Woodland Care: Medication Errors, Allergen Served - CA
Federal inspectors documented the medication errors during an April inspection, finding that licensed nurses ignored physician orders for three diabetic residents over multiple weeks in March 2025.
Resident 27 received insulin injections in her left arm on March 1 and March 2, then in the same spot on her right lower abdomen on March 8, March 9, and March 10. The physician had ordered staff to "rotate injection site" with each dose.
Registered Nurse 1 told inspectors the repeated use of the same injection sites were "medication errors" that could cause "damage to the skin tissues of the resident."
The pattern repeated with Resident 116, who received insulin in the same lower left section of her abdomen six times between March 6 and March 16. Licensed Vocational Nurse 1 explained that nurses must rotate injection sites "every time that they administer insulin, to prevent from skin tissue damage."
The potential consequences are serious. LVN 1 told inspectors that failing to rotate sites can cause "bruise and hardened areas under the resident's skin." The Director of Nursing added that hardened areas "can reduce insulin absorption."
Resident 38 faced the same problem in March and April. Nurses gave him insulin in the left upper quadrant of his abdomen on March 21, March 22, and March 23, continuing the pattern into April with injections in the same spot on April 4, April 5, April 6, and April 7.
The Assistant Director of Nursing confirmed "multiple instances when the insulin injection sites were not rotated" and called the failures to follow physician orders "medication errors."
A separate medication error involved blood pressure medication. Resident 12 received midodrine on April 1 when his blood pressure measured 126/76 mm Hg. The physician had ordered staff to hold the medication if the resident's systolic pressure exceeded 120.
The Director of Nursing said midodrine "should not have been given" because Resident 12 "could be at risk for elevated blood pressure resulting in health complications."
Beyond medication errors, kitchen staff served a potentially life-threatening meal to Resident 71, who has a gluten allergy. Two staff members served cream of wheat to the resident despite the known allergy.
Inspectors found no training had been provided to kitchen staff regarding gluten-free diets. The facility's own assessment warned that serving gluten to Resident 71 could cause "anaphylactic shock, severe tachycardia, cardiac arrest, diarrhea, dehydration and/or death."
The medication storage problems extended beyond administration errors. Nurses improperly stored budesonide inhalation solution for Resident 6, who uses the medication to treat shortness of breath and chronic obstructive pulmonary disease.
Licensed Vocational Nurse 5 discovered five inhalation solutions stored outside their protective foil pouch without any date marking when they were removed. The manufacturer requires the solutions to remain in foil pouches or be discarded within two weeks if stored outside.
"It was unknown when the five budesonide inhalation solutions would expire," LVN 5 told inspectors. Using expired solutions could result in "ineffective medication" that fails to treat breathing problems, "potentially causing harm by not treating the shortness of breath and chronic obstructive pulmonary disease leading to difficulty in breathing, requiring immediate treatment and potential hospitalization."
The facility's own policies require dating multi-dose products when first opened. The manufacturer's guidelines specify that opened solutions must be "protected from light" and unused portions "should be returned to the aluminum foil envelope."
Woodland Care Center admitted Resident 27 in December 2024 with Type 2 diabetes, major depressive disorder, end-stage renal disease requiring dialysis, and a history of falling. Despite her complex medical needs, she retained the capacity to understand and make decisions.
Resident 116 was initially admitted in April 2024 and readmitted later with Type 2 diabetes, major depressive disorder, and dependence on renal dialysis. Her care plan specifically aimed to keep her "free from sign and symptoms of hypoglycemia and hyperglycemia for the next three months."
Resident 38 first came to the facility in 2015 and was readmitted in 2022 with acute kidney failure, Type 2 diabetes, and atherosclerotic heart disease. Despite requiring extensive assistance with daily activities, he maintained intact cognition.
The facility's insulin administration policy, reviewed in January 2025, clearly states that "injection sites should be rotated, preferably within the same general area." FDA labeling for the insulin products used at the facility specifically warns to "rotate injection sites to reduce the risk of lipodystrophy."
The medication error policy requires immediate reporting of all administration errors to the Director of Nursing, attending physician, and Administrator. The policy defines medication errors as including "administration of medication via the wrong route."
For Resident 12, who was admitted in December 2024 with a brain bleed, irregular heartbeat, and dementia, the blood pressure medication error represented a direct violation of physician orders designed to prevent dangerous spikes in blood pressure.
The Director of Nursing acknowledged that expired inhalation treatments "have lost effectiveness" and when given in error "will not treat the shortness of breath or COPD further causing respiratory distress and stoppage of breathing" requiring "immediate treatment and hospitalization."
Kitchen staff serving cream of wheat to a resident with a documented gluten allergy highlighted gaps in dietary training. The facility acknowledged that two staff members were involved in serving the problematic meal, with no evidence that either had received training on managing gluten-free dietary requirements.
The inspection revealed systematic breakdowns in medication administration, storage protocols, and dietary safety measures affecting multiple residents with serious medical conditions requiring precise care management.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WOODLAND CARE CENTER in RESEDA, CA was cited for violations during a health inspection on April 11, 2025.
The physician had ordered staff to "rotate injection site" with each dose.
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.