Inspection Reports for
La Cañada Care Center
7970 N La Cañada Dr, Tucson, AZ 85704, AZ, 85704
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
54% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 2
Date: Feb 2, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to safe and appropriate respiratory care and nurse staffing information posting at LA Canada Care Center.
Findings
The facility failed to ensure oxygen was administered per physician orders for one resident, with oxygen settings observed above the ordered rate. Additionally, the facility failed to post accurate daily nurse staffing information including actual hours worked and resident census.
Deficiencies (2)
Failed to ensure oxygen was administered per physician orders for one resident, with oxygen observed at 6 liters per minute instead of the ordered 4 liters.
Failed to post nurse staffing information daily that included actual hours worked by licensed and unlicensed nursing staff and resident census.
Report Facts
Sample size: 20
Oxygen order: 4
Oxygen observed: 6
Oxygen care plan setting: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (Staff #70) | Interviewed regarding oxygen settings and rounding practices | |
| Director of Nursing (Staff #13) | Interviewed regarding oxygen orders, nurse responsibilities, and staffing posting accuracy | |
| Staffing Coordinator (Staff #18) | Interviewed regarding accuracy of daily nurse staffing postings | |
| Administrator (Staff #115) | Interviewed regarding policy on accuracy of staff postings |
Inspection Report
Routine
Deficiencies: 6
Date: Oct 14, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, PASARR screening, activities of daily living assistance, nutritional status, nurse staffing postings, and food safety in the facility.
Findings
The facility was found deficient in multiple areas including failure to issue a Notice of Medicare Non-Coverage to a resident, incomplete PASARR screenings for mental disorders for three residents, inadequate assistance with activities of daily living for one resident, failure to maintain acceptable nutritional status for one resident, inaccurate posting of nurse staffing information, and lack of consistent temperature monitoring of a reach-in refrigerator.
Deficiencies (6)
Failed to ensure one resident (#397) was issued a written Notice of Medicare Non-Coverage (NOMNC) at the end of Medicare services.
Failed to ensure PASARR screenings were completed as required for 3 residents (#57, #34, and #41), increasing risk of inappropriate placement or lack of needed services.
Failed to provide care and assistance for activities of daily living to one resident (#191), resulting in poor personal hygiene.
Failed to provide care and services to maintain acceptable nutritional status for one resident (#24), resulting in significant weight loss and risk for nutritional decline.
Failed to post accurate daily nurse staffing information including actual hours worked.
Failed to provide evidence that temperatures for the reach-in refrigerator were consistently monitored, risking foodborne illness.
Report Facts
Sample size: 3
Sample size: 3
Sample size: 10
Sample size: 4
Weight loss percentage: 17
Weight loss percentage: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #5 | Social Service Director/Case Management | Interviewed regarding NOMNC process and documentation |
| Staff #20 | Director of Nursing (DON) | Interviewed regarding NOMNC process, PASARR, ADL care, and staffing postings |
| Staff #90 | Nursing Assistant | Interviewed regarding bathing schedule and resident #191 care |
| Staff #65 | Licensed Practical Nurse (LPN) | Interviewed regarding bathing documentation and resident care |
| Staff #115 | Clinical Resource Nurse | Interviewed regarding PASARR process |
| Staff #39 | Speech Language Pathologist (SLP) | Interviewed regarding resident #24 swallowing and feeding needs |
| Staff #22 | Staffing Coordinator | Interviewed regarding nurse staffing postings |
| Staff #26 | Director of Nursing (DON) | Interviewed regarding nurse staffing postings and resident #24 weight monitoring |
| Staff #1110 | Kitchen Manager | Interviewed regarding refrigerator temperature monitoring |
Inspection Report
Routine
Census: 75
Deficiencies: 9
Date: Oct 7, 2021
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, medication administration, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to obtain informed consent for psychotropic medications, call lights not accessible to residents, incomplete PASRR screening, inconsistent pressure ulcer care, oxygen therapy not administered as ordered, administration of pain medication outside physician parameters, inadequate monitoring of psychotropic medication efficacy, improper storage of narcotics, and lapses in infection prevention and control practices.
Deficiencies (9)
Failure to ensure residents and/or their representatives were informed of the risks and benefits of psychotropic medications prior to administration.
Failure to ensure call lights were accessible to residents, potentially delaying assistance.
Failure to complete Level I PASARR screening prior to or upon admission for one resident.
Failure to provide consistent care and treatment for pressure ulcers, including missing weekly skin assessments and incomplete treatment documentation.
Failure to administer oxygen therapy according to physician orders, including unauthorized increase in oxygen flow rate.
Failure to ensure pain medication (oxycodone) was administered only within physician ordered parameters.
Failure to monitor efficacy and target behaviors for residents receiving psychotropic medications.
Failure to store narcotic medications and controlled substances in a double-locked system.
Failure to implement infection prevention and control program including improper use of PPE and inadequate hand hygiene.
Report Facts
Resident census: 75
Pain medication administrations outside order parameters: 18
Oxygen flow rate: 4.5
Medication order date: 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication consent, oxygen therapy, call light accessibility, PASRR screening, and infection control | |
| Licensed Practical Nurse | Interviewed regarding medication administration and PASRR screening | |
| Registered Nurse | Interviewed regarding psychotropic medication monitoring and hand hygiene | |
| Wound Nurse (LPN) | Interviewed regarding pressure ulcer care and assessments | |
| Licensed Practical Nurse | Interviewed regarding oxygen therapy administration | |
| Housekeeper | Observed and interviewed regarding infection control and PPE use | |
| Occupational Therapy Assistant | Interviewed regarding PPE use for isolation rooms | |
| Infection Preventionist/Assistant Director of Nursing | Interviewed regarding infection control policies and staff education | |
| Licensed Practical Nurse | Interviewed regarding medication administration and pain assessment | |
| Nursing staff | Observed during meal tray distribution with hand hygiene lapses |
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