Woodland Care Center: Insulin Injection Failures - CA
The resident, identified in inspection records as Resident 38, received both Insulin Glargine and Humulin R injections. On April 4, 5, 6, and 7 of 2025, nurses administered the shots to the left upper quadrant of the resident's abdomen, again and again, without rotating to a different site. On April 5 and April 6, the same quadrant was used twice in a single day, once at 11:30 in the morning and again at 9:00 at night.
The pattern wasn't limited to that week.
When inspectors sat down with the Assistant Director of Nursing on April 10 to review Resident 38's medication administration record, the ADON acknowledged that injection sites had not been rotated in either March or April. Two full months. The ADON told inspectors the sites should be rotated to prevent damage to the skin tissues of the resident.
That explanation was accurate. Repeating injections in the same spot causes lipodystrophy, a condition where fat tissue under the skin hardens or atrophies. Once it develops, insulin absorbs unpredictably from the affected area, making blood sugar control unreliable. The damage can be permanent.
The facility's own written policy, last reviewed just three months before the inspection in January 2025, stated plainly that injection sites should be rotated, preferably within the same general area such as the abdomen, thigh, or upper arm. The prescribing information for Insulin Glargine, the brand name version known as Lantus, stated the same thing: rotate injection sites to reduce the risk of lipodystrophy. The Humulin R documentation, dated 2011, said injection sites should be rotated within the same region.
Every document in the building pointed the same direction. The nurses went the other way.
Inspectors classified the violation as causing minimal harm or the potential for actual harm, a designation that places it below the most serious tiers of deficiency but still reflects a failure that affected more than one resident, according to the inspection report.
Woodland Care Center is a skilled nursing facility located at 7120 Corbin Ave. in Reseda. The inspection was completed April 11, 2025.
What the records don't show is whether anyone at the facility noticed the pattern before inspectors arrived. The ADON's acknowledgment during the April 10 interview suggests the problem became visible only when someone sat down and looked at the medication administration record closely. Two months of entries. The same quadrant, checked off, shift after shift.
Insulin-dependent residents in nursing homes depend entirely on staff to manage injections they cannot administer themselves. They cannot reposition the needle. They cannot flag a nurse and say the site hasn't changed in weeks. If the person recording the injection doesn't rotate, it doesn't rotate.
For Resident 38, that meant the left upper quadrant of the abdomen absorbed somewhere between dozens of injections over March and April before an inspector pulled the chart.
Whether the tissue at that site was already showing signs of damage, the inspection report does not say.
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 3, 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 as Resident 38, received both Insulin Glargine and Humulin R injections.
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.