La Canada Care Center

NOT REVIEWED BY 22 Based on facility documentation, staff interviews, and policy review, the facility failed to ensure that daily staff posting information was accurate for 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 out of 9 days reviewed. The census was 92. The deficient practice could result in residents, visitors, and facility staff not being informed of accurate and current staffing information. Findings include: Review of 9 randomly selected days of daily staff postings with corresponding punch details revealed the actual hours worked on the daily staff postings were inaccurate related to the number of actual RN, LPN and CNAs working each shift, the actual number of hours worked each shift, and the total number of actual staff hours worked each day. The daily staff posting dated 10/25/2024, revealed a census of 101 residents with no evidence of the total number of nurses and CNAs that worked each shift or the total number of hours worked by all…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, review of facility documents, and review of policies, the facility failed to protect the resident right to be free from chemical restraints by not administering pain medication in accordance with the physician's order for one resident (#1). The deficient practice could result in medications being administered without following the physician's order and could place the resident's health at risk for illnesses.Findings include:Resident #1 was admitted to the facility on [DATE], with diagnoses that included a fracture of her right thigh with subsequent encounter for closed fracture with routine healing, Chronic Obstructive Pulmonary Disease (COPD), muscle weakness, and epilepsy.The admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15.0, indicating that the Resident was cognitively intact. Further, the assessment revealed that the Resident used opioid medications.A review of the physician's orders revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, review of facility documents, and review of policies, the facility failed to ensure that a blood pressure medication order was followed in compliance with a physician order according to accepted standards of clinical practice for one resident (#44). The deficient practice could result in medications being administered without following the physician's order and could place the resident's health at risk for illnesses.Findings include:Resident #44 was admitted to the facility on [DATE] with diagnoses of high blood pressure (hypertension), chronic pain syndrome, and urinary tract infection.A review of the Quarterly Minimum Data Set assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15.0, indicating that the Resident cognition was intact.The Resident's care plan initiated on 10/10/2024, revealed that the Resident had hypertension. The interventions included for the staff to administer antihypertensive medications as ordered and monitor for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and policy review, the facility failed to provide housekeeping services necessary to maintain a clean and homelike environment for residents in three of four resident rooms and hallways. This deficient practice can increase the risk of infection, and not provide the residents with a safe and clean environment. Findings Include:A complaint received on the online complaint portal system, dated January 2, 2026, revealed that the facility did not seem to have enough staff to keep the facility clean, and that the overall cleanliness of the facility is not good. Additionally, the complainant revealed that staff would not clean up the floor after her meal tray spilled. On March 3, 2026, at approximately 8:42 a.m., an observation of room [ROOM NUMBER] was conducted while both residents in Beds A and B were present. During the observation, trash and crumbs were noted on the floor. Multiple visible dark streaks were also observed in high-traffic areas of the flooring. During the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and facility policy, the facility failed to protect the rights of one of 13 sampled resident's (#600) to be free from abuse by another resident (#525). The deficient practice could result in residents being abused by other residents or staff.Findings include:A facility 5-day incident report, dated April 17, 2023, revealed that on April 9, 2023 at 10:55 p.m. Resident #525 was overheard by a Licensed Practical Nurse (LPN/staff #64) and a Certified Nursing Assistant (CNA/staff #801), using obscenities including the racial profanity nigger towards Resident #600. The facility report included that the abuse was substantiated, resulting in no injury.-Resident #525 (alleged perpetrator):Resident #525 was originally admitted on [DATE] with diagnoses that included malnutrition, hemorrhagic telangiectasia, anxiety disorder, blindness in one eye, and insufficient sleep syndrome. A Medicare 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure that oxygen was administered per physician orders for one resident (#12). The sample size was 20. Findings include: The resident was admitted on [DATE] with diagnosis including anxiety disorder, unspecified dementia, psychotic disturbance, mood disturbance , anxiety, depression, schizophrenia, acute respiratory failure with hypoxia, pleural effusion, other non specific findings of the lung field, pneumonia, chronic obstructive pulmonary disease and a wedge compression fracture. A review of the MDS (minimum data set) dated December 07, 2023 revealed that the resident had a BIMS (brief interview of mental status) score of 14, indicating that the resident was cognitively intact. The MDS further noted that the resident was on oxygen therapy. A review of the of the physician's orders dated January 2, 2024 for resident #12 revealed an order for 4 liters of oxygen per minute via nasal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility documentation and staff interview, the facility failed to ensure that nurse staffing information was posted on a daily basis that included the actual hours worked by licensed and unlicensed nursing staff and the resident census. Findings include: An interview was conducted on 2/2/2024 at 12:36 PM with the Staffing Coordinator (staff #18) who said daily staff postings should be accurate. She said that that she gets the numbers from the daily staff tracking form so staff must have left early or late that day. She reviewed the posting for 12/30/2023 and said that it was not accurate. An interview was conducted on 2/2/2024 at 12:56 PM with the Director of Nursing (DON/staff#13) who said that daily staff postings should be accurate. She said that she'd have to assume that their numbers are accurate but she would have to double check. An interview was conducted on 2/2/2024 at 1:31 PM with the Administrator (staff #115) who said that he did not know if there was a policy regarding the accuracy of staff postings and that he would check with the Director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record reviews, staff interviews, and review of policy, the facility failed to ensure that Preadmission Screening and Resident Reviews (PASRR) were completed as required for 3 residents (#57, #34, and #41). The sample size was 3. The deficient practice increases the risk for residents being inappropriately placed into nursing facilities and/or not receiving the services they need. Findings include: -Resident #57 was readmitted to the facility on [DATE] with diagnoses that included osteomyelitis, acquired absence of right leg below the knee, and bipolar disorder. Review of the Level 1 PASRR dated 03/06/21 indicated the resident did not have serious mental illness, including bipolar disorder. Review of the clinical record revealed the resident was discharged from the facility on 12/03/21 and subsequently readmitted on [DATE]. The Level I PASRR evaluation dated 12/06/21 revealed the physician had certified before admission to the facility that the resident required 30 days or less of nursing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility logs and staff interview, the facility failed to provide evidence that temperatures for the reach-in refrigerator was consistently monitored. The deficient practice could result in foodborne illness. Findings include: During the initial kitchen observation conducted on October 11, 2022 at 8:12 a.m. the October kitchen log for the freezer and refrigerators were reviewed. The Kitchen Manager (staff #1110) was present during the walk-through and review of the logs conducted on October 11, 2022 at approximately 8:12 a.m. During the review, it was noticed that the reach-in refrigerator did not have a temperature log. The refrigerator had a thermometer inside and it indicated that the temperature was 40 degrees Fahrenheit. The refrigerator had items inside such as individual serving containers of salad and cottage cheese. During an interview with the Kitchen Manager (staff #1110) conducted on October 11, 2022 at 8:21 a.m., he stated that they did not have a temperature log for the reach-in refrigerator. When asked if there were logs from previous months, he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff interviews, and facility documentation, the facility failed to ensure one resident (#397) signed and was issued a written Notice of Medicare Non-Coverage (NOMNC) when there was an ending of Medicare services. The sample size was 3. The deficient practice could result in residents not being informed of their potential liability for payment. Findings include: Resident #397 was admitted [DATE], with diagnoses that included unspecified fracture of left femur, muscle weakness, and difficulty walking. The resident was discharged [DATE]. The admission Minimum Data Set assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 15 indicating the resident was cognitively intact. Review of the resident's face sheet revealed the resident was the financially responsible party. A weekly skilled nursing note dated April 20, 2022 indicated the resident was discharge ready and that the NOMNC was to be issued. Discharge was set for April 27, 2022. Review of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident and staff interviews, clinical record review, review of facility documentation and policy and procedure, the facility failed to ensure that one resident (#191) who was unable to carry out activities of daily living (ADLs) received services to maintain good grooming. The sample size was 10. The deficient practice may result in residents with poor personal hygiene. Findings include: Resident #191 admitted to the facility on [DATE] with diagnoses that included COVID-19, alcohol abuse, and chronic obstructive pulmonary disease. An ADL self-care performance deficit care plan dated 09/28/22 related to decline with function and mobility had a goal to improve independence with ADL tasks and functional mobility. Interventions included required staff participation with bathing. The admission Minimum Data Set assessment dated [DATE] revealed the resident scored 9 on the Brief Interview for Mental Status, indicating moderately impaired cognition. The assessment also revealed the resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, observation, staff interviews, and policy review, the facility failed to provide care and services to maintain acceptable parameters of nutritional status for one resident (#24). The sample size was 4. The deficient practice could result in residents being at risk for potential nutritional decline. Findings include: Resident #24 was admitted to the facility on [DATE] with diagnoses that included unspecified protein-calorie malnutrition, respiratory failure, hemiplegia and hemiparesis following cerebral infarction, dysphagia and muscle weakness. A care plan initiated on April 14, 2022 included a problem for moderate malnutrition related to acute illness. The care plan goals stated resident #24 will maintain adequate nutritional status as evidenced by maintaining weight with no signs and symptoms of malnutrition. The intervention included the RD (registered dietician) evaluating and making diet changes recommendations as needed; supplement; and weekly weights for 4 weeks and then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.