Woodland Care Center: Medication Error Violations - CA
The inspection, completed April 11, 2025, documented that a licensed vocational nurse identified in records as LVN 4 failed to apply lidocaine patches to both wrists of a resident identified as Resident 8. The patches had been ordered by a physician. Only one wrist received the treatment. The other did not.
Lidocaine patches are a topical anesthetic used to manage localized pain. Not applying them as prescribed means the patient goes without the full pain relief the doctor ordered.
The director of nursing said so directly. During an interview on April 7, 2025, she told inspectors that LVN 4 had not followed what the facility calls the five rights of medication administration: the right resident, the right medication, the right dose, the right time, and the right method. She said the nurse failed to apply the lidocaine patch to both wrists as prescribed. She called it a medication error. She said that not administering the correct medications can lead to harm by causing more adverse effects to Resident 8 and does not treat their conditions.
That acknowledgment came from inside the building, not from inspectors pressing for an answer. The director of nursing named the failure, named the nurse, and named the consequence.
The facility's own written policy, last reviewed on January 16, 2025, states that medications must be administered in accordance with prescriber orders and that the person giving the medication must verify the right resident, right medication, right dosage, right time, and right method before administering it. A separate policy on medication errors, also reviewed on January 16, 2025, sets a target of keeping error rates at five percent or lower and defines a medication error as the administration of a medication at the wrong dose or one that is not currently prescribed.
Under that definition, what happened to Resident 8 qualifies. A prescribed treatment was not fully administered.
Inspectors classified the level of harm as minimal harm or potential for actual harm, and noted that some residents were affected. The deficiency did not rise to the level of immediate jeopardy, the most serious classification CMS assigns.
What the inspection record does not explain is how long the error went undetected, whether Resident 8's pain went unmanaged in the interval, or whether anyone at the facility caught the mistake before inspectors arrived. The report does not say.
What it does say is that a nurse skipped half of a prescribed treatment, the facility's director of nursing confirmed it was wrong, and the facility's own policies had been reviewed less than three months before it happened.
Woodland Care Center is located at 7120 Corbin Ave. in Reseda. The inspection was conducted under CMS event ID 056066.
Resident 8 was left with one wrist treated and one that was not, and a pain management plan that was not followed as the physician wrote it.
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 7, 2026 · Our methodology
WOODLAND CARE CENTER in RESEDA, CA was cited for violations during a health inspection on April 11, 2025.
The patches had been ordered by a physician.
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.