Woodland Care Center: Controlled Substance Failures - CA
The violation centered on how the nursing home tracked narcotics and other controlled medications, a category of drugs that carry heightened risks of diversion, misuse, and patient harm. When a licensed nurse removes a controlled substance and administers it to a resident, the facility's own policy requires that nurse to immediately record the date, the time, the amount given, and their signature on both the accountability record and the medication administration record. Inspectors found that was not happening as required.
The gap between what the policy said and what staff were actually doing was the core of the deficiency.
Woodland Care Center's written policy, reviewed by inspectors and dated January 16, 2025, assigned responsibility for controlled substance compliance to two people: the Director of Nursing and the Consultant Pharmacist. The policy spelled out in plain terms what each administration required, including the immediate, contemporaneous entry of information at the moment the medication leaves the supply. Not later. Not at the end of a shift.
Inspectors classified the violation as causing minimal harm or the potential for actual harm to some residents.
That classification sits at the lower end of the federal harm scale, but controlled substance recordkeeping failures carry consequences that extend beyond any single resident interaction. Accurate accountability records are the primary mechanism a facility has to detect whether medications are being diverted, whether residents are receiving the doses they are prescribed, or whether discrepancies exist between what was removed from storage and what was actually administered. When those records are incomplete or not entered at the time of removal, the ability to reconstruct what happened, and to whom, is compromised.
The facility's own policy acknowledged the seriousness of the category. Controlled substances, it noted, are subject to special handling, storage, disposal, and recordkeeping requirements under both federal and state law.
Inspectors documented the deficiency under a tag tied to medication administration and recordkeeping requirements. The finding was part of a broader inspection completed April 11, 2025.
For residents at Woodland Care Center, controlled substances most commonly appear in the context of pain management, anxiety treatment, and sleep. These are medications where accurate dosing and accurate records matter in direct and immediate ways. A resident who does not receive a prescribed dose of a pain medication suffers. A resident who receives an incorrect dose faces different risks. The accountability record is supposed to be the safeguard that catches either problem.
The Director of Nursing and the Consultant Pharmacist, the two staff members the policy identified as responsible for maintaining compliance, had a policy in place that addressed exactly this scenario. The inspectors' finding was not that the policy was inadequate. It was that the policy was not being followed.
Woodland Care Center has 120 certified beds and serves long-term care and rehabilitation residents in the northwestern San Fernando Valley. The facility was given the opportunity to submit a plan of correction to address the deficiency.
What the plan of correction said, and whether the recordkeeping practices changed after inspectors left, is information the facility holds. Residents and their families who want to know more can contact Woodland Care Center directly or reach the California Department of Public Health, which conducted the survey on behalf of the Centers for Medicare and Medicaid Services.
The nurses responsible for entering those records in real time, at the moment of administration, are the last line of a system designed to account for every controlled substance that moves through the building. In April, inspectors found that system had a gap.
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.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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.
Inspectors found that was not happening as required.
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.