Woodland Care Center: Oxygen Given Without Order - CA
Federal inspectors documented the lapse during an April 7 visit to the facility at 7120 Corbin Ave. in Reseda. What they found was straightforward: a resident receiving a medical treatment that her physician had discontinued, administered by licensed nurses who either didn't know or didn't check, while the resident herself had no idea anything had changed.
The resident, identified in inspection records as Resident 6, had been readmitted to Woodland Care Center on April 1, 2025, following a hospitalization. Her physician discontinued the oxygen order that same day. Her care plan, last revised in February, had called for continuous oxygen at two liters per minute through a nasal cannula, along with weekly tubing changes and keeping the head of her bed elevated at 30 degrees to reduce the risk of respiratory distress.
None of that was relevant anymore. The order was gone.
Inspectors observed Resident 6 at 8:51 a.m. on April 7, sitting on her bed and eating breakfast. The oxygen tubing was clipped to her bed rail. The oxygen machine was on and running, but at three liters per minute, one liter higher than her canceled prescription had specified. She wasn't wearing the tubing while she ate. She told inspectors she normally skips the oxygen during meals.
Nine minutes later, the Director of Nursing and a licensed vocational nurse were at the resident's bedside, checking her oxygen saturation. It read 97 percent, within the normal range for a healthy adult. The Director of Nursing then shut off the machine and pulled the tubing from the bedside.
Resident 6 said she had been using the oxygen since coming back from the hospital. No licensed nurse had told her the order was no longer active.
The Director of Nursing confirmed to inspectors that no physician order existed for the oxygen. She confirmed the order had been discontinued on April 1. She also described what could go wrong. Administering oxygen to a resident with COPD without a physician's order, she said, can cause oxygen-related complications and harm to the resident.
That's not a minor caveat. In patients with COPD, the respiratory drive can be sensitive to elevated oxygen levels. The concern isn't hypothetical, and the Director of Nursing knew it. She said so directly to inspectors, in the same conversation where she confirmed her own facility had been doing exactly that for nearly a week.
The licensed vocational nurse who spoke with inspectors that morning also confirmed there was no physician order. She knew. The Director of Nursing knew. The facility's own oxygen administration policy, last reviewed in January 2025, states that staff must verify a physician's order before administering oxygen.
What the inspection record doesn't explain is how the machine stayed on for six days without anyone catching it. Resident 6 returned April 1. Inspectors arrived April 7. Across multiple shifts, across multiple nurses, nobody flagged that the treatment had no order behind it.
Inspectors rated the violation at the lowest level of harm, noting minimal harm or potential for actual harm. Resident 6's oxygen saturation was normal when it was measured that morning. She was not in distress.
But she was also not informed. For nearly a week, she believed she was receiving a treatment her doctor had ordered. She had built a routine around it, skipping the cannula during meals, attaching it to her bed rail when she wasn't using it. She had no reason to think otherwise. Nobody had told her.
The Director of Nursing turned off the machine and walked out of the room. Resident 6 had been managing her breathing around a prescription that no longer existed, and the first she learned of it was when an inspector showed up and the oxygen disappeared.
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 5, 2026 · Our methodology
WOODLAND CARE CENTER in RESEDA, CA was cited for violations during a health inspection on April 11, 2025.
Federal inspectors documented the lapse during an April 7 visit to the facility at 7120 Corbin Ave.
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.