Woodland Care Center: Medical Record Errors - Reseda, CA
The inspection, completed August 22, 2025, stemmed from a complaint filed against the facility. What investigators found was a single entry in a medication administration record that raised a question nobody at the facility had answered: what actually happened to Resident 1 on the evening of August 1?
The number in the record was 66/58 millimeters of mercury. That is a blood pressure reading associated with shock. The facility's own blood pressure policy defines hypotension as anything below 100/60. The reading logged for Resident 1 sat nearly 35 points below that threshold for the systolic number alone.
When an inspector reached LVN 2 by phone that afternoon, the nurse's explanation was immediate. The reading was a mistake, she said. Resident 1's systolic blood pressure was never lower than 90. She had entered it wrong.
Then came the part that made the error worse than the error itself.
LVN 2 told the inspector she didn't know how to correct a mistake in the medication administration record. The wrong number had been sitting in Resident 1's chart for three weeks. Nobody had fixed it. Nobody had flagged it. Nobody had called the physician.
That last part matters because of what a blood pressure of 66/58 would have required if it were real. The facility's own policy is specific: recheck the blood pressure, review whether any medications for hypotension are ordered, administer them if so, and notify the physician if the reading stays low. LVN 2 acknowledged during the interview that a reading that low would have required initiating a Change of Condition report and contacting the doctor.
She did none of those things. Her explanation was that she knew the number was wrong when she entered it.
The problem is that a medical record does not know that. The nurses and physicians and family members who look at that chart after the fact have no way of knowing what LVN 2 knew or believed in the moment. What they see is a documented blood pressure of 66/58, with no correction, no follow-up note, no physician notification, and no Change of Condition report to explain why none of those responses occurred.
A medication administration record is supposed to be the authoritative account of what was observed and what was done. When a nurse enters a number that would represent a medical emergency, and then leaves that number uncorrected for weeks because she doesn't know the process for fixing it, the record becomes something else: a source of confusion for anyone who reads it later, and a gap in the chain of accountability that's supposed to protect the resident.
The inspector's finding was tagged F0842, covering requirements for complete and accurate medical records. The level of harm was listed as minimal harm or potential for actual harm, and the number of residents affected was listed as few.
That characterization reflects the regulatory framework's assessment of what was documented, not a judgment that nothing could have gone wrong. A medical record with an uncorrected crisis-level blood pressure reading is a record that could lead a covering nurse, an on-call physician, or an emergency responder to make decisions based on information that the nurse who created it says was never true.
LVN 2 told the inspector she entered the reading mistakenly. She could not recall what Resident 1's actual blood pressure was on August 1. That detail, buried near the end of the inspector's notes, is the one that lingers. Three weeks after the fact, the nurse responsible for the entry could not say what the correct number should have been. The wrong number remained in the chart. The right one existed nowhere.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodland Care Center from 2025-08-22 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: November 4, 2026 · Our methodology
WOODLAND CARE CENTER in RESEDA, CA was cited for violations during a health inspection on August 22, 2025.
The inspection, completed August 22, 2025, stemmed from a complaint filed against the facility.
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.