25 at 1225 hours, an observation of Resident 34 and concurrent interview was conducted with CNA 3. Resident 34 was observed not eating her lunch and requesting a turkey sandwich from CNA 3. CNA 3 was asked about the cabbage and shredded carrots on the lunch tray. CNA 3 acknowledged Resident 34 disliked those items. CNA 3 verified the lunch tray should not been served with cabbage and chopped carrots. CNA 3 verified the findings.
Review of Resident 27's Nutrition Evaluation and RD Nutritionist Review dated 10/8/24, showed the resident was to have a magic cup for lunch and dinner.
Review of Resident 27's Order Summary Report dated 3/20/25, showed a physician order dated 2/7/25, may benefit from a sippy cup to promote independence with self-feeding.
Review of Resident 27's Diet Card dated 3/20/25, showed for breakfast, lunch, and dinner to include the adaptive equipment: sippy cup.
On 3/17/25 at 1220 hours, an observation of Resident 27 and concurrent interview was conducted with CNA 4. Resident 27 finished one cup of nectar milk in a regular cup and drank 3/4 of nectar cranberry juice from a regular cup. CNA 4 verified the resident did not have a sippy cup and the kitchen should have provided it. CNA 4 further stated LVN 8 checked the food tray.
On 3/17/25 at 1230 hours, an interview and concurrent medical record review was conducted with LVN 8. LVN 8 stated Resident 27 should have been provided with a sippy cup and verified the findings.
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The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705
Review of the facility's P&P titled Meal Service (undated) showed the food will be served on the tray line at the recommended temperatures indicated below and recorded on the daily therapeutic menu.
The temperature of the foods should be periodically monitored throughout the meal service to ensure proper hot or cold holding temperatures.
Further review of the facility's P&P showed the service temperature for milk was 41 degrees or less.
Cold food items will be placed on the trays as close to serving time as possible to assure the temperature is below 41 degrees Fahrenheit.
The recommended temperature at the delivery to the resident for milk/cold beverages showed less than or equal to 45 degrees.
On 3/18/25 at 1136 hours, during the tray line observation, a concurrent observation and interview was conducted with the RD and DSS.
The milk beverage had a temperature of 43 degrees Fahrenheit.
Furthermore, during the test tray observation with the RD and DSS, the milk beverage had a temperature of 49.1 degrees Fahrenheit.
The RD and DSS acknowledged the findings.
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The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705
Review of Resident 15's Order Summary Report showed a physician's order for weekly fluid intake and output evaluation, dated 11/30/23.
On 3/20/25 at 1548 hours, an interview and concurrent medical record review was conducted with the DON.
Review of Resident 15's MAR for January, February, and March 2025 showed the following documented weekly fluid intake amounts for Resident 15: - on 1/11 and 1/25/25, weekly fluid intake of 1200 ml - on 1/18, 2/1, 2/15, 2/22, 3/1, and 3/15/25, weekly fluid intake of 1400 ml - on 3/8/25, weekly fluid intake of 1500 ml The DON verified the documentation specific to Resident 15's weekly fluid intake amounts (for the above listed dates) was inaccurate.
The DON stated most likely the nurses mistakenly calculated and documented daily (versus weekly) fluid intake totals for Resident 15.
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The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705
Review of the facility's P&P titled IPCP Standard and Transmission-Based Precautions revised date 3/2024 showed EBP: used in conjunction with standard precautions and expand the use of PPE through the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of MDROs to staff hands and clothing then indirectly transferred to residents or from resident-to-resident. (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs).
Medical record review for Resident 24 was initiated on 3/17/25. Resident 24 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 24's H&P examination dated 7/24/23, showed Resident 24 had no capacity to understand and make decisions.
Review of Resident 24's Order Summary Report dated 3/18/25, showed a physician's order dated 3/12/25 for EBP: PPE required for high resident contact care activities; and Indication: wounds, indwelling medical device every shift.
Review of Resident 24's plan of care showed a care plan focus addressing Resident 24's Respiratory MDRO and an intervention dated 3/14/25, showed to use EBP.
On 3/17/25 at 1003 hours, an observation of Resident 24 and concurrent interview was conducted with RN 4. Resident 24's room was observed with an orange sticker for EBP posted by the door. RN 4 was observed standing at the bedside and troubleshooting the GT feed tubing, priming the line and machine. RN 4 was only wearing the gloves but did not wear the gown and mask. RN 4 verified the orange sticker by the door and stated it was for EBP. RN 4 verified she should have donned PPE, and did not realize Resident 24 was on EBP.
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The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705
Review of Resident 815's H&P examination dated 3/14/25, showed Resident 815 could make needs known but could not make medical decisions.
Review of Resident 815's Order Summary Report showed a physician's order dated 3/18/25, for oxygen via nasal cannula at 2 liters per minute if the oxygen saturation level less than 90% as needed.
Review of Resident 815's Weights and Vitals Summary showed Resident 815's oxygen saturation level in room air was 98% on 3/18/25.
On 3/18/25 at 0932 hours, a follow-up observation of Resident 815 was conducted. Resident 815 was observed sitting at the edge of the bed.
The oxygen tubing was observed on the bed and had no bag and label.
The oxygen concentrator was observed to be on.
On 3/18/25 at 1019 hours, an observation of Resident 815 and concurrent interview was conducted with LVN 1.
The oxygen tubing was observed rolled and tucked in the oxygen concentrator's handle. LVN 1 stated the oxygen tubing should be labeled with the date when it was first used or changed and should be kept inside a plastic bag when not in use to avoid the buildup of residue in the tubing and for infection control measure. LVN 1 further stated the oxygen tubing was being changed every 72 hours. LVN 1 verified the oxygen tubing for Resident 815 was not labeled with the date when it was provided or changed and was not kept in a sanitary condition. LVN 1 stated she would dispose the oxygen tubing and replace with a new one.
555765
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555765 B.
Wing 03/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705
Review of the facility's P&P titled Insertion of Peripheral I.V.
Device (undated) showed to label the dressing with the date and time the site was inserted, the gauge and length of the catheter inserted, and the initials of the inserting nurse.
1.
Medical Record Review for Resident 24 was initiated on 3/17/25. Resident 24 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 24's Order Summary Report dated 3/18/25, showed a physician order dated 3/12/25, to measure the arm circumference in inches on admission and every seven days during the dressing changes every day shift, and measure the external catheter length in cm from end to the hub to the insertion site into skin.
555765
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 555765 B.
Wing 03/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.