Woodland Care Center: Medication Errors Found - CA
Inspectors from the Centers for Medicare and Medicaid Services visited the facility on April 11, 2025, and found the error recorded in Resident 12's medication administration record for April 1, 2025. The MAR showed a licensed nurse had signed off on giving midodrine at 2 p.m. that afternoon. Midodrine is used to raise low blood pressure. At the time of administration, Resident 12's blood pressure was 126/76 mm Hg, a reading within normal range.
The Director of Nursing, interviewed by inspectors at 1:15 p.m. on the day of the visit, was direct about what that meant. The DON said midodrine should not have been given at that reading because Resident 12 could be at risk for elevated blood pressure resulting in health complications. Giving a drug designed to raise blood pressure to someone whose blood pressure is already normal creates the risk of pushing it too high.
The DON confirmed it was a medication administration error.
The Assistant Director of Nursing reviewed the MAR alongside inspectors during a concurrent interview at 5:06 p.m. and confirmed the same facts: the nurse had signed that the medication was given, and the blood pressure reading was documented at the time.
The midodrine finding was not the only medication concern inspectors documented. Reviewers also identified problems with how insulin injections were being handled at the facility, specifically with site rotation.
Insulin is supposed to be injected at different spots each time, a practice that prevents lipodystrophy, a condition where fatty tissue under the skin breaks down or accumulates at overused injection sites. When that happens, insulin absorption becomes unpredictable, which can make blood sugar control unreliable. The FDA label for Lantus, a long-acting insulin, instructs nurses to rotate injection sites to reduce that risk. Prescribing information for Insulin Glargine states plainly: do not use the exact spot for each injection. The facility's own insulin administration policy, last reviewed in January 2025, says injection sites should be rotated, preferably within the same general area.
The inspection record does not describe a specific resident harmed by improper insulin site rotation, but the documentation of the issue alongside a confirmed medication error points to a pattern inspectors found worth recording.
Woodland Care Center's medication error policy, also last reviewed in January 2025, states that all errors related to the administration of medications or treatments must be reported to the Director of Nursing, the attending physician, and the administrator immediately. The policy defines medication error to include administration of a medication via the wrong route. Whether the midodrine error was reported through those channels before inspectors arrived is not addressed in the inspection record.
The deficiency was cited at a level of minimal harm or potential for actual harm. That classification sits below the most serious tiers in CMS's harm scale, but it reflects a finding that the error created real risk, not merely a paperwork problem. Resident 12 received a drug that could have driven their blood pressure into a dangerous range, and the nurse who gave it signed the record as though nothing was wrong.
The facility's plan of correction was not included in the inspection documents reviewed.
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: October 28, 2026 · Our methodology
WOODLAND CARE CENTER in RESEDA, CA was cited for violations during a health inspection on April 11, 2025.
The MAR showed a licensed nurse had signed off on giving midodrine at 2 p.m.
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.