Woodland Care Center: Side Rail Care Plan Failure - CA
That's what state inspectors found when they visited the facility at 7120 Corbin Ave. in April 2025.
The resident, identified in inspection records as Resident 38, required setup assistance for eating, moderate-to-maximal help with upper body dressing and personal hygiene, and was totally dependent on two or more helpers for toileting hygiene, showering, and transfers from bed to chair. On the morning of April 7, inspectors walked in and observed the resident in bed with both upper side rails raised.
There was no care plan addressing those side rails. Not a partial one. Not an outdated one. None.
When inspectors sat down with the facility's Minimum Data Set Coordinator on April 9, she reviewed Resident 38's care plans herself and confirmed she could not find anything addressing the resident's use of side rails. The coordinator didn't dispute it. She just couldn't find the document.
Two days later, the facility's Assistant Director of Nursing told inspectors it was important for the interdisciplinary team to determine what specific care plan the resident would need to ensure safe use of the rails. That conversation happened on April 10, three days after inspectors first spotted the problem.
Woodland Care Center had its own written policy on the subject, last reviewed as recently as January 16, 2025, less than three months before inspectors arrived. That policy stated clearly that a licensed nurse would complete a bedrail evaluation and develop a care plan reflecting that evaluation, to ensure the safe use of side rails as an assistive device, to aid mobility, or to treat medical symptoms. The facility had reviewed the policy, apparently found it satisfactory, and then failed to apply it to at least one resident who needed it.
The gap matters because side rails are not a neutral intervention. For a resident who depends on two people to transfer out of bed, a raised rail is either a tool that helps them reposition or a barrier that traps them, depending on the person and the situation. A care plan is how a facility documents which one it is, and what staff should do. Without one, the nurses and aides rotating through Resident 38's room had no written guidance on whether the rails were there to help, whether they posed a fall or entrapment risk, or under what circumstances they should be raised or lowered.
The inspection identified the deficiency as causing minimal harm or potential for actual harm, and noted that some residents were affected.
Woodland Care Center's comprehensive care planning policy, also last reviewed January 16, 2025, required that each resident have a plan with measurable objectives and timetables to meet their physical, psychosocial, and functional needs. Resident 38's situation required significant daily assistance across nearly every basic function of living. The absence of a side rail assessment was not a paperwork technicality. It was a missing piece of the record that was supposed to guide every person who walked into that room.
The inspection was completed April 11, 2025. What changed for Resident 38 after inspectors left, and whether a care plan was ever written, 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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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 29, 2026 · Our methodology
WOODLAND CARE CENTER in RESEDA, CA was cited for violations during a health inspection on April 11, 2025.
That's what state inspectors found when they visited 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.