Woodland Care Center: Infection Control Failures - CA
That was the scene on the morning of April 7, 2025, at Woodland Care Center, a nursing facility on Corbin Avenue in Reseda. At 11:15 a.m., during a walkthrough with the infection preventionist, inspectors observed the nasal cannula tubing belonging to Resident 71 making contact with the floor. The resident had been on supplemental oxygen since at least November 2024, under a physician's order to receive two liters per minute via nasal cannula as needed for low oxygen levels.
The infection preventionist did not dispute what inspectors found. She told them on the spot that the tubing was already contaminated, that floor contact could introduce bacteria to the resident, and that it had to be replaced immediately.
Resident 71 had been living at Woodland since 2022, readmitted in July 2024 with cachexia, a condition involving severe weight and muscle loss, and atelectasis, a collapse of part of the lung. The resident's cognitive function was recorded as intact. They needed moderate help with showering and dressing, and supervision with toileting and personal hygiene. This was not a resident who could easily advocate for themselves in a clinical emergency, but they were aware of their surroundings. Whether they were aware that the device delivering oxygen to their lungs had been resting on a contaminated surface is not recorded.
Federal guidelines from the Centers for Disease Control and Prevention, cited in the inspection report, are direct on what floors in health care settings carry: airborne microorganisms, bacteria transferred from shoes, bacteria transferred from equipment wheels, body substances. Floors become contaminated rapidly. That is not a theoretical risk in a nursing home. It is a baseline condition.
Inspectors also found two unlabeled urinals during the same inspection sweep. Resident 94 and Resident 2 each had a urinal in their rooms with no identifying label. A urinal without a resident's name on it cannot be reliably tracked to one person. In a shared care environment, that creates a direct path for cross-contamination between residents.
The facility's own written policy, reviewed by inspectors and dated January 16, 2025, stated that standard precautions apply to all residents regardless of diagnosis or infection status, and that used care equipment soiled with blood, body fluids, or excretions must be handled in a way that prevents the transfer of microorganisms to other residents and environments. The urinals fell under that policy. So did the oxygen tubing.
Woodland Care Center cited these three findings together under a single infection control deficiency. CMS rated the level of harm as minimal harm or potential for actual harm, and noted that some residents were affected. That is the lower end of the federal harm scale, but the infection preventionist's own words at the bedside told a more urgent story: contaminated, introduce bacteria, replaced immediately.
There is a particular quality to a violation that the facility's own specialist identifies out loud, in real time, without being asked. It means the knowledge was there. The standard was understood. The tubing was on the floor anyway.
The inspection was completed April 11, 2025. Resident 71, whose lung had already partially collapsed and whose body had already been losing muscle and weight, was breathing through equipment that had been in contact with a contaminated floor for an unknown length of time before anyone noticed.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 3, 2026 · Our methodology
WOODLAND CARE CENTER in RESEDA, CA was cited for violations during a health inspection on April 11, 2025.
That was the scene on the morning of April 7, 2025, at Woodland Care Center, a nursing facility on Corbin Avenue in Reseda.
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.