Woodland Care Center: Care Plan Failures Found - CA
Inspectors from the Centers for Medicare and Medicaid Services visited the Reseda facility on April 11, 2025, and flagged the lapse as a deficiency affecting a small number of residents. The violation was rated at the lowest level of harm, meaning inspectors found minimal harm or potential for actual harm rather than immediate danger. But the facility's own director of nursing described, in plain terms, what the failure meant.
The director of nursing told inspectors that care plans are required to be reviewed and revised when physician orders change. She said care plans need to reflect the correct and current interventions being implemented. Then she said this: if a care plan isn't updated, staff lose the ability to provide appropriate care and services to the resident.
That acknowledgment came from inside the building.
Oxygen is not a minor detail to leave untracked. A care plan that still shows oxygen as an active intervention tells staff that a resident requires it. One that doesn't reflect a discontinued order can leave the same staff without guidance on what changed, when it changed, and what the resident's current condition actually requires. The director of nursing's own words captured the risk: without an accurate care plan, appropriate care becomes harder to deliver.
The facility's written policies said the same thing in different language. Woodland Care Center's policy on oxygen administration, last reviewed in January 2025, states that staff should verify a physician's order exists for the procedure and review the resident's care plan to assess for any special needs. The care plan policy, also reviewed in January 2025, states that assessments are ongoing and that care plans must be reviewed or revised as information about the resident and the resident's condition changes. The interdisciplinary team is responsible for updating care plans after a significant change in condition, after a hospital readmission, and at minimum every quarter.
The oxygen order had been discontinued. The care plan had not been revised. Both policies said it should have been.
This is a narrow finding in terms of scope. Inspectors identified it as affecting few residents, and the severity rating reflects that no serious harm was documented. Woodland Care Center, located at 7120 Corbin Ave., is a licensed Medicare and Medicaid provider operating under facility ID 056066.
But the narrowness of a finding and the clarity of what it reveals are different things. A care plan is the central document that tells everyone involved in a resident's care what that person needs, what has changed, and what interventions are in place. When a physician changes an order and the care plan doesn't follow, the document stops being a reliable guide. Staff working from it are working from something that no longer matches the resident's actual situation.
The director of nursing did not dispute any of this. She confirmed the standard, confirmed the failure, and described the consequence in the same conversation.
Woodland Care Center's own January 2025 policy review meant that both the oxygen administration policy and the comprehensive care plan policy had been examined less than three months before inspectors arrived and found a care plan that hadn't been updated after a physician order changed. The policies were current. The care plan was not.
The resident whose care plan still reflected the discontinued oxygen order was not identified by name in the inspection report. Whether the outdated documentation affected any decisions made about their care during the period it went unrevised, the 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.
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.
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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 violation was rated at the lowest level of harm, meaning inspectors found minimal harm or potential for actual harm rather than immediate danger.
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.