Woodland Care Center: Fall Safety Order Ignored - CA
The resident, identified in inspection records only as Resident 125, fell on February 18, 2025, at Woodland Care Center, a nursing facility at 7120 Corbin Ave. in Reseda. His physician responded by ordering the bed lowered and landing pads placed on both sides, with staff required to check their placement every single shift.
The facility's own interdisciplinary care team documented the plan two days later. According to notes from a February 20 team conference, Resident 125 had been moved closer to the nursing station for closer supervision, and the bilateral landing pads were confirmed as part of his care.
None of it held.
On April 7, 2025, at 10:19 in the morning, an inspector walked into Resident 125's room and found him lying in his bed. One landing pad was pushed against the wall to the right of his bed. The other was sitting in front of the unoccupied bed next to him. Neither pad was where the doctor had ordered them placed.
The Assistant Director of Nursing was standing in the room during the observation. She did not dispute what the inspector saw. The landing pads were not on both sides of the bed as ordered, she said, and the potential outcome was injuries if the resident fell.
The Director of Nursing said the same thing four days later, on April 11. Staff had failed to monitor the placement of the pads, she acknowledged. The potential outcome, in her words, was insufficient care and increased risk for injuries in the event of a fall.
That gap, between what a doctor ordered and what staff actually did, stretched across weeks. The physician's order came down after the February 18 fall. The interdisciplinary team confirmed the plan on February 20. Inspectors didn't arrive until April 7. For all of that time, there is no indication in the inspection record that anyone caught the problem or corrected it.
Resident 125's care plan, initiated on December 28, 2024, set a goal that he would be free from falls for 90 days. The listed interventions were to keep a call light within his reach while in bed and to keep personal items nearby. The landing pad requirement, added after the February fall, was the physician's direct response to that goal failing.
The facility's fall management policy, last reviewed in January 2025, states that after a fall, staff should update the care plan with new interventions. The care plan was updated. The interventions just weren't followed.
The inspection, completed April 11, 2025, cited the deficiency at a level of minimal harm or potential for actual harm, with some residents affected. That classification reflects the regulatory finding. It does not change what Resident 125's room looked like on a Tuesday morning in April, with the pads that were supposed to catch him if he rolled out of bed sitting uselessly across the room.
The Assistant Director of Nursing put it plainly. The pads were not where they were supposed to be. The Director of Nursing put it plainly too. Staff failed to check.
Resident 125 had already fallen once. His doctor had already responded. His care team had already met and documented what needed to happen. What remained was for someone to walk into his room each shift, look at both sides of his bed, and make sure the pads were there.
Nobody did.
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: November 7, 2026 · Our methodology
WOODLAND CARE CENTER in RESEDA, CA was cited for violations during a health inspection on April 11, 2025.
The resident, identified in inspection records only as Resident 125, fell on February 18, 2025, at Woodland Care Center, a nursing facility at 7120 Corbin Ave.
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.