LA VERNE, CA - Federal inspectors cited Woods Health Services for multiple violations including failure to properly manage resident medications and maintain infection control protocols during an April 2025 inspection.
Medication Management Failures
The most serious violations centered on the facility's failure to respond to pharmacist recommendations for medication adjustments. Inspectors found that facility staff repeatedly ignored consultant pharmacist warnings about potentially harmful medication combinations and inappropriate dosages for residents with dementia and cognitive impairment.
A resident with severe cognitive impairment and dementia was taking multiple medications that the facility's pharmacist identified as problematic. In January 2025, the pharmacist recommended reevaluating the continued use of both Famotidine and Pantoprazole - two medications that treat stomach ulcers but should not typically be used together. The physician never responded to this recommendation, leaving the resident on both medications unnecessarily.
The same resident was also taking Simvastatin, a cholesterol medication that the pharmacist recommended discontinuing in February 2025. Again, no physician response was documented. In March 2025, the pharmacist recommended reducing the resident's Seroquel dosage from 25 mg to 12.5 mg, noting the importance of gradual dose reduction for antipsychotic medications in elderly patients. This recommendation also went unanswered.
Medical Significance of Medication Interactions
The combination of Famotidine and Pantoprazole represents a concerning duplication of therapy. Both medications reduce stomach acid production through different mechanisms, and using them together provides no additional benefit while potentially increasing side effects. In elderly patients with cognitive impairment, unnecessary medications can contribute to confusion, falls, and other adverse events.
Seroquel (quetiapine) is an antipsychotic medication that requires careful monitoring in nursing home residents. The FDA has issued black box warnings about increased mortality risk when antipsychotics are used in elderly patients with dementia. Proper dosing and regular review are essential to minimize these risks while maintaining therapeutic benefit.
The Hospice Registered Nurse told inspectors she was "not aware of the pharmacist recommendation regarding Simvastatin" and stated that "any new development regarding Resident 13 was usually relayed by HRN to the resident's physician."
Facility Policy vs. Practice
Woods Health Services' own medication review policy requires that when pharmacists identify irregularities that represent a risk to resident safety, they must contact physicians immediately and document the response. The policy states that physicians must document their review of irregularities and any actions taken.
The Director of Nursing acknowledged during interviews that "pharmacist recommendations should be followed because the pharmacist is specialized in medications regarding the use and drug interactions." She stated that physicians should be informed of recommendations within one to two days to ensure residents receive appropriate medications based on their medical conditions.
Infection Control Violations
Inspectors also documented multiple infection control failures that exposed residents to potential health risks. Staff were observed providing direct care to a resident requiring enhanced barrier precautions without wearing required personal protective equipment.
The resident requiring enhanced precautions had pressure-induced deep tissue damage and other conditions that necessitated strict infection control measures. A certified nursing assistant was observed wiping the resident's face while standing within one foot of the resident, without wearing gloves or a gown as required by posted protocols.
Oxygen Equipment Contamination
Two residents receiving oxygen therapy had their nasal cannulas touching the floor, creating infection risks. Nasal cannulas deliver supplemental oxygen directly to patients' respiratory systems, making contamination particularly dangerous. Floor contact can introduce bacteria and viruses that could cause respiratory infections.
A Licensed Vocational Nurse acknowledged that nasal cannulas "should not be touching the ground for infection control purposes because the resident could get a respiratory infection." The Director of Nursing stated this practice was "not appropriate for infection control" and noted concerns about unknown "viruses or bacteria on the floor and what the resident could contract."
Food Safety and Documentation Issues
Additional violations included expired food storage and inadequate record-keeping. Inspectors found five beef base containers stored past their expiration date in a walk-in refrigerator. The items were labeled with a "best if used by" date of February 23, 2025, but were still being stored during the April inspection.
The facility also failed to maintain required sanitation logs, ice machine cleaning records, and dishwasher temperature monitoring. These documentation gaps prevent proper oversight of food safety protocols and equipment maintenance schedules.
Medical Record Inaccuracies
A separate violation involved incorrect discharge documentation that could affect resident access to appropriate follow-up care. One resident's discharge records showed conflicting information about their destination - with one document indicating discharge to a long-term care facility while another showed discharge to an acute care hospital.
The MDS Coordinator acknowledged the error and noted that "accurate completion of resident information in the medical record directly impacted patient care and regulatory compliance." Incorrect discharge documentation can affect the type of services and support residents receive after leaving the facility.
Industry Standards and Expectations
Federal nursing home regulations require facilities to ensure that residents receive appropriate pharmaceutical services and that medication regimens are reviewed regularly by qualified pharmacists. When pharmacists identify potential problems, facilities must have systems in place to ensure physician review and appropriate action.
Infection control protocols exist to protect vulnerable nursing home residents from preventable infections and disease transmission. Enhanced barrier precautions are specifically designed to prevent spread of multidrug-resistant organisms in healthcare settings.
The violations at Woods Health Services represent failures in fundamental nursing home operations that directly affect resident safety and quality of care. Proper medication management and infection control are basic requirements for facilities caring for elderly and vulnerable populations.
All violations were classified as causing minimal harm or having potential for actual harm, indicating that while no serious injuries occurred, the practices created unnecessary risks for residents. The facility must develop and implement corrective action plans to address each cited deficiency.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woods Health Services from 2025-04-04 including all violations, facility responses, and corrective action plans.
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