RESEDA, CA - Federal inspectors cited Woodland Care Center for multiple safety violations including administering oxygen without physician orders and failing to properly track controlled medications during an April 2025 inspection.
Oxygen Therapy Administered Without Medical Authorization
Inspectors documented serious respiratory care violations affecting multiple residents receiving oxygen therapy. The facility provided oxygen to residents without proper physician orders and failed to maintain basic infection control standards for oxygen equipment.
Resident 6, who had chronic obstructive pulmonary disease (COPD) with acute respiratory failure, was found receiving oxygen at 3 liters per minute despite having no current physician order. The resident's oxygen order had been discontinued on April 1, 2025, due to hospitalization, yet nursing staff continued providing oxygen therapy for six days without medical authorization.
When inspectors questioned Licensed Vocational Nurse 3 about the oxygen administration, the nurse confirmed there was no physician order in place. The Director of Nursing immediately turned off the oxygen machine and removed the tubing from the resident's bedside. The resident stated they had been using oxygen since readmission and that "licensed nurses did not inform her that she no longer needs oxygen."
For patients with COPD, improper oxygen administration can cause dangerous complications. COPD patients rely on low oxygen levels to drive their breathing reflex, and excessive oxygen can actually suppress their respiratory drive, potentially leading to carbon dioxide retention and respiratory failure. This makes physician supervision essential for any oxygen therapy.
Another resident, Resident 58, had oxygen equipment in their room with tubing that lacked proper labeling indicating when it was last changed. The resident reported receiving oxygen only once approximately two weeks prior, yet the oxygen tank and tubing remained in the room without proper maintenance protocols being followed.
Controlled Medication Tracking Failures Create Risk for Drug Diversion
The facility demonstrated significant deficiencies in tracking controlled substances, with accountability records failing to match actual medication counts for three residents. These discrepancies raise concerns about potential medication errors and drug diversion.
Inspectors found missing doses of controlled substances including hydrocodone-acetaminophen (a powerful pain medication), pregabalin (used for nerve pain), and lorazepam (an anti-anxiety medication). In each case, the physical count of remaining medications in bubble packs did not match the facility's accountability records.
For Resident 26, one tablet of hydrocodone-acetaminophen 7.5-325 mg was missing from the medication supply. Resident 62 was missing both one pregabalin 150 mg capsule and one hydrocodone-acetaminophen 5-325 mg tablet. Resident 111's medication supply was missing one lorazepam 1 mg tablet.
Licensed Vocational Nurse 5 admitted to administering these medications without properly documenting the administration on required accountability logs. The nurse acknowledged understanding that accurate documentation prevents medication diversion and accidental overdoses that could cause respiratory depression and potential hospitalization.
Controlled substances require special handling due to their high potential for abuse and dependence. Federal regulations mandate immediate documentation when these medications are administered to prevent diversion and ensure patient safety. The missing documentation creates accountability gaps that could mask theft or lead to dangerous double-dosing if another nurse unknowingly administers the same medication.
High Medication Error Rate Exceeds Federal Standards
The facility's medication error rate reached 7.41%, significantly exceeding the federal requirement that error rates remain below 5%. Inspectors observed two medication errors during 27 total administration opportunities, affecting residents' prescribed treatment plans.
Resident 8 received a lidocaine pain patch applied to only one wrist instead of both wrists as ordered by their physician. The bilateral application was specifically prescribed to treat neuropathy pain in both hands and wrists. Licensed Vocational Nurse 4 acknowledged the error and admitted failing to follow the "five rights" of medication administration: right patient, right medication, right dose, right time, and right route.
Resident 55, who has Parkinson's disease and chronic kidney disease, did not receive their prescribed Omega 3 supplement during morning medication administration. The nurse administered eight other medications correctly but completely omitted the Omega 3 capsule. Licensed Vocational Nurse 5 stated this oversight could negatively impact the resident's heart, kidney, and brain health.
Medication errors in nursing homes can have serious consequences, particularly for elderly residents who may be more sensitive to missed doses or incorrect administration. Omega 3 supplements support cardiovascular health and brain function, which are especially important for patients with Parkinson's disease. Pain medication errors can leave residents experiencing inadequate pain relief, affecting their quality of life and rehabilitation progress.
Medical Context and Industry Standards
These violations reflect failures in fundamental nursing home care standards. Oxygen therapy requires ongoing medical supervision because oxygen needs can change rapidly based on a patient's condition. The facility's own policy required physician orders for oxygen administration, yet staff continued therapy without authorization.
Proper oxygen equipment maintenance is essential for infection prevention. The Centers for Disease Control and Prevention recommends changing oxygen tubing weekly and labeling equipment with change dates to prevent bacterial growth that could cause respiratory infections. For vulnerable nursing home residents, respiratory infections can quickly become life-threatening.
Controlled substance tracking exists to prevent diversion while ensuring patients receive prescribed medications. The Drug Enforcement Administration requires immediate documentation when controlled substances are dispensed. Gaps in this documentation can indicate theft, improper disposal, or double-dosing risks.
The "five rights" of medication administration represent the gold standard for preventing medication errors. These basic safety checks should catch most administration mistakes before they reach patients. When facilities exceed the 5% error rate threshold, it suggests systemic problems with training, supervision, or safety protocols.
Additional Issues Identified
The inspection also documented the facility's infection control policies were current, with oxygen administration procedures last reviewed January 16, 2025. However, implementation of these policies clearly fell short of written standards.
The facility's controlled medication policy specifically required immediate documentation on accountability records when medications are administered, demonstrating staff were aware of proper procedures but failed to follow them consistently.
Both the Director of Nursing and staff nurses acknowledged the medication errors during interviews, indicating awareness of proper protocols but inconsistent implementation in daily practice.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodland Care Center from 2025-04-11 including all violations, facility responses, and corrective action plans.
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