Woodland Care Center: Catheter Care Undocumented - CA
Federal inspectors visited the facility on April 11, 2025, and reviewed the care plans and treatment administration records for Resident 49, a man with an indwelling catheter. His care plan was specific: provide catheter care every day and as needed, monitor him for signs and symptoms of urinary tract infection, and check his skin for irritation during every shift. None of it was documented anywhere in his chart.
The Medical Director of Skilled Care, identified in the inspection report as MDSC 1, confirmed what the records showed. Licensed nurses were responsible for providing the catheter care and documenting it. They hadn't. MDSC 1 told inspectors directly that the potential outcome of failing to implement a care plan intervention is the inability to provide appropriate care and services to the resident.
The Director of Nursing said the same thing, in almost the same words.
During an interview at 3:20 p.m. on the day of the inspection, the Director of Nursing acknowledged that licensed staff are required to monitor residents for complications associated with urinary catheters, required to provide catheter care, and required to document it in the medical record. Then she confirmed that licensed nurses had not documented anywhere in Resident 49's chart that they had implemented any of those interventions.
She described the potential outcome plainly: the risk of infection, and the inability to provide appropriate care and services to the resident.
Urinary tract infections are not a minor risk for nursing home residents with indwelling catheters. The catheter itself creates a direct pathway for bacteria to reach the bladder. Without regular cleaning, monitoring for early symptoms like fever or changes in urine, and attention to skin breakdown around the insertion site, an infection can develop and advance before anyone catches it. The care plan existed precisely because these risks are predictable and preventable.
The facility's own policy on urinary catheter care, last reviewed on January 16, 2025, less than three months before the inspection, stated its purpose as decreasing and eliminating difficulties associated with urinary catheter use. The policy was current. The care plan was in place. The staff who were responsible knew what was required. What was missing was any evidence that the work had been done.
That gap is what inspectors cited. The deficiency was tagged at a level of minimal harm or potential for actual harm, affecting a small number of residents. In the language of federal inspection reports, that framing describes not what did happen, but what could have. It does not mean nothing happened to Resident 49. It means inspectors could not confirm, from the record, what his care actually looked like, because the record contained nothing.
That is its own kind of answer.
The facility is located at 7120 Corbin Ave. in Reseda, a neighborhood in the western San Fernando Valley. The inspection was completed April 11, 2025.
For Resident 49, the care plan called for someone to check on him every shift. Whether anyone did, and what they found when they looked, is not in his chart.
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.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: October 29, 2026 · Our methodology
WOODLAND CARE CENTER in RESEDA, CA was cited for violations during a health inspection on April 11, 2025.
None of it was documented anywhere in his chart.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.