Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at La Canada Care Center during CMS and state inspections, most recent first.
Inaccurate Daily Staffing Postings: The facility failed to ensure daily staffing postings were accurate for RN, LPN/LVN, and CNA hours and did not consistently include the number of direct care staff working each shift. Review of sampled postings and punch details showed repeated mismatches between posted hours and actual hours worked, and the Staffing Coordinator stated she did not know how to prove the accuracy of the postings. The DON stated the postings were expected to be accurate and maintained consistently, but call-outs and punch discrepancies were not always identified until the end of the pay period.
A resident with a right femur fracture, COPD, muscle weakness, and epilepsy had PRN opioid pain medication ordered only for pain levels 6-10, with acetaminophen ordered for pain levels 1-5. The MAR showed the oxycodone-acetaminophen was given several times when the resident’s documented pain level was 4 or 5. An LPN and the DON both stated that medication administration should follow the physician’s order, and the DON confirmed the doses were given outside the ordered parameter.
Blood Pressure Medication Given Without Following Hold Parameter: A resident with HTN had a Lisinopril order to hold if systolic BP was below 120, but the MAR showed the medication was given when the documented systolic BP was 118 and later given without BP documentation. An LPN stated the medication should be held when below the ordered parameter, and the DON stated BP should be checked and documented before administration and that the order must be followed.
Surveyors found that the facility failed to maintain a clean and homelike environment in multiple rooms and hallways. A complaint alleged inadequate staffing for cleaning and that staff did not clean a spilled meal tray. Observations revealed trash, crumbs, visible dirt, dark streaks, dried spills, and scuff marks on floors in several resident rooms, as well as spillage on a drink cart. Two residents reported that their room and floor had been dirty for some time and that housekeeping did not clean their room daily. A CNA and an RN both acknowledged that the observed rooms did not meet facility standards and that spills and trash should be cleaned immediately. The Housekeeping Supervisor and ADON described expectations for daily room cleaning, floor care, and infection control, and acknowledged that conditions such as feces on a toilet and tube‑feeding residue on a floor mat did not meet the facility’s cleanliness expectations, despite policies requiring a homelike environment and an infection control program to identify and correct related problems.
A resident with normal cognition and multiple medical conditions, including malnutrition and anxiety disorder, verbally abused a cognitively intact roommate with post‑CVA hemiplegia, asthma, and depression by yelling obscenities and using a racial slur, as overheard and reported by an LPN and a CNA. Facility documentation confirmed the incident and substantiated verbal abuse, but the alleged victim’s progress notes contained no entry about the altercation, despite facility policies stating that residents have the right to be free from verbal abuse, including racial and derogatory language.
A resident with severe cognitive impairment and multiple neurologic and cardiovascular diagnoses was admitted for rehab with reconciled medication orders and was receiving anticoagulants, antiplatelets, and other prescribed drugs per eMAR. During a therapy session, an RN unfamiliar with the unit prepared medications for another resident and, after a PTA incorrectly confirmed identity and the cognitively impaired resident verbally agreed she was that other person, administered a full set of medications for which there were no physician orders, including amiodarone, aripiprazole, aspirin 325 mg, citalopram 40 mg, apixaban, Lasix, midodrine, and several supplements. The PTA later realized the error and notified nursing leadership. That afternoon, the resident’s family found the resident slumped over in a wheelchair, minimally responsive, unable to answer orientation questions, with eyes rolling back and elevated BP, and the resident was sent to the hospital, where she was admitted for observation for unintentional medication use and elevated blood pressure.
A resident with multiple chronic conditions and an established medication regimen was mistakenly given a full set of medications prescribed for another patient while in a group therapy session. An RN, unfamiliar with the unit, prepared medications for a different patient and, unable to find that patient in their room, went to the therapy gym. There, a PTA who had not previously met either patient incorrectly confirmed the resident’s identity, and the resident also verbally identified herself as the other patient. Relying on these statements, the RN administered medications including cardiac, psychotropic, anticoagulant, diuretic, and supplement agents that were not ordered for this resident. Later, the resident was found slumped over in a wheelchair, minimally responsive, disoriented, and with elevated BP, and was subsequently sent to the hospital, where the admitting diagnosis included unintentional use of medication. The facility’s own policy requiring verification of resident identity and physician orders before medication administration was not followed.
A resident with COPD and acute respiratory failure was observed receiving 6 liters of oxygen per minute, contrary to the physician's order of 4 liters per minute. Staff interviews confirmed the discrepancy, highlighting a failure to adhere to the prescribed oxygen settings.
The facility failed to post accurate daily nurse staffing information, as confirmed by the Staffing Coordinator, DON, and Administrator. The facility lacks a policy to ensure the accuracy of these postings.
Inaccurate Daily Staffing Postings
Penalty
Summary
The facility failed to ensure that daily staff posting information was accurate for the total numbers of direct care staff, actual hours worked by direct care staff, and actual staffing totals worked by licensed and unlicensed direct care nursing staff for 9 of 9 days reviewed. Review of daily staff postings and corresponding punch details showed that the posted RN, LPN/LVN, and CNA hours did not match the punch records on each sampled day, and several postings also did not include the total number of nurses and CNAs that worked each shift or the total number of hours worked by all licensed staff and CNAs each day. For the sampled dates, the daily postings listed hours that differed from the punch details, including large discrepancies on some days. Examples included a posting showing 7.28 RN hours, 97.31 LPN/LVN hours, and 194.13 CNA hours when punch details showed 34.82 RN hours, 84.06 LPN/LVN hours, and 196.86 CNA hours. Other sampled days showed differences in LPN/LVN and CNA hours, and one day showed a difference of 16 RN hours, 8 LPN/LVN hours, and 6.89 CNA hours between the posting and punch details. The census on the reviewed days ranged from 92 to 104. During interview, the Staffing Coordinator stated she completed the daily staff postings and that the postings reflected hours worked per shift rather than the number of staff members, and she did not know how to prove the accuracy of the postings. The DON stated the Staffing Coordinator was responsible for completing the postings and that the facility expected them to be accurate and maintained consistently, but staff call-outs and punch-in/punch-out inaccuracies were not always identified until the end of the pay period. The facility policy stated it would post the number of staff working who are directly responsible for resident care and include hours worked by RNs, LPNs/VNs, and Nursing Assistants for each shift.
Pain Medication Given Outside Ordered Pain Parameter
Penalty
Summary
The facility failed to protect a resident’s right to be free from chemical restraints by not administering pain medication in accordance with the physician’s order. The resident was admitted with diagnoses including a right thigh fracture with routine healing, COPD, muscle weakness, and epilepsy. The admission MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and also noted use of opioid medications. The physician’s orders included acetaminophen 650 mg by mouth every 4 hours as needed for pain level 1-5 and oxycodone-acetaminophen 5-325 mg by mouth every 4 hours as needed for pain level 6-10. The April 2026 MAR showed that oxycodone-acetaminophen was administered on multiple occasions when the resident’s documented pain level was 4 or 5, which was outside the ordered parameter of 6-10. These administrations were documented on 04/4/2026 at 4:53 PM and 8:58 PM, and on 04/21/2026 at 4:38 PM and 8:41 PM. The care plan identified that the resident was prescribed an opioid for pain and had potential for adverse outcomes related to status post right femur fracture and right hip pain. During interviews, an LPN stated she would not give the controlled pain medication if the resident’s pain level was below the ordered range and would instead use another ordered pain medication or contact the provider or pain specialist. The DON stated staff were expected to follow the physician’s order and confirmed that giving the oxycodone-acetaminophen outside the ordered pain parameter did not meet her expectation. Facility policies stated drugs shall be administered only upon the order of a licensed prescriber and that pain not relieved by current measures should be discussed with the physician.
Blood Pressure Medication Given Without Following Hold Parameter
Penalty
Summary
The facility failed to ensure that a blood pressure medication order was followed for one resident with hypertension. Resident #44 was admitted with diagnoses including hypertension, chronic pain syndrome, and urinary tract infection. The resident’s quarterly MDS showed a BIMS score of 15, indicating intact cognition, and the care plan directed staff to administer antihypertensive medications as ordered and monitor for side effects such as orthostatic hypotension and increased heart rate. A physician order dated 11/30/2025 directed Lisinopril 2.5 mg by mouth once daily for high blood pressure and to hold the medication if systolic blood pressure was below 120. During a medication administration observation on 04/24/2026, an LPN prepared and administered Lisinopril to the resident. Review of the December 2025 MAR showed that on 12/3/2025 the documented blood pressure was 118/47, yet the medication was administered even though the systolic pressure was below the ordered hold parameter. The December MAR also showed that from 12/4/2025 onward, no blood pressure was documented when Lisinopril was administered. Review of the February, March, and April 2026 MARs showed the same transcribed Lisinopril order with the hold parameter, but no blood pressure was documented during administration. In interviews, an LPN stated that blood pressure medications with hold parameters should be held when the systolic pressure is below the ordered limit. The DON stated that medication administration must follow the physician’s order and that blood pressure should be checked and documented before giving the medication; she also stated she did not know why no blood pressure was recorded in the MAR. The facility policy on Physician Orders stated that drugs shall be administered only upon the order of a duly licensed prescriber and that orders must be accurately implemented.
Failure to Maintain Clean, Homelike Environment in Resident Rooms and Hallways
Penalty
Summary
The deficiency involves the facility’s failure to provide housekeeping services necessary to maintain a clean, safe, and homelike environment in multiple resident rooms and hallways. A complaint submitted through the online complaint portal stated that the facility did not appear to have enough staff to keep the building clean, that overall cleanliness was poor, and that staff did not clean the floor after a resident’s meal tray spilled. During an observation of a shared resident room on March 3, 2026, trash and crumbs were seen on the floor, and multiple dark streaks were visible in high‑traffic areas of the flooring. One resident in the room stated that it took a lot of effort to get the rooms cleaned, and the other resident reported that the floor and room had been dirty for quite a while and that cleaning staff did not clean the room on a daily basis. An observational tour of one hallway with the Business Office Manager revealed additional rooms that did not meet the facility’s cleanliness expectations. The manager identified three rooms with visible dirt and streaks on the floor, two rooms with multiple pieces of trash on the floor, and one room with visible food crumbs on the floor along with multiple dark streaks and scuff marks on the flooring surface. In another room observed with a CNA, small pieces of paper and loose debris were noted on the floor, along with discarded items near the trash can. The CNA stated that housekeeping typically cleans resident rooms daily but had not yet arrived on the unit that morning, and also pointed out that a drink cart in another hallway had multiple areas of visible spillage on the cooler, drink dispensers, and cart surfaces. During a medication pass, an RN identified a resident room that failed to meet facility standards due to a buildup of streaked dirt, dried spills on the floor, and trash on the floor, and stated that the room was neither homelike nor appropriate for decreasing the risk of spreading infection. The RN stated that trash, messes, and spills should be cleaned up immediately and not allowed to accumulate. The Housekeeping Supervisor described that maintaining a clean and homelike environment should include sweeping and mopping floors, regular trash removal, and cleaning bathroom fixtures, and that housekeeping staff are assigned to specific halls and are expected to clean resident rooms, hallways, and common areas daily. The supervisor also acknowledged that the conditions reported to her by the DON, including feces on a toilet and tube‑feeding residue on a floor mat in specific rooms, did not meet the facility’s expectations for environmental cleanliness. In a follow‑up interview, a resident reiterated that he was not joking about the need for housekeeping improvement and confirmed that his room was not cleaned on a daily basis. The facility’s Infection Control Program policy states that the goal is to identify and correct problems related to infection control practices, and the Homelike Environment policy states that it is the facility’s policy to provide a homelike environment.
Failure to Protect Resident From Verbal Racial Abuse by Roommate
Penalty
Summary
The facility failed to protect a resident’s right to be free from abuse when one cognitively intact resident verbally abused a roommate using a racial slur. According to the facility’s 5‑day incident report, late in the evening a resident with diagnoses including malnutrition, anxiety disorder, blindness in one eye, and insufficient sleep syndrome, and with a BIMS score of 15 indicating normal cognition, was overheard by an LPN and a CNA yelling obscenities at the roommate and calling the roommate a “nigger.” A daily skilled progress note for that date documented that this resident was alert and oriented x3, had no active symptoms or treatments affecting mood or behavior, and that the resident yelled obscenities at the roommate, was redirected, and then proceeded to use the racial slur. The facility’s investigation substantiated verbal abuse, defined in facility policy as the willful use of disparaging and derogatory terms to or within hearing distance of residents. The roommate who was the target of the slur had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non‑dominant side, asthma, and depression, and also had a BIMS score of 15 indicating normal cognition. Review of this resident’s progress notes revealed no documentation regarding the altercation that occurred on the date of the incident. Interviews with the witnessing LPN and the ADON confirmed that verbal abuse includes yelling, cursing, profanities, and racial or prejudicial remarks, and the Executive Director/Abuse Coordinator stated that the incident involved “colorful language” with racial verbiage and that the facility’s investigation substantiated verbal abuse. Facility policies on Abuse: Prevention of and Prohibition Against and Resident Rights state that residents have the right to be free from verbal abuse, including willful use of disparaging and derogatory terms, which was not upheld in this incident.
Wrong-Resident Medication Administration Without Physician Orders Leading to Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications administered to a resident had corresponding physician orders, resulting in a significant medication error. A resident with metabolic encephalopathy, essential tremor, epilepsy, dementia, spinal stenosis, cognitive communication deficit, syncope and collapse, and a history of TIA was admitted for inpatient rehabilitation. The resident’s medications had been reviewed and reconciled, and active physician orders included medications such as clopidogrel, propranolol ER, lamotrigine, heparin, and others, all of which were documented as administered per the eMAR. The resident had a BIMS score of 05, indicating severe cognitive impairment, and was documented as receiving anticoagulants, antiplatelets, and injectable medications. On the day of the incident, a nurse assigned to another resident prepared that other resident’s medications and went to administer them. When the intended resident was not in their room, the RN went to the therapy gym and asked therapists to locate the other resident. A physical therapist assistant, who had not previously met either resident, told the RN that he had the other resident, and the resident being treated in therapy also verbally identified herself as that other resident. The RN, who had limited prior exposure to this resident and had never worked on that hall before, then administered the prepared medications to the resident in therapy. These medications included amiodarone, aripiprazole, aspirin 325 mg, citalopram 40 mg, apixaban 2.5 mg, ferrous sulfate, folic acid, Lasix 40 mg, midodrine 10 mg, a multivitamin with minerals, potassium ER 20 mEq, vitamin B12 1000 mcg, and vitamin D3 1000 IU, none of which had physician orders for this resident. Approximately 20 to 40 minutes later, the PTA realized while escorting the resident back to her room that the medications had been given to the wrong resident and informed the RN and DON. Documentation and interviews show that the resident’s morning vital signs had been within normal limits prior to the event. Later that afternoon, when the resident’s family arrived, they found the resident slumped over in a wheelchair, unresponsive to verbal cues but responsive to physical stimulation, unable to state her birthday, the current year, or her location, and with eyes rolling back and falling asleep immediately afterward. Nursing documentation recorded a blood pressure of 162/81 and a change in condition, and the family reported that the resident could not lift her head and that her blood pressure had “skyrocketed.” The facility’s own policies on oral medication administration and quality of care required that no medication be administered without a physician’s order and that residents be properly identified before medication administration, but these requirements were not followed in this incident, leading to the administration of multiple medications without orders and subsequent hospitalization for unintentional use of medication and elevated blood pressure. Interviews with involved staff further detailed the actions and inactions that led to the deficiency. The LPN assigned to the resident that day stated she had correctly administered the resident’s ordered medications earlier in the shift and later learned from another nurse that medications intended for a different resident had been given to her resident in the therapy gym. The DON explained that staff were expected to verify resident identity using name, date of birth, door tags, and EMR photos, and that no medication should be given without a physician’s order, but acknowledged that the RN had relied on the PTA’s statement and the resident’s verbal confirmation in the group therapy setting. The PTA admitted he should have taken more time to verify the resident’s identity and that he believed he was working with the other resident when he told the RN he had that person. Collectively, these actions and failures in resident identification and adherence to medication administration policy resulted in the resident receiving multiple medications without physician orders and experiencing a documented change in condition requiring hospital admission for observation and unintentional medication use.
Resident Given Another Patient’s Medication Regimen During Therapy Session
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a full set of medications prescribed for another resident was administered in error. The affected resident had multiple diagnoses, including metabolic encephalopathy, essential tremor, epilepsy, dementia, spinal stenosis, cognitive communication deficit, and syncope and collapse, and had active physician orders for a specific regimen of medications such as clopidogrel, fluconazole, loratadine, propranolol ER, lamotrigine, acetaminophen, and heparin, among others. These ordered medications were correctly transcribed to the MAR and documented as administered as ordered earlier in the day. Later that day, an RN who was responsible for another resident’s medications prepared that other resident’s medications and went to administer them. When the intended resident was not in their room, the RN went to the therapy gym and asked therapists to locate the intended resident. A PTA, who had not previously met either resident, told the RN that he had the intended resident, and the resident being treated in therapy also verbally identified herself as that other resident. Without further verification, the RN administered the other resident’s medications to this resident. The list of medications given in error, as documented in a handwritten note by an LPN, included amiodarone, aripiprazole, aspirin, citalopram, apixaban, ferrous sulfate, folic acid, furosemide (Lasix), midodrine, a multivitamin with minerals, potassium ER, vitamin B12, and vitamin D3, none of which had physician orders for this resident. Following the administration of the wrong medications, staff became aware of the error approximately 20–40 minutes later when the PTA realized that the resident he was escorting back to her room was not the intended resident and informed the RN and DON. Documentation shows that the resident’s vital signs were monitored, with a morning blood pressure of 140/72 and later a blood pressure of 162/81. A nursing note described that when the family arrived, the resident was slumped over in her chair, not responding to verbal cues but responding to physical stimulation, unable to state her birthday, the current year, or her location, and with eyes rolling back and falling asleep immediately afterward. The family reported finding the resident slumped over in a wheelchair with no staff present, having to seek help, and being told that the resident had been given medications intended for another resident, including medications to treat schizophrenia. The facility’s own policy on oral medication administration required that no medication be given without a physician’s order and that the resident be identified before administering any medications, which was not followed in this incident. Interviews with staff further detailed the actions and inactions that led to the error. The RN stated she had never worked on that hall before, had only seen the resident once previously, and relied on the PTA’s statement and the resident’s verbal confirmation to identify the resident before administering the medications. The PTA acknowledged that he had not met either resident before that day and that he believed he had the intended resident but did not take additional steps to verify identity. The DON stated that staff were expected to verify resident identity using name, date of birth, door tag, and photo in the electronic record, and that in this case the resident received medications prescribed for another resident while in a group therapy session after being misidentified by both the PTA and the RN. These combined failures in resident identification and adherence to the facility’s medication administration policy resulted in the resident receiving multiple medications without physician orders and experiencing a subsequent change in condition, including altered responsiveness and elevated blood pressure, leading to hospital admission with a diagnosis that included unintentional use of medication.
Failure to Administer Oxygen Per Physician Orders
Penalty
Summary
The facility failed to ensure that oxygen was administered per physician orders for a resident. The resident, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease (COPD) and acute respiratory failure with hypoxia, had a physician's order for 4 liters of oxygen per minute via nasal cannula. However, observations on January 30, 2024, revealed that the resident was receiving 6 liters of oxygen per minute, which was above the ordered amount. This discrepancy was noted during two separate observations on the same day. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that the oxygen settings should have been at 4 liters per minute as per the physician's order. The LPN acknowledged that the oxygen settings are checked every 2 hours during rounding, and the DON emphasized that the nurse assigned to the resident is required to sign off on the oxygen order every shift. Despite these protocols, the oxygen settings were not in compliance with the physician's orders, as confirmed by the facility's oxygen administration policy reviewed in May 2023.
Inaccurate Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted on a daily basis with accurate details of the actual hours worked by licensed and unlicensed nursing staff and the resident census. During an interview, the Staffing Coordinator acknowledged that the daily staff postings should be accurate but admitted that the numbers might be incorrect due to staff leaving early or late. The Director of Nursing also confirmed that the postings should be accurate but was unsure of their accuracy without double-checking. The Administrator was unaware of any policy regarding the accuracy of staff postings, and a follow-up interview with the Director of Nursing revealed that the facility does not have a policy in place to ensure the accuracy of these postings.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tucson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountain View Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Casas Adobes Post Acute Rehab Center | 2 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of Tucson | 2.2 mi | ★★★★★ | 5 | 0 |
| Brookdale Santa Catalina | 4.1 mi | ★★★★★ | 4 | 0 |
| Skilled Nursing Unit At Oro Valley Hospital | 5.7 mi | ★★★★★ | 3 | 0 |
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