Woodland Care Center

F-F657

2. Provide respiratory care (the health care discipline that specializes in the promotion of optimum cardiopulmonary function and health and wellness) consistent with standard precautions of practice to one out of three sampled residents (Residents 58) by failing to label Resident 58's oxygen tubing (a flexible, clear hose that delivers oxygen to a patient during oxygen therapy) with the date it was last changed and not obtaining a physician order for oxygen (a colorless, odorless, and tasteless gas, that supports life) administration.

These deficient practices placed Resident 58 at risk for developing respiratory infections and complications associated with oxygen therapy.

Findings:

a. During a review of Resident 6's Admission Record (face sheet), the Admission Record indicated that the facility originally admitted the resident on 3/31/2022 and readmitted on [DATE REDACTED] with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing) with acute (appear rapidly) exacerbation (worsening of a pre-existing condition or disease), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and acute and chronic (something that continues over an extended period of time) respiratory failure (a serious condition that makes it difficult to breathe on your own).

During a review of Resident 6's Minimum Data Set (MDS - a resident assessment tool) dated 1/30/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated that Resident 6 was dependent on staff (helper does all of the effort) for toileting hygiene, showering and bathing, lower body dressing, and putting on/talking off footwear.

The MDS further indicated that Resident 6 was receiving continuous oxygen therapy on admission and while

a resident in the facility.

During a review of Resident 6's Physician Order dated 1/27/2025, the order indicated to administer oxygen at two liters per minute via nasal cannula (NC-a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) continuously for shortness of breath (SOB) during every shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 During a review of Resident 6's Physician Order dated 4/1/2025, the order indicated that the administration of oxygen at two liters per minute via NC order was discontinued due to Resident 6`s hospitalization . Level of Harm - Minimal harm or potential for actual harm During a review of Resident 6`s Care Plan (a document outlining a detailed approach to care customized to

an individual resident's need) for risk for respiratory complications initiated on 12/6/2022 and last revised on Residents Affected - Few 2/10/2025, the care plan indicated a goal that the resident will have no sign and symptoms of respiratory distress (the condition where someone has difficulty breathing) for 90 days. The care plan interventions were to administer oxygen at two liters per minute continuously as ordered by the physician, change the oxygen tubing weekly on Mondays during day shift, and to keep the resident`s head of bed at 30 degrees.

During an observation on 4/7/2025 at 8:51 a.m., inside Resident 6`s room, Resident 6 was observed sitting

on her bed, not using oxygen while eating breakfast. Resident 6's oxygen tubing was connected to the left side of her bed rail and the oxygen machine was on, running at 3 liters per minute. Resident 6 stated that

she normally does not use oxygen when she eats.

During a concurrent interview and record review on 4/7/2025 at 9:00 a.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 6`s physician orders were reviewed. LVN 3 stated that there was no physician order for administration of oxygen to Resident 6. LVN 3 stated that the physician order to administer continuous oxygen at 2 liters per minute to Resident 6 was discontinued on 4/1/2025.

During a concurrent observation and interview on 4/7/2025 at 9:04 a.m., inside Resident 6`s room, the Director of Nursing (DON) and LVN 3 were observed at Resident 6`s bedside checking the resident`s oxygen saturation (a measurement of how much oxygen your blood is carrying compared to its maximum capacity-for healthy adults, normal oxygen saturation is between 95% and 100%). Resident 6`s oxygen saturation was 97 %. The DON then turned off the oxygen machine and removed the oxygen tubing from the resident`s bedside and stated that there was no physician order to administer oxygen to her. Resident 6 stated that she has been using oxygen since her readmission to the facility on [DATE REDACTED], and licensed nurses did not inform her that she no longer needs oxygen.

During a concurrent interview and record review on 4/7/2025 at 9:10 a.m., with the DON, Resident 6`s physician orders were reviewed. The DON confirmed that there was no physician order to administer oxygen to Resident 6. The DON stated that Resident 6`s physician order to administer oxygen at two liters per minutes via NC was discontinued on 4/1/2025. The DON stated a physician order is required for administering oxygen to residents. The DON stated the potential outcome of administering oxygen to a resident that has COPD without physician order is oxygen related complications and harm to the resident.

During a review of the facility's Policy and Procedure (P&P) titled Oxygen Administration, last reviewed on 1/16/2025, the P&P indicated the purpose of this guideline is to provide guidelines for safe oxygen administration. Verify that there is a physician`s order for this procedure. Review the physician`s order or facility protocol for oxygen administration.

47883

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 b. During a review of Resident 58's Admission Record, the Admission Record indicated that the facility admitted Resident 58 on 3/8/2025, with diagnoses including aftercare following surgical amputation of right Level of Harm - Minimal harm or second and third toes (the surgical removal of a body part), acute osteomyelitis (an infection in the bone), potential for actual harm and type two diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly). Residents Affected - Few

During a review of Resident 58's History and Physical (H&P) dated 3/11/2025, the H&P indicated that Resident 58 had the capacity to understand and make decisions.

During a review of Resident 58's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/11/2025, the MDS indicated that the resident had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 58 required moderate assistance for activities of daily living (ADL-activities related to personal care).

During a review of Resident 58's Care plan (a form where licensed nurses can summarize a person's health conditions, specific care needs, and current treatments), dated 3/8/2025, the care plan indicated that Resident 58 was at risk for respiratory complications related to asthma (a lungs condition here the airway get inflamed and narrow, making it difficult to breathe), obstructive sleep apnea (a sleep disorder where the airway collapses during sleep, leading to pauses in breathing [apnea]), and shortness of breath when lying flat. The care plan interventions indicated to provide continues oxygen at 2 liters/min (l/min- a unit of measurement of oxygen flow) as ordered via nasal canula as needed.

During a review of Resident 58's Change in Condition Evaluation (COC) dated 3/31/2025, the COC indicated that Resident 58 had a minor shortness of breath (SOB), and pulse oximeter (a dive that measures how much oxygen is in the blood) reading was at 94% on room air. Oxygen was given at two (2) l/ min via nasal canula (a small flexible tube with two prongs that fit inside the nostrils, used to deliver extra oxygen), and pulse oximeter reading was improved to 99%.

During an observation on 4/7/2025 at 9:06 a.m., Resident 58 was observed in his room in his bed, an oxygen tank (metal cylinder that store oxygen under pressure [compressed oxygen]) was observed next to the resident's bed with oxygen tubing and nasal canula around the oxygen tank with no label when it was last changed. Resident 58 stated that he received oxygen one time about two (2) weeks ago and since that time

the oxygen tank connected to the oxygen tubing has remained in his room.

During a concurrent observation and interview on 4/7/2025 at 9:07 a.m., in Resident 58's room with LVN 1, LVN 1 stated that the oxygen tubing with nasal canula was not labeled with the date when it was last changed.

During an interview on 4/9/2025 at 8:45 a.m., with the Infection Preventionist (IP), the IP stated that the oxygen tubing should be changed in the facility every week and as needed and labeled with the date it was last changed to prevent the resident from acquiring respiratory infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 During concurrent record review and an interview on 4/9/2025 at 2:21 p.m., with Director of Nursing (DON), reviewed Resident 58 physician orders, the DON stated that there was no physician order for oxygen Level of Harm - Minimal harm or administration found. The DON stated that if oxygen was administered to the resident for shortness of potential for actual harm breath, the physician should be notified and an order for oxygen administration should be obtained by the licensed nurse. The DON stated oxygen tubing should be labeled with the date it was last changed to Residents Affected - Few prevent the risk of respiratory infection in Resident 58.

During a review the facility Policy and Procedure named Oxygen Administration, last reviewed on 1/16/2025,

the document indicated: Verify that there is a physician's order for this procedure. Review the physician order or facility protocol for oxygen administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 43455

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure the Antibiotic or Controlled Drug Record (accountability record of medications that are considered to have a strong potential for abuse) coincided with the bubble pack (a medication packaging system that contains individual doses of medication per bubble) for three of three sampled residents (Residents 26, 62, and 111).

These deficient practices had the potential to result in medication error and/or drug diversion (illegal distribution or abuse of prescription drug).

Findings:

During a review of Resident 26's Admission Record, the Admission Record indicated the facility originally admitted the resident on 3/19/2023 and readmitted the resident on 2/27/2025 with diagnose of chronic (refers to a condition, illness, or disease that is long-lasting and persistent) pain.

During a review of Resident 26' s Medication Administration Record (MAR - a record of mediations administered to residents) for 4/2025, the MAR indicated Resident 26 was prescribed hydrocodone-acetaminophen (a controlled medication [medications which have a potential for abuse and may also lead to physical or psychological dependence] used to treat moderate to severe pain) 7.5-325 milligrams (mg- unit of measurement) every six (6) hours as needed for severe pain.

During a review of Resident 62's Admission Record, the Admission Record indicated the facility originally admitted the resident on 10/14/2024 and readmitted the resident on 1/23/2025 with a diagnosis including osteoarthritis (breakdown of cartilage and bones in the joints) of right hip and knee, and neuropathy (condition where the nerves are damaged.)

During a review of Resident 62' s MAR for 4/2025, the MAR indicated Resident 62 was prescribed pregabalin (a controlled medication used for pain) 150 mg three times a day for neuropathy at 9 a.m., 1 p.m., and 9 p.m. and hydrocodone-acetaminophen 5-325 mg every six (6) hours as needed for severe pain.

During a review of Resident 111's Admission Record, the Admission Record indicated the facility originally admitted the resident on 8/8/2024 and readmitted the resident on 10/3/2024 with a diagnosis including anxiety (intense, excessive, and persistent worry and fear about everyday situations).

During a review of Resident 111's MAR for 4/2025, the MAR indicated Resident 111 was prescribed lorazepam (a controlled medication used to treat anxiety) one (1) mg once a day for anxiety at 9 a.m.

During a concurrent observation, interview, and record review on 4/7/2025 at 12:06 p.m., with Licensed Vocational Nurse 5 (LVN 5), observed Medication Cart Station 1 Cart 1. There was a discrepancy in the count between the Antibiotic or Controlled Drug Record and the amount of medication remaining in the medication bubble pack (a medication packaging system that contains individual doses of medication per bubble) for the following residents:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 - One dose of hydrocodone-acetaminophen 7.5-325 mg tablet was missing from the medication bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record accountability log for Resident Level of Harm - Minimal harm or 26. Resident 26's Antibiotic or Controlled Drug Record accountability log indicated the medication bubble potential for actual harm pack should have contained a total of 29 hydrocodone-acetaminophen 7.5-325 mg tablets, after the last administration of hydrocodone-acetaminophen 7.5-325 mg documented/signed-off on 4/7/2025 at 3:10 a.m., Residents Affected - Some however Resident 26's medication bubble pack contained 28 hydrocodone-acetaminophen 7.5-325 mg tablets and contained no other documentation of subsequent administrations.

- One dose of pregabalin 150 mg capsule and one dose of hydrocodone-acetaminophen 5-325 mg tablet was missing from the medication bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record accountability logs for Resident 62. Resident 62's Antibiotic or Controlled Drug Record accountability log for pregabalin indicated the medication bubble pack should have contained a total of 30 pregabalin 150 mg capsules, after the last administration of pregabalin 150 mg documented/signed-off on 4/6/2025 at 9 p.m., however Resident 62's medication bubble pack contained 29 pregabalin 150 mg capsules and contained no other documentation of subsequent administrations. Resident 62's Antibiotic or Controlled Drug Record accountability logs for hydrocodone-acetaminophen indicated the medication bubble pack should have contained a total of seven (7) hydrocodone-acetaminophen 5-325 mg tablets, after the last administration of hydrocodone-acetaminophen 5-325 mg documented/signed-off on 4/6/2025 at 9:40 p.m., however Resident 62's medication bubble pack contained six (6) hydrocodone-acetaminophen 5-325 mg tablets and contained no other documentation of subsequent administrations.

- One dose of lorazepam one (1) mg tablet was missing from the medication bubble pack compared to the count indicated on the Antibiotic or Controlled Drug Record accountability log for Resident 111. Resident 111's Antibiotic or Controlled Drug Record accountability log for lorazepam indicated the medication bubble pack should have contained a total of 12 lorazepam one (1) mg tablet, after the last administration of lorazepam 1 mg documented/signed-off on 4/6/2025 at 9 a.m., however the medication bubble pack contained 11 lorazepam 1 mg tablet and contained no other documentation of subsequent administrations.

LVN 5 stated LVN 5 administered hydrocodone-acetaminophen 7.5-325 mg tablet to Resident 26, hydrocodone-acetaminophen 5-325 mg tablet and pregabalin 150 mg capsule to Resident 62, and lorazepam 1 mg tablet to Resident 111 earlier that day and forgot to sign off the Antibiotic or Controlled Drug

Record accountability log for each for Resident 26, Resident 62, and Resident 111. LVN 5 stated LVN 5 failed to follow the facility's policy of signing each controlled medication dose on the Antibiotic or Controlled Drug Record accountability log after preparing the doses for Resident 26, Resident 62, and Resident 111. LVN 5 stated LVN 5 understands it was important to sign each dose once administered to ensure accountability, prevention of controlled medication diversion, and accidental exposures of harmful substances to residents. LVN 5 stated if documentation was not accurate then it can lead to overdose (receiving more than the prescribed dose) harming Resident 26, Resident 62, and Resident 111, leading to respiratory depression (stoppage of breathing) and potential hospitalization .

During an interview on 4/7/2025 at 1:49 p.m., with the Director of Nursing (DON), the DON stated LVN 5 failed to follow the policy of documenting the preparation of controlled medications immediately on the accountability records for Resident 26, 62, and 111. The DON stated not documenting on the Antibiotic or Controlled Drug Record accountability log timely can lead to accountability failures, controlled medication diversion, inaccurate clinical records, and accidental use and overdose of harmful substances for residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 During a review of the facility's policy and procedure (P&P) titled, Controlled Medications, last reviewed 1/16/2025, the P&P indicated, Medications included in the Drug Enforcement Administration classification as Level of Harm - Minimal harm or controlled substances are subject to special handling, storage, disposal, and recordkeeping at the facility, in potential for actual harm accordance with federal and state laws and regulations.

Residents Affected - Some The DON and the Consultant Pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications.

When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR:

Date and time of administration

Amount administered

Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 43455 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that its medication error rate Residents Affected - Some was less than five (5) percent (%). Two (2) medication errors out of 27 total opportunities contributed to an overall medication error rate of 7.41% affecting two (2) of four (4) residents (Resident 8 and 55) observed for medication administration. The medication errors were as follows:

1. Resident 8 received lidocaine (a medication used to relieve pain) patch (a medication delivery system) applied to one (1) wrist instead of both, as ordered by Resident 8's physician.

2. Resident 55 did not receive Omega 3 (a medication used to support overall health and well-being, such as heart and kidney health, brain function, and reducing blood lipid [fat] levels) as ordered by Resident 55's physician.

These deficient practices had the potential to result in Resident 8's and 55's health and well-being to be negatively impacted.

Findings:

a. During a review of Resident 55's Admission Record, the Admission Record indicated the facility originally admitted the resident on 3/24/2025 with diagnoses including Parkinson's disease (brain disorder that causes unintended or uncontrollable movements), hypotension (low blood pressure [force of your blood against your arteries is abnormally low]) and chronic kidney disease (gradual loss of kidney function).

During a review of Resident 55's Order Summary Report, dated 4/7/2025, the Order Summary Report indicated Resident 55 was prescribed:

- Aspirin (a medication used to prevent blood from clotting) 81 milligrams (mg- unit of measurement) give one (1) tablet by mouth once a day for blood clot (gel-like clump of blood) prevention, starting 3/25/2025.

- Eliquis (a medication used for deep vein thrombosis [DVT - formation of one or more blood clots] prophylaxis [PPX - measures designed to preserve health]) 2.5 mg give one (1) tablet by mouth twice a day for DVT PPX, starting 3/26/2025.

- Fludrocortisone (a medication used for low blood pressure) 0.1 mg give two (2) tablets by mouth once a day for hypotension, starting 3/25/2025.

- Rivastigmine (a medication used for Parkinson's disease) 1.5 mg to give one (1) capsule by mouth twice a day for Parkinson's disease, starting 3/27/2025.

- Docusate (a medication used for softening the stool) 100 mg to give one (1) capsule by mouth twice a day for stool softener, starting 3/25/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 - Cholecalciferol (vitamin D) 25 micrograms (mcg- unit of measurement) one (1) tablet by mouth once a day for supplement, starting 3/25/2025. Level of Harm - Minimal harm or potential for actual harm - Multivitamin give one (1) tablet by mouth once a day for supplement, starting 3/25/2025.

Residents Affected - Some - Vitamin C 500 mg one (1) tablet by mouth twice a day for supplement, starting 3/25/2025.

- Omega 3 1000 mg to give one (1) capsule by mouth once a day for supplement, starting 3/25/2025.

During a review of Resident 55's Medication Administration Record (MAR - a record of mediations administered to residents) for 4/2025, the MAR indicated Resident 55 was prescribed Omega 3 1000 mg to give one (1) capsule by mouth once a day for supplement, to give at 9 a.m.

During an observation on 4/7/2025 at 9:02 a.m., with Licensed Vocational Nurse 5 (LVN 5), observed LVN 5 administer aspirin, Eliquis, fludrocortisone, rivastigmine, docusate, cholecalciferol, multivitamin, and vitamin C tablets orally, and did not administer Omega 3 to Resident 55. Resident 55 was observed swallowing the aspirin, Eliquis, fludrocortisone, rivastigmine, docusate, cholecalciferol, multivitamin, and vitamin C tablets with a full glass of water.

During an interview on 4/7/2025 at 11:20 p.m., with LVN 5, LVN 5 stated LVN 5 administered aspirin, Eliquis, fludrocortisone, rivastigmine, docusate, cholecalciferol, multivitamin and vitamin C to Resident 55, and failed to prepare and administer Omega 3 to Resident 55 as prescribed by the physician, during the morning medication administration at 9:02 a.m. LVN 5 stated not administering Omega 3 was not beneficial for Resident 55 and can harm Resident 55 by not maintaining a healthy heart, kidney, brain and blood lipid levels. LVN 5 stated that LVN 5 failed to follow the five (5) rights (right patient, right medication, right time, right dose, right route) of medication administration, and this was considered a medication error. LVN 5 stated that LVN 5 will notify the supervisor.

During an interview on 4/7/2025 at 1:49 p.m., with the Director of Nursing (DON), the DON stated LVN 5 failed to follow the five (5) rights of medication administration and the facility medication administration guidelines to ensure physician orders were followed as prescribed and the right medications were administered to Resident 55. The DON stated that LVN 5 overlooked to administer Omega 3 to Resident 55.

The DON stated this was considered a medication error. The DON stated not administering the correct medications can lead to harm by causing more adverse effects (unpleasant symptom or event) to Resident 55 and does not treat their conditions.

b. During a review of Resident 8's Admission Record, the Admission Record indicated the facility originally admitted the resident on 7/26/2018 and readmitted the resident on 4/21/2024 with diagnoses including chronic kidney disease, anxiety (intense, excessive, and persistent worry and fear about everyday situations), depression (mood disorder that causes a persistent feeling of sadness and loss of interest), hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]), and arthritis (a diseases that causes pain in the joints).

During a review of Resident 8's Order Summary dated 4/7/2025, the Order Summary indicated Resident 8 was prescribed lidocaine (a medication used to relieve pain) 5% one (1) patch to be applied transdermal (medication delivered through the skin) once a day to bilateral (both) hands/wrist for neuropathy (nerve pain), starting 4/30/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 During an observation on 4/7/2025 at 9:59 a.m., observed LVN 4 applying lidocaine 5 % patch to Resident 8's left wrist. Level of Harm - Minimal harm or potential for actual harm During an interview on 4/7/2025 at 11:15 a.m., with LVN 4, LVN 4 stated during the medication administration on 4/7/2025 at 9:59 a.m., LVN 4 applied the lidocaine 5% patch to Resident 8's left wrist. LVN Residents Affected - Some 4 acknowledged the physician's order specified to administer lidocaine 5% patch bilaterally to both wrists. LVN 4 stated that LVN 4 failed to follow the five (5) rights of medication administration, and this was considered a medication error.

During an interview on 4/7/2025 at 1:49 p.m., with the DON, the DON stated LVN 4 failed to follow the five (5) rights of medication administration and the facility medication administration guidelines to ensure physician orders were followed as prescribed and the right medications were administered to Resident 8.

The DON stated that LVN 4 did not administer lidocaine patch to both wrists to Resident 8. The DON stated

this was considered a medication error. The DON stated not administering the correct medications can lead to harm by causing more adverse effects to Resident 8 and does not treat their conditions.

During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed 1/16/2025, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed.

Medications must be administered in accordance with prescriber orders.

The individual administering the medication checks to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

During a review of the facility's P&P titled, Medication Errors, last reviewed 1/16/2025, the P&P indicated,

The Facility will work to keep medication error rates five (5) % or lower. Medication Error means the administration of medication: at the wrong dose; which is not currently prescribed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 49947 potential for actual harm Based on interview and record review the facility failed to ensure residents were free of any significant Residents Affected - Some medication errors by failing to:

1. Rotate (a method to ensure repeated injections are not administered in the same area) the insulin (a medication that regulates sugar in the blood) injections sites to three out three sampled residents (Residents 38, Resident 116, and Resident 38) reviewed under the insulin care area.

This failure had the potential to result in bruising, pain, and/or lipodystrophy (lump or accumulation of fatty tissue under skin) to Resident 38, Resident 116 and Resident 38.

Cross reference to

F-F658.

2. Follow the hold parameters for midodrine (a medication to elevate blood pressure for those with low blood pressure) as ordered by the physician for one of six residents (Resident 12) reviewed for unnecessary medications.

This deficient practice had the potential to cause complications such as high blood pressure that could require hospitalization to Resident 12.

Findings:

1.a. During a review of Resident 27's Admission Record, the Admission Record indicated the facility admitted Resident 27 on 12/12/2024 with diagnoses that included, but not limited to type 2 diabetes mellitus (DM - a disease that occurs when the glucose, also called blood sugar, is too high), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), end stage renal disease (the final, permanent stage of chronic kidney [organ that filters blood] disease, where kidney function has declined to the point that the kidneys can no longer function on their own), dependence on renal dialysis (treatment that filters the blood when the kidneys cannot), and a history of falling.

During a review of Resident 27's History and Physical (H&P), dated 12/13/2024, the H&P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 27's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/14/2025, indicated Resident 27 had the capacity to make herself understood and understand others, needed partial assistance from staff for activities such as toileting, dressing, and personal hygiene, and was on a high-risk drug class medication hypoglycemic (a group of drugs used to help reduce the amount of sugar present in the blood).

During a review of Resident 27's Order Summary Report, printed on 4/4/2025, the Order Summary Report indicated an order for:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 -1/8/2025 - 3/27/2025 (increased) Insulin Glargine (Lantus) subcutaneous (SQ - in the fatty layer of the skin) Solution 100 units per milliliters (unit/ml, a unit of fluid volume) inject 16 units SQ at bedtime. Rotate injection Level of Harm - Minimal harm or site. potential for actual harm

During a review of Resident 27's Medication Administration Record (MAR) dated 3/1/2025-3/31/2025, the Residents Affected - Some MAR indicated Insulin Glargine was administered on the following dates and location:

Insulin Glargine SQ 100 unit/ml subcutaneous solution:

3/1/2025 - arm - left

3/2/2025 - arm - left

3/8/2025 - abdomen - right lower quadrant (RLQ)

3/9/2025 - abdomen - right lower quadrant (RLQ)

3/10/2025 - arm - left

During a review of Resident 27's DM Care Plan (CP), the CP indicated an intervention of medication as ordered.

During a concurrent interview and record review on 4/9/2025 at 11:27 am with Registered Nurse 1 (RN 1), reviewed medication administration record of Resident 27 with RN 1. RN 1 stated there were multiple instances where the injection sites of insulin were not rotated in 3/2025. RN 1 stated the sites of insulin administration should be rotated to prevent damage to the skin tissues of the resident. RN 1 also stated the failure to follow the physician's order to rotate the insulin administration site were medication errors.

44309

b. During a review of Resident 116's Admission Record (face sheet), the Admission Record indicated the facility originally admitted the resident on 4/3/2024, and readmitted on [DATE REDACTED], with diagnoses including type two diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed).

During a review of Resident 116's Minimum Data Set (MDS - a resident assessment tool) dated 2/21/2025,

the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was intact (decisions consistent/reasonable). The MDS indicated that Resident 116 required staff partial/moderate assistance (helper does less than half the effort) for showering/bathing, lower body dressing, and putting on/taking off footwear. The MDS further indicated that Resident 116 was taking hypoglycemic (a group of drugs used to help reduce the amount of sugar present in the blood) medication which was considered a high-risk drug class medication (a group of medications that pose a significantly elevated risk of causing harm to patients if used incorrectly or if errors occur during administration).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During a review of Resident 116`s care plan (a document outlining a detailed approach to care customized to

an individual resident's need) for DM initiated on 4/16/2024, the care plan indicated a goal that the resident Level of Harm - Minimal harm or will be free from sign and symptoms of hypoglycemia (when the blood sugar level is lower than normal), and potential for actual harm hyperglycemia (when the blood sugar level is higher than normal) for the next three months. The care plan interventions were to check the blood sugar and administer medications as ordered by the physician, monitor Residents Affected - Some effectiveness of the medications and inform the physician if ineffective.

During a review of Resident 116's physician Order Summary Report (physician orders) dated 2/13/2025, the Order Summary Report indicated to administer insulin Glargine solution (a long-acting insulin injected once daily that provides a consistent, steady level of insulin throughout the day) via pen injector, 100 units per milliliters (unit/ml, a unit of fluid volume), inject 26 units subcutaneous (SQ- injecting in the fatty layer of the skin) at bedtime for DM. The Order Summary Report further indicated to rotate the insulin injection sites.

During a review of Resident 116's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from 3/1/2025-3/31/2025, the MAR indicated that Resident 116 received insulin Glargine SQ as follows:

3/6/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ-the lower left section of the abdomen, below the belly button)

3/7/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ)

3/13/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ)

3/14/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ)

3/15/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ)

3/16/2025 at 9:00 p.m. - abdomen - left lower quadrant (LLQ)

During a concurrent interview and record review on 4/10/2025 at 11:27 a.m., with MDS Coordinator 1 (MDSC 1), Resident 116`s physician orders and MAR for March 2025 were reviewed. MDSC 1 stated that Resident 116`s physician ordered to rotate insulin Glargine SQ injection sites. However licensed staff did not rotate the injection sites on 3/6/2025, 3/7/2025, and from 3/13/2025 through 3/16/2025. MDSC 1 stated the sites of insulin administration should be rotated to prevent damage to the resident`s skin tissues.

During a concurrent interview and record review on 4/11/2025 at 10:30 a.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 116`s physician orders and MAR for March 2025 were reviewed. LVN 1 stated based on

the documentation in Resident 116`s MAR for March 2025, the resident received insulin Glargine in the LLQ of her abdomen on 3/6/2025, 3/7/2025, and from 3/13/2025 through 3/16/2025. LVN1 stated licensed staff are required to rotate resident`s insulin injection sites every time that they administer insulin, to prevent from skin tissue damage. LVN 1 stated the potential outcome of not rotating insulin injection sites is the development of bruise and hardened areas under the resident`s skin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During an interview on 4/11/2025 at 3:25 p.m., with the Director of Nursing (DON), the DON stated that licensed staff should rotate residents` insulin injection sites each time they (licensed nurses) administer Level of Harm - Minimal harm or insulin. The DON stated licensed nurses did not rotate Resident 116`s insulin Glargine injection sites on potential for actual harm 3/6/2025, 3/7/2025, and from 3/13/2025 through 3/16/2025. The DON stated the potential outcome of not rotating insulin injection sites is the development of bruise and hardened areas under resident`s skin that can Residents Affected - Some reduce insulin absorption. The DON stated not following the physician's order to rotate the insulin administration site is considered a medication administration error.

47883

c. During a review of Resident 38's Admission Record, the Admission Record indicated that the facility initially admitted Resident 38 on 9/30/2015 and readmitted the resident on 2/19/2022 with diagnoses including acute kidney failure (a condition in which the kidneys are damaged and cannot filter blood well), diabetes type 2 (a long-term medical condition in which the body does not use insulin [a hormone that lowers

the level of sugar in the blood] properly), and atherosclerotic heart disease (a condonation where plaque [a buildup of fat or cholesterol] forms inside the arteries that supply blood to the heart, making it hard for blood to flow to the heart muscle).

During a review of Resident 38's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 2/6/2025, the MDS indicated that the resident had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 38 required setup assistance for eating, moderate-to -maximal assistance with bed mobility, upper body dressing and personal hygiene and was totally dependent on two or more helpers for toileting hygiene, shower and bed- to-chair transfer.

During a review of Resident 38's Order Summary Report, printed on 4/8/2025, the Order Summary report indicated the following orders:

-10/29/2024 Insulin Glargine subcutaneous (SQ - in the fatty layer of the skin) Solution 100 units per milliliters (unit/ml, a unit of fluid volume) inject 35 units SQ at bedtime for diabetes mellites (medical condition

in which the body does not use insulin properly), rotate sites.

-10/29/2024 Humulin R injection Solution 100 units per milliliter (unit/ml, a unit of fluid volume) inject as per sliding scale:

70-150=none, notify MD for Fasting Blood Sugar (FBS) less than 70

151-200=2 units

201-250=4 units

251-300=6 units

301-350=8 units

351-400=10 units

401+= 12 units FSBS more than 400, subcutaneously before meals and at bedtime, rotate sites.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During a review of Resident 38's Medication Administration Record (MAR) dated 3/1/2025-3/31/2025, the MAR indicated Insulin Glargine was administered on the following dates, times, and location: Level of Harm - Minimal harm or potential for actual harm Insulin Glargine SQ 100 unit/ml subcutaneous solution and Humulin R injection Solution 100init/ml:

Residents Affected - Some 3/21/2025 at 5:36 pm-abdomen - left upper quadrant (LUQ)

3/22/2025 at 11:56 am-abdomen - left upper quadrant (LUQ)

3/23/2025 at 1:16- pm-abdomen - left upper quadrant (LUQ)

3/23/2025 at 9:39 pm-abdomen - left upper quadrant (LUQ)

During a review of Resident 38's 4/2025 Medication Administration Record (MAR), the MAR indicated Insulin Glargine was administered on the following dates, times, and location:

Insulin Glargine SQ 100 unit/ml subcutaneous solution and Humulin R injection Solution 100 unit/ml:

4/4/2025 at 9:00 pm- abdomen - left upper quadrant (LUQ)

4/5/2025 at 11:30 am- abdomen - left upper quadrant (LUQ)

4/5/2025 at 9:00 pm- abdomen - left upper quadrant (LUQ)

4/6/2025 at 11:30 am- abdomen - left upper quadrant (LUQ)

4/6/2025 at 9:00 pm - abdomen - left upper quadrant (LUQ)

4/7/2025 at 9:00 pm- abdomen - left upper quadrant (LUQ)

During a concurrent interview and record review on 4/10/25 at 1:30 p.m. with the Assistant Director of Nursing (ADON), reviewed Resident 38's MAR. The ADON stated there were multiple instances when the insulin injection sites were not rotated in 3/2025 and 4/2025. The ADON stated the sites of insulin administration should be rotated to prevent damage to the skin tissues of the resident. The ADON also stated the failure to follow the physician's order to rotate the insulin administration site constitutes a medication error.

2. During a review of Resident 12's Admission Record, the Admission Record indicated the facility admitted Resident 12 on 12/18/2024 with diagnoses including nontraumatic subacute subdural hemorrhage (a bleed between the brain and dura[ the brain outer covering]that occurs without a head injury), paroxysmal atrial fibrillation (a heart condition that causes an irregular and often abnormally fast heart rate), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities).

During a review of Resident 12's Minimum Data Set (MDS - a resident assessment tool), dated 12/25/2024,

the MDS indicated the resident had moderately impaired cognition (thought processes) and required moderate- to -maximal assistance from staff for most activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During a review of Resident 12's Physician's Orders, the Physician's Orders indicated an order dated 01/21/2025 for midodrine oral tablet 5 milligrams (mg- metric unit of measurement, used for medication Level of Harm - Minimal harm or dosage and/or amount) give one tablet by mouth three times a day for hypotension, hold if systolic blood potential for actual harm pressure (SBP - the pressure in the arteries when the heart contracts and pumps blood throughout the body, normal reference range is less than or equal to 120 millimeters of mercury [mm Hg]) is greater than120 mm Residents Affected - Some Hg.

During a review of Resident 83's 4/2025 MAR, covering the dates 4/1/2025 through 4/8/2025, the MAR indicated Resident 12 was given midodrine when the SBP was greater than 120 mm Hg (BP of 126/76 mm Hg) on 4/1/2025 at 2 pm.

During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 4/11/2025 at 5:06 p.m., reviewed Resident 12's 4/2025 MAR. The ADON confirmed that the licensed nurse signed in

the MAR that midodrine was given to Resident 12 on 4/1/2025 2 pm, when Resident 12's blood pressure was 126/76 mm Hg.

During an interview with the Director of Nursing (DON) on 4/11/2025 at 1:15 p.m., the DON stated midodrine should not have been given on 4/1/2025 at 2 pm, when Resident 12's blood pressure was 126/76 mm Hg because Resident 12 could be at risk for elevated blood pressure resulting in health complications. The DON stated not following the doctor's order is considered a medication administration error.

During a review of the facility's recent policy and procedure (P&P) titled, Insulin Administration, last reviewed

on 1/16/2025, the P&P indicated the injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).

During a review of the facility provided FDA Label for Lantus, undated, it indicated to rotate injection sites to reduce the risk of lipodystrophy.

During a review of information for the physician Humulin Regular dated 2011, it indicated that the injection site should be rotated within the same region.

During a review of Highlights of prescribing medication Insulin Glargine injection, dated11/2018, it indicated: Change (rotate) injection sites within the area you chose with each dose. Do not use the exact spot for each injection.

During a review of the facility's recent policy and procedure titled, Administrating Medication, last reviewed

on 1/16/2025, the policy indicated Medications are administering in accordance with prescriber orders.

During a review of the facility's P&P titled, Medication Errors, last reviewed on 1/16/2025, the P&P indicated all errors related to the administration of medications or treatments will be reported to the Director of Nursing Services, the attending physician and the Administrator immediately. The P&P further states medication error includes the administration of medication via the wrong route.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43455 Residents Affected - Few Based on observation, interview, and record review, the facility failed to label and store one (1) opened budesonide (a medication used to treat and prevent shortness of breath) inhalation solution foil pouch (package made of foil protecting the inhalation solution from light and degradation) for one of one sampled resident (Resident 6) in accordance with the facility's policy and manufacturer's requirements in one of two inspected medication carts (Medication Cart Station 1 Cart 1).

This deficient practice increased the risk that Residents 6 could have received medication that had become ineffective or toxic due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death.

Findings:

During a concurrent observation and interview on [DATE REDACTED] at 12:06 p.m., with Licensed Vocational Nurse 5 (LVN 5), observed Medication Cart Station 1 Cart 1.

Observed one (1) open budesonide inhalation solution foil pouch for Resident 6 not labeled with a date indicating when the inhalation solutions were removed from the foil (aluminum) pouch (envelope). Five (5) inhalation solutions were observed stored outside the foil pouch. LVN 5 stated Resident 6's budesonide inhalation solution foil pouch stored in the Medication Cart Station 1 Cart 1 was not labeled with a date indicating when the foil pouch was opened, and five (5) inhalations were stored outside the foil pouch. LVN 5 stated per the facility policy, multi-dose (containing more than one dose) products such as inhalation solutions should be labeled with the date when it was first opened to know when they expire. LVN 5 stated according to the manufacturer's guidelines, the inhalation solutions needed to remain in the foil pouch, or when stored outside the pouch discarded within two (2) weeks. LVN 5 stated it was unknown when the five (5) budesonide inhalation solutions would expire and if used beyond the two (2) weeks, were considered expired and lost potency (effectiveness), potentially leading to the administration of ineffective medication to Resident 6 potentially causing harm by not treating the shortness of breath and chronic obstructive pulmonary disease (COPD- progressive lung disease) leading to difficulty in breathing, requiring immediate treatment and potential hospitalization . LVN 5 stated the five (5) budesonide inhalation solutions for Resident 6 should be discarded from Medication Cart Station 1 Cart 1.

During an interview on [DATE REDACTED] at 1:49 p.m., with the Director of Nursing (DON), the DON stated that breathing inhalation solutions stored in foil pouches should be labeled with a date when removed from the pouch to know when the beyond use date is (a date identifying an expiration date after opening a multi-dose product), otherwise unable to determine the expiration date. The DON stated once stored out of the pouch,

the inhalation solutions expire in two (2) weeks. The DON stated that expired inhalation treatments have lost effectiveness and when administered in error will not treat the shortness of breath or COPD further causing respiratory distress and stoppage of breathing for Resident 6 requiring immediate treatment and hospitalization .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed [DATE REDACTED], the P&P indicated, The expiration/beyond use date on the medication label is labeled prior to Level of Harm - Minimal harm or administering. When opening a multi-dose container, the date opened is recorded on the container. potential for actual harm

During a review of the manufacturer's guide titled, Highlights of Prescribing Information, for budesonide Residents Affected - Few inhalation dated ,d+[DATE REDACTED], the guide indicated, Budesonide inhalation suspension should be stored upright at controlled room temperature 68 to 77 degrees Fahrenheit and protected from light. When an envelope has been opened, the shelf life of the unused ampules is 2 weeks when protected. After opening the aluminum foil envelope, the unused ampules should be returned to the aluminum foil envelope to protect them from light. Any opened ampule must be used promptly.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47441

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when:

1. Two (2) of 2 staff served cream of wheat to a resident (Resident 71), who was allergic to gluten.

2. There was no training provided to staff regarding gluten free diet.

These failures resulted in Resident 71 being served cream of wheat which had the potential to result in a life-threatening condition such as anaphylactic shock (severe allergic reaction including closure of airways), severe tachycardia (increased heart rate), cardiac arrest (sudden loss of heart function, breathing, and consciousness [the state of being awake and aware of one's surroundings]), diarrhea, dehydration and/or death for Resident 71.

Cross reference

F-F806

Findings:

During a review of Resident 71's Admission Record, the Admission Record indicated the facility initially admitted Resident 71 on 8/18/2022 and readmitted on [DATE REDACTED], with diagnoses that included cachexia (a condition marked by a loss of more than 10% of body weight, including loss of muscle mass and fat, in a person who is not trying to lose weight), intestinal malabsorption (a disorder that prevents your body from effectively absorbing nutrients from your food), and non-celiac gluten sensitivity (when the digestive system cannot tolerate any form of the protein gluten).

During a review of Resident 71's Minimum Data Sheet (MDS - a federally mandated resident assessment tool) dated 2/25/2025, the MDS indicated Resident 71's understood others and made self-understood. The MDS indicated the resident required set-up or clean up assistance when eating.

During a review of Resident 71's Physician Orders dated 11/4/2024, the Physician Orders indicated to provide gluten free (a diet that excludes foods that contain gluten found in wheat, and other several grains), no lactose (a diet that excludes food that contain lactose [a sugar that is a normal part of milk products), regular texture and thin consistency diet.

During a review of Resident 71's order summary report dated 4/8/2025, the order summary report indicated Resident 71's allergies included lactose and gluten.

During a review of Resident 71's Allergy List dated 5/2/2024, the Allergy List indicated Resident 71 was allergic to lactose and gluten.

During a review of the facility's daily spreadsheet (a list of food items and amount included in each diet) titled Cycle 2 2025 Spring, dated 4/8/2025, the daily spreadsheet indicated residents on gluten restricted diet would include the following foods in the tray for breakfast:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 o Juice four (4) ounces (oz, a unit of measurement)

Level of Harm - Minimal harm or o Hot or cold cereal one (1) serving gluten free (GF) potential for actual harm o Scrambled eggs with onions and peppers 1/3 cup ([c], household measurement) Residents Affected - Some o Gluten free toast 1 piece (pc)

o Jelly 1 pc

o Low fat milk 8 fluid oz

o Coffee 8 fluid oz

o Margarine 1 each

During an interview on 4/8/2025 at 7:37 a.m. with the Dietary District Manager 1 (DDM 1) in the trayline (an area where residents food was assembled), DM 1 stated there were two (2) hot cereals prepared by the cook today and it was oatmeal and cream of wheat.

During a review of Resident 71's meal tray ticket on 4/8/2025 at 8:10 a.m., Resident 71's meal ticket indicated Resident 71 was on gluten restricted diet, was allergic to gluten and lactose, liked no salt on the tray and lactose intolerance and small portion entree.

During a concurrent observation and interview, on 4/8/2025 at 8:17 a.m., Resident 71 had the breakfast tray

on the bedside table. The tray contained a bowl of hot creamy cereal with a smooth texture. Resident 71 stated the hot cereal on his tray looked like oatmeal or cream of wheat and he would not eat it. Resident 71 stated he was allergic to gluten and lactose and could not eat cream of wheat or oatmeal because it caused him to have loose bowel movements and lots of gas. Resident 71 stated he has been given oatmeal and regular bread, despite having informed the nursing staff about his allergies. Resident 71 stated he had requested that someone from the kitchen came to talk to him, but nobody came.

During an interview on 4/8/2025 at 8:26 a.m. with [NAME] 1 and Registered Dietitian (RD), [NAME] 1 stated

she only prepared oatmeal and cream of wheat for breakfast. [NAME] 1 stated the hot cereal bowl on Resident 71's tray was cream of wheat. The RD stated they could not serve cream of wheat to Resident 71.

During an interview on 4/8/2025 at 8:35 a.m. with the Dietary Supervisor (DS), the DS stated the cereal in

the bowl of Resident 71 was cream of rice as she told [NAME] 1 to prepare cream of rice for Resident 71.

The DS stated she saw [NAME] 1 prepare cream of rice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 During an interview with the RD, on 4/8/2025 at 8:28 a.m., the RD stated cream of wheat had gluten and the software (programs used to operate computers and execute specific tasks) the facility use for their menus Level of Harm - Minimal harm or should have adjusted Resident 71's meal ticket to indicate cream of rice was the choice instead of oatmeal potential for actual harm or cream of wheat but it did not. The RD stated Resident 71 had a gluten allergy diagnosis and should not receive cream of wheat or oatmeal because of his possible allergic reaction such as having diarrhea, loose Residents Affected - Some bowel movement, shortness of breath, and swallowing problems. The RD stated she needed to find out the reason Resident 71's meal ticket did not indicate No Wheat.

During an interview on 4/8/2025 at 8:44 a.m. with the RD, the RD stated the cream of rice was out of stock.

During an interview with [NAME] 1, on 4/8/2025 at 8:40 a.m., [NAME] 1 stated she only cooked oatmeal and cream of wheat for breakfast and did not cook cream of rice because it was not available in stock in the facility.

During a concurrent observation inside the dry storeroom (a designated area used for storing food that do not require temperature control or refrigeration) and interview with Dietary Aide 1 (DA 1), on 4/8/2025 at 10:22 a.m., there was cream of rice available in the facility. DA 1 stated the last time he placed an order for cream of rice was in 3/2025.

During an interview with DA 2, on 4/8/2025 at 10:31 a.m., DA 2 stated she was responsible for checking the accuracy of the tray for breakfast by making sure the food on the tray matched the food listed on the meal ticket. DA 2 stated she checked for allergies, likes, dislikes and other special request of each resident in the tray line. DA 2 stated she also checked for gluten-free diet to provide gluten-free bread and other foods that were safe to give to residents with gluten free diet. DA 2 stated Resident 71 had water, orange juice, lactose free milk, and cream of wheat in his tray that morning. DA 2 stated a previous DS told her cream of wheat was okay to give to residents with gluten-free diet. DA 2 stated they served cream of wheat to residents on gluten free diet every day.

During an interview with the DS, on 4/8/2025 at 10:47 a.m., the DS stated there were three staff assigned on

the tray line. The first was the starter, responsible for setting up the trays and tray tickets. The second staff placed the drinks, desserts, salads, and breakfast cereals. The third staff was the caller, whose role involved calling residents' diet texture, allergens, diets and any missing items on the tray, as well as ensuring the accuracy of each tray. The DS stated she expected DA 1 to remove cream of wheat from trays for residents with allergies to gluten. The DS stated no training on gluten free diets had been provided to the kitchen staff since she assumed the position in 3/ 2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 During a review of the facility's policies and procedures (P&P) titled Food Allergies and Intolerances, dated 1/16/2025, the P&P indicated Residents with food allergies and/or intolerances are identified upon admission Level of Harm - Minimal harm or and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident potential for actual harm exposure to the allergen(s). Policy and Interpretation: (1) Food allergies are immune system responses to allergens (foods). [NAME] antibodies (a type of protein in the body called antibody) to foods attach to mast Residents Affected - Some cells (immune cells) in the body tissue (e.g. skin, nose, throat, lungs and gastrointestinal tract) and basophils

in blood. When allergens are eaten, the [NAME] antibodies attach to mast cells and basophils in certain sites and those cells produce histamine, an inflammatory compound. (2) Food intolerances are unpleasant reactions to specific foods that are not life threatening ut can necessitate avoidance of the triggering foods. Assessment and interventions:

oResident are assessed for a history of food allergies and intolerances upon admission and as part of the comprehensive assessment.

oAll resident reported food allergies and intolerances are documented in the assessment notes and incorporated into the resident's care plan.

oMeals for resident with severe food allergies are specially prepared so that cross-contamination with allergens does not occur.

oResidents with food intolerances and allergies are offered appropriate substitutions or food that they cannot eat.

During a review of the facility's P&P titled Diet Manual dated 1/16/2025, the P&P indicated, the diet manual has been developed to provide explanation of the diets used in the development of the menu program. The diets have been developed using current scientific research, information from best practices, and recommendations from Position Papers of Professional Associations. The menu is developed to meet the Recommended Daily Allowances (RDAs) of the National Academies for persons 51 and over. Diet should be adjusted to meet the needs and preferences of the individual resident. The diet manual is intended as a guide for the physician or other qualified healthcare professional to use in prescribing modified diets and for

the healthcare personnel in following the diet orders.

During a review of the facility's diet manual titled Gluten Restricted Diet dated 2/2025, the diet manual indicated Intended Use: This diet is used in the treatment of gluten-induced enteropathy (non-tropical sprue, celiac disease). The diet aims to eliminate symptoms, such as flatulence, diarrhea, steatorrhea, weight loss, indigestion and bloating, caused by sensitivity to gluten and gluten-containing products. The tropical sprue is not responsive to a gluten restricted diet. Adequacy: The Gluten restricted diet eliminates all foods containing wheat, rye, and barley. Grains not allowed on a gluten restricted diet: wheat, einkorn, [NAME], wheat starch, wheat bran, wheat germ, cracked wheat, barley, rye, graham flour, plain flour, white flour. Gluten free foods are made from the recommended grains listed above. There are many gluten-free substitutions to wheat-containing foods. You must read labels, as many products contain wheat ingredients where it is not obvious.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0802 During a review of the facility's P&P titled Tray Identification dated 1/16/2025, the P&P indicated, The Food service manager or supervisor will check trays for correct diets before the food carts are transported to their Level of Harm - Minimal harm or designated areas. Nursing staff shall check each food tray for the correct diet before serving the residents. If potential for actual harm there is an error, the nurse supervisor will notify the dietary department immediately by phone so that the appropriate food tray can be served. Residents Affected - Some

During a review of the facility's P&P titled Resident Food Preferences dated 1/16/2025, the P&P indicated,

The dietary manager will complete a dietary profile for residents to reflect current food preferences and nutritional needs upon admission, readmission, quarterly, annually or as needed. The dietary manager will complete the dietary profile for residents to capture and update the information regarding nutritional needs and food preferences (b) allergies.

During a review of the facility's job description (JD), titled [NAME] dated and signed on 10/25/2019 by [NAME] 1, the JD indicated The [NAME] prepares and serves food including texture modified and therapeutic diets according to the facility menu. Prepares food in accordance with current applicable federal, state, and local standards, guidelines and regulations, in line with our established policies and procedures, and, as may be directed by the Dining Services Director or Chef, to ensure that quality dining services are provided at all times. Job function:

Prepares food for meals, including modified textures for restricted and therapeutic diets.

Prepares food by methods that conserve nutritive value and flavor. Ensures food are palatable, nutritive and

in the proper form to meet the individual needs of the resident.

Review tray card to assure that current food information is consistent with food served.

Maintain knowledge of current nutritional practice regarding therapeutic diets.

During a review of the facility's competency checklist titled Dining Services Competency Evaluation dated 1/9/2024 signed by [NAME] 1 and an evaluator, the competency checklist indicated [NAME] 1 was competent on regular and therapeutic diet preparation but did not specify gluten free diet knowledge verification.

During a review of the facility's competency checklist titled Competency Evaluation- Aide dated and signed

on 1/14/2024 by DA 2 and DS, the competency checklist indicated, DA 2 was competent on accurately checking meal tray and assembly per tray card but did not specify DA 2 was competent in checking gluten free diet meal tray.

During a review of the facility's in-service lesson plan and sign in sheets titled Resident Allergies, Intolerances, Preferences, Substitutes and In-service Completion Sign Sheet dated 5/1/2024 and 5/3/2024 respectively, the documents indicated staff were provided in-service on food allergies and food preferences topics. The lesson plan did not indicate gluten free diet in-service was provided to the staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34659

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure facility kitchen staff or licensed nurses checked the contents of a meal tray against the meal tray ticket (form that indicates the specific meal being served to a resident based on their dietary restriction and preference) during breakfast

on 4/7/2025 for one of 142 residents (Resident 18) served meals from the kitchen.

This deficient practice had the potential to place residents at risk for anaphylactic reaction (a severe, life-threatening allergic reaction that can develop rapidly) which could then lead to hospitalization and death.

Findings:

During a review of Resident 18's Admission Record, the Admission Record indicated the facility admitted the resident on 3/19/2025 with diagnoses that included paraplegia (loss of movement and/or sensation, to some degree, of the legs).

During a review of Resident 18's Minimum Data Set (MDS, a resident assessment tool) dated 3/22/2025, the MDS indicated Resident 18 was moderately impaired in cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making.

The MDS indicated Resident 18 needed setup or clean-up assistance (helper sets up or cleans up; resident completes activity) with eating.

During a review of Resident 18's physician orders, the physician orders indicated Resident 18 had an order for a regular diet, with regular texture, thin consistency, dated 3/19/2025.

During a review of Resident 18's Care Plan for Nutritional Risk, initiated 3/22/2025, the care plan indicated a note, dated 4/1/2025, that Resident 18 stated they are not allergic to apple juice.

During a review of Resident 18's Allergy Report (a report indicating medications and food a resident is allergic to), the Allergy Report indicated an allergy to apple juice that was struck out (a line through the entry indicating it was an allergy but had been removed as an allergy).

During a review of Resident 18's Nutritional Assessment, dated 4/1/2025, the Nutritional Assessment indicated a note to discontinue apple juice in the allergies, per resident, they are not allergic to apple juice.

During a concurrent observation, interview, and record review on 4/7/2025 at 9:15 a.m., with Resident 18, reviewed Resident 18's Meal Tray Ticket which indicated Resident 18 was allergic to apple juice, but also indicated apple juice was a beverage preference. Observed apple juice on Resident 18's tray which was 3/4 cup full. Resident 18 confirmed by stating the juice was apple juice. Resident 18 stated they did not have an allergy to apple juice.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 During a concurrent interview and record review on 4/10/2025 at 8:29 a.m., with Dietary Aide 1 (DA 1), reviewed Resident 18's Meal Tray Ticket from 4/7/2025. DA 1 stated DA 1 checks the Meal Tray Ticket with Level of Harm - Minimal harm or what is on the tray to make sure there is nothing on the tray that should not be there. DA 1 stated he did not potential for actual harm review the tray on 4/7/2025 for breakfast but if he did, DA 1 would ask their supervisor if Resident 18 had an allergy to apple juice and would remove from the tray if an allergy existed. DA 1 stated this was important Residents Affected - Few because if a resident has an allergy, it could be bad for a resident if they had worse symptoms such as a rash or constricted throat.

During a concurrent interview and record review on 4/10/2025 at 10:04 a.m., with the Registered Dietician (RD), reviewed Resident 18's Nutritional assessment dated [DATE REDACTED] and Meal Tray Ticket. The RD stated the RD had visited with Resident 18 on 4/1/2025 and confirmed Resident 18 was not allergic to apple juice. The RD stated the allergy was removed from Resident 18's Allergy Report and care plan but had not been removed from the Meal Tray Ticket. The RD stated the facility had recently switched to a new dietary meal ticket system and there was a glitch switching from the old system to the new system. The RD stated, from 4/1/2025 to 4/7/2025, dietary staff and licensed nurses should have caught this discrepancy and removed it from the dietary meal ticket system. The RD stated it is important to have the correct Meal Tray Ticket to ensure a resident is served the correct diet and not at risk for having an allergic reaction.

During an interview on 4/11/2025 at 2:12 p.m., with the Director of Nursing (DON), the DON stated the discrepancy on Resident 18's Meal Tray Ticket should have been caught by the kitchen staff and licensed nurses. The DON stated it is important to ensure a resident is not served food they are allergic to. The DON stated residents could experience major symptoms such as rash or constricted throat if they do not receive

the correct diet.

During a review of the facility's policy and procedure titled, Tray Identification, last reviewed 1/16/2025, the policy indicated to assist in setting up and serving the correct food trays/diets to residents, the Food Services Department will use appropriate identification (e.g., generated diet cards) to identify the various diets. The Food Services Manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas. Nursing staff shall check each food tray for the correct diet before serving the residents. If there is an error, the Nurse Supervisor will notify the Dietary Department immediately by phone so that the appropriate food tray can be served.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 47441 potential for actual harm Based on observation, interview, and record review, the facility failed to prepare food by methods that Residents Affected - Some conserved temperature, flavor and appearance when:

a. Pineapple Bavarian was at 70 degrees Fahrenheit ( F, a scale of temperature) and puree pineapple Bavarian was at 73 F.

b. Cheese enchilada was crunchy, hard, dry and lacking sauce.

c. Liquid was coming out from the puree mixed vegetables

This deficient practice placed 97 of 149 facility residents on regular, therapeutic diets (a meal plan that controls the intake of certain food and nutrients) except consistent carbohydrate diet ([CCHO], a diet with the same amount of carbohydrate each meal) and puree diets (food with soft pudding like consistency) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen.

Findings:

a. During a review of the facilities' daily spreadsheet (a list of food, amount of food that each diet would receive) titled Cycle 2 2025 Spring, dated 4/7/2025, the spreadsheet indicated residents on therapeutic diets except CCHO diet would include pineapple Bavarian cream one (1) square.

During a review of the facility's daily spreadsheet titled Cycle 2 2025 Spring, dated 4/7/2025, the spreadsheet indicated residents on puree diet would receive puree Bavarian cream 1/2 cup ([c] a household measurement).

During a concurrent observation and interview on 4/7/2025 at 2:02 p.m. of the test tray (a process of tasting, temping, and evaluating the quality of food) of a regular diet with the Dietary Supervisor (DS), observed the DS using a facility food thermometer and tempted the pineapple Bavarian cream. The DS stated the temperature of the pineapple Bavarian cream was at 70 F.

During a concurrent observation and interview on 4/7/2025 at 2:07 p.m. of the puree test tray with the DS, observed the DS using a facility food thermometer and tempted the puree pineapple Bavarian. The DS stated the temperature of the puree Bavarian cream was at 73 F.

During an interview on 4/7/2025 at 2:12 p.m. with the DS, the DS stated the puree pineapple Bavarian should be below 40 F and would not be acceptable for residents' palatability wise, as a result residents might not eat it.

During an interview on 4/7/2025 at 2:22 p.m. with the DS, the DS stated the temperature for pineapple Bavarian cream was not acceptable as it was at room temperature, and it needed to be cold and chill. The DS stated residents might not eat the food resulting to decrease in food intake.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During a review of the facility's policies and procedures titled Food and Nutrition Services, dated 1/16/2025,

the P&P indicated (7) Food and nutrition services staff will inspect food trays to ensure that the correct meal Level of Harm - Minimal harm or is provided to each resident, the food appears palatable and attractive, and it is served at a safe and potential for actual harm appetizing temperature.

Residents Affected - Some During a review of the facility's P&P titled Standardized Recipes dated 1/16/2025, the P&P indicated, Standardized recipes shall be developed and used in the preparation of foods.

During a review of the facility's standardized recipe titled Pineapple Bavarian Cream, dated 1/16/2025, the recipe indicated, Service: Maintain temperature of finished product at or below 41 F during the entire service period.

b. During a review of the facilities' daily spreadsheet titled Cycle 2 2025 Spring, dated 4/7/2025, the spreadsheet indicated residents on regular diet would receive cheese enchilada two (2) each.

During the start of trayline (an area where foods were assembled from the steamtable to resident's plate)

observation on 4/7/2025 at 12:41 p.m., observed the cheese enchiladas were very dry on the steamtable.

During a concurrent test tray observation and interview on 4/7/2025 at 2:22 p.m. with the DS and the Registered Dietitian (RD), observed the cheese enchilada was dry and hard with a small amount of sauce on top. The RD stated the cheese enchilada looked dry and crunchy. The RD stated cheese enchiladas should be soft. The DS stated she agreed with the RD that the cheese enchiladas were dry, crunchy and it tasted more of a tostada than enchiladas. The RD stated resident might not eat the food because it was dry and would not be satisfied and may result to weight loss. The DS stated resident could also choke on the dry enchiladas as a potential outcome.

During a review of the facility's P&P titled Food and Nutrition Services, dated 1/16/2025, the P&P indicated Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

During a review of the facility's P&P titled Menus dated 1/16/2025, the P&P indicated, Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy.

During a review of the facility's standardized recipe titled Cheese Enchiladas, dated 1/16/2025, the recipe indicated, (8) Serve 2 enchiladas (both topped with 2 oz sauce) per portion.

c. During an observation on 4/7/2025 at 12:52 p.m. at trayline, observed puree vegetables looked runny, and liquid was coming out from it.

During a concurrent test tray observation and interview on 4/7/2025 at 2:12 p.m. with the DS and the RD, the RD stated the puree vegetables were runny and there was liquid coming out of the puree vegetables. The RD said it should be more round holding its shape. The DS stated the puree vegetable was oozing with water and resident would not eat it and could result to weight loss. The RD said resident could have swallowing difficulties as they would not easily swallow the food as a potential outcome of a runny puree food item.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During a review of the facility's standardized recipe titled Puree Cooked Vegetables undated, the recipe indicated (1) Place portions needed from regular prepared recipe into a food processor. Process to a fine Level of Harm - Minimal harm or texture. (2) Add thickener and process until smooth. If product is too thick, add 1 Tbsp of hot liquid at a time, potential for actual harm and re-process. Finished product should pass both the (1) Spoon tilt test (a test used to determine the stickiness of the sample and the ability of the sample to hold together) (2) Fork drip test (the food should drip Residents Affected - Some slowly or in dollops/stands through the slots of the fork).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm 47441

Residents Affected - Some Based on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when puree (foods that are smooth with pudding like consistency) cheese enchilada was grainy, puree rice had rice grains and puree vegetables did not hold it shape with liquid coming out from

the product

These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 11 of 97 residents on puree diet, resulting to unintended (not planned) weight loss and chocking (when food gets stuck in your airway, blocking the flow of air to your lungs).

Findings:

During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Cycle 2, 2025 Spring, dated 4/7/2025, the spreadsheet indicated residents on puree diet would include the following foods on the tray:

Puree cheese enchiladas two (2) number 8 scoop (1/2 cup [c] a household measurement)

Spanish cream of rice four (4) ounce (oz, a unit of measurement)

Puree cooked vegetables number 12 scoop (1/3 c)

Puree pineapple Bavarian cream 1/2 c

Two percent (2%) milk 4 fluid oz.

During an observation on 4/7/2025 at 12:01 p.m. of the puree preparation done by [NAME] 1, observed [NAME] 1 get rice from the steam table, pureed it using a blender and added a little water. Observed rice particles on the finish product for puree Spanish rice.

During an observation on 4/7/2025 at 12:52 p.m. at trayline (an area where foods were assembled from the steamtable to resident's plate), observed the puree vegetables with runny consistency, and liquid was coming out from it. Observed puree cheese enchilada went flat when scooped on the plate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 4/7/2025 at 2:12 p.m. with the DS and the RD, observed cheese enchilada was grainy, Level of Harm - Minimal harm or puree rice had rice particles and puree vegetables with runny consistency with liquid coming out from the potential for actual harm food. The RD stated the puree cheese enchiladas was not smooth enough compared to a pudding like consistency and puree rice still has chunks and not puree consistency. The RD stated the puree vegetables Residents Affected - Some were runny and there was liquid coming out of the puree vegetables. The RD said it should be more round holding its shape. The RD stated puree should be smooth, no lumps, with baby food texture and must have a pudding like consistency. The RD stated swallowing difficulty could be the potential outcome of not having

the correct consistency and texture of the puree foods. The DS stated the puree vegetable was oozing with water and resident would not eat it and could result to weight loss. The RD stated resident could have swallowing difficulties as they would not easily swallow the food as a potential outcome of a runny puree food item.

During a review of the facility's P&P titled Diet Manual dated 1/16/2025, the P&P indicated, the diet manual has been developed to provide explanation of the diets used in the development of the menu program. The diets have been developed using current scientific research, information from best practices, and recommendations from Position Papers of Professional Associations. The menu is developed to meet the Recommended Daily Allowances (RDAs) of the National Academies for persons 51 and over. Diet should be adjusted to meet the needs and preferences of the individual resident. The diet manual is intended as a guide for the physician or other qualified healthcare professional to use in prescribing modified diets and for

the healthcare personnel in following the diet orders.

During a review of the facility's diet manual titled Dysphagia Diet, Puree IDDSI Level 4 dated 2/2025, the diet manual indicated, A diet used in the dietary management of dysphagia with the food texture prepared lump-free, not firm or sticky and holds it shape on a plate. The diet requires no biting or chewing. Any liquids must not separate from the food and the food can fall off a spoon intact. The food is more easily swallowed and prevent aspiration. All prepared recipes should be tested prior to service to ensure the texture meets the IDDSI guidelines. They should pass the fork drip test and spoon tilt test. We recommend using water in the preparation of puree recipes as utilizing water will not alter the nutritional composition. However, broth, milk, or juice may also be used. Refer to your facility registered dietitian for appropriate substitution.

During a review of the facility's P&P titled Standardized Recipes dated 1/16/2025, the P&P indicated, Standardized recipes shall be developed and used in the preparation of foods.

During a review of the facility's standardized recipe titled Puree Cooked Vegetables undated, the recipe indicated (1) Place portions needed from regular prepared recipe into a food processor. Process to a fine texture. (2) Add thickener and process until smooth. If product is too thick, add 1 Tbsp of hot liquid at a time, and re-process. Finished product should pass both the (1) Spoon tilt test (a test used to determine the stickiness of the sample and the ability of the sample to hold together) (2) Fork drip test (the food should drip slowly or in dollops/stands through the slots of the fork).

During a review of the facility's standardized recipe titled Spanish Cream of Rice, undated, the recipe indicated, All IDDSI texture modifications need to pass their established testing methods at the start and every 15 minutes for the duration of the service.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0805 During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to Level of Harm - Minimal harm or hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: potential for actual harm Spoon tilt test and Fork drip test.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47441 safety Based on observation, interview, and record review, the facility failed to ensure one of three sampled Residents Affected - Few residents (Resident 71) with known food allergies (a substance that causes an allergic reaction [a condition that causes illness when someone eats certain foods or touches or breathes in certain substances]), was not served food containing allergens, by:

1. Serving for breakfast, on 4/8/2025, cream of wheat (a type of hot cereal that contains gluten [a protein found in the wheat plant and some other grains]; wheat is commonly used in breads, baked goods, and pastas) to Resident 71, who was known to be allergic to gluten as indicated in Resident 71's Physician's Order, Care Plan (a form where you can summarize a person's health conditions, specific care needs, and current treatments), Allergy List, Dietary Profile (based on individual assessments that consider factors like medical conditions, allergies, preferences, and chewing/swallowing abilities), History and Physical (H&P, a physician's examination of a patient), Interdisciplinary (IDT) Care Conference (a meeting where people from different fields [like doctors, therapists, social workers, nurses, and dietitian] come together to discuss a patient's situation and work as a team to create a coordinated plan for their care) notes, Medication Administration Record (MAR, a report detailing the drugs administered to a resident by a healthcare professional), and Nutritional Assessment (a check-up to see how well a person's body is getting the nutrients it needs).

2. Resident 71's meal ticket (a slip of paper or digital record that specifies which meal a resident is supposed to have and when and used by the kitchen staff to ensure each resident receives the correct food at the correct time) not indicating cream of rice was the choice.

3. Dietary staff in the tray line (an assembly line used in healthcare settings to prepare and distribute meals to patients) and Licensed Vocational Nurse 3 (LVN 3) lacking knowledge that cream of wheat should not be served to Resident 71.

4. Not having cream of rice in stock to provide Resident 71 as substitute for cream of wheat.

5. The food service manager or supervisor not checking Resident 71's tray for correct diet before the tray was transported to it designated area, in accordance with the facility's policy and procedures (P&P) titled, Tray Identification.

As a result, this deficient practice had the potential to cause a life-threatening condition such as anaphylactic shock (severe allergic reaction including closure of airways), severe tachycardia (increased heart rate), cardiac arrest (sudden loss of heart function, breathing, and consciousness [the state of being awake and aware of one's surroundings]), diarrhea, dehydration (occurs when your body loses too much water and other fluids), and/or death for Resident 71.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 On 4/9/2024 at 11:08 a.m., the State Survey Agency (SSA) called an Immediate Jeopardy (IJ- a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to Level of Harm - Immediate cause serious injury, harm, impairment, or death of a resident) under 42 CFR S483.60(d)(4) Resident jeopardy to resident health or Allergies, Preferences and Substitutes in the presence of the Administrator (ADM) and the Director of safety Nursing (DON) for the facility's failure to ensure that facility staff did not provide food containing a known allergen to Resident 71. Residents Affected - Few

On 4/10/2025 at 3:32 p.m., the ADM provided an IJ Removal Plan (a plan that identifies all actions the facility will take to immediately address the noncompliance that has resulted in the IJ situation) which included the following summarized actions:

1. On 4/8/2025, the DON immediately assessed Resident 71 for any adverse reaction and there were none noted.

2. On 4/8/2025 the facility notified Resident 71's attending physician and Resident 71's family of the incident of giving food containing allergies. The attending physician did not give any new orders.

3. On 4/8/2025, the Minimum Data Set Coordinator 1 (MDSC 1) updated Resident 71's allergy Care Plan to remove gluten allergy and Resident 71's nutrition risk Care Plan to reflect gluten intolerance prior to a diagnostic test for allergies.

4. On 4/8/2025, the Registered Dietitian (RD) evaluated Resident 71 and updated food preferences, reviewed allergies and food intolerances, and completed a nutritional assessment.

5. On 4/8/2025, the Director of Staff Development (DSD) provided one-on-one (1:1 - when one trainer works with one learner at a time) in-service training to Licensed Vocational Nurse 3 (LVN 3, who checked Resident 71's breakfast prior to serving) to ensure:

a. Identification of food allergies using the daily Allergy Report provided by DON and/or designee. The daily Allergy Report can be found in a special needs binder located at each nursing station and dining room.

b. Prior to tray passing to residents during mealtimes, a licensed nurse will check all trays for accuracy of meal ticket a printed sheet or card that details the meal items to be served to a patient or resident) and physician diet orders against what is on the residents' meal tray using the diet report.

c. Prior to passing the meal trays to the residents during mealtimes, a licensed nurse will check the diet type report and the meal ticket on each tray against the food on the resident's meal tray.

d. Prior to tray passing to residents during mealtime, a licensed nurse will check all the trays to ensure any resident with a gluten allergy is not served unless food item on food tray is labeled gluten free.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 6. On 4/8/2025 and 4/9/2025, the DON, the DSD, the RD, the Dietary Supervisor (DS) initiated an in-service to staff (including Registered Nurses (RNs), LVNs, Certified Nursing Assistants (CNAs), Rehabilitation Level of Harm - Immediate Therapists, the Dietary Manager, cooks, tray line (a system of food preparation, in which trays move along jeopardy to resident health or an assembly line) staff, dishwashers, Dietary Preparation staff, and Department Heads) about identification safety of food allergies using the daily Allergy Report, 2 licensed nurse will check all the trays to ensure meal ticket, physicians orders and Diet Type Report are accurate against resident's food trays. The in-service also Residents Affected - Few included checking all the trays to ensure all trays are checked for gluten allergies and not served foods containing gluten. Snacks for residents on gluten free diet will be labeled gluten free. A licensed nurse will check the diet type report, snacks label and food to ensure accuracy before serving it to the residents.

7. On 4/8/2025 and 4/9/2025, the DS completed an in-service to the dietary staff (Dietary Manager, cooks, tray line staff, dishwashers, and dietary preparation staff) related to food allergy, labeling of gluten-free food items, and ensuring all trays are checked accurately to ensure residents are not served a food item they are allergic prior to trays being sent out of the kitchen. Tray line staff will refer to Diet Manual for Guidance on alternatives for residents on gluten restricted diet/gluten allergy/intolerance. Staff that have not yet been in-serviced (those on vacation and per diem employees) will be in-serviced on their first reported day back to work.

8. The DON and or designee will update the Allergy report daily starting 4/9/2025 at the clinical meeting (Monday to Friday), and ensure it is available at each nursing station and dining room and a copy will be provided to the kitchen.

9. On 4/9/2025 for breakfast, the DON, the Assistant DON (ADON), the MDS Nurse and the DSD observed

the licensed nurses checking for tray accuracy prior to trays being served to residents. No issues were identified and the 10 residents who had food allergies and or food intolerances had accurate trays. The DON and ADON assessed the 10 residents for any signs and symptoms of allergic reaction, and none noted.

10. On 4/9/2025, the RD provided in-service to final tray line staff who checked Resident 71's breakfast tray

on 4/8/2025.

11. On 4/9/2025, the DON reviewed all residents and identified 10 residents with food allergies. Resident 71

the only resident identified to be on a gluten restricted diet. One resident identified having gluten allergy had been hospitalized since 4/3/2025 for unrelated medical condition. Upon this resident readmitted to the facility,

the nurse will obtain an order from the MD for allergy test.

12. On 4/9/2025, the Regional RD observed breakfast tray line to ensure accuracy of the meal tickets to what was being placed on resident's meal trays. There were no issues identified and the 10 residents who had food allergies and or intolerances had accurate trays.

13. On 4/9/2025, the DON completed competency for the licensed nurse who checked Resident 71's tray and met expectations as evidenced by the licensed nurse being able to correctly check the diet orders, resident allergies against the food tray.

14. The DON and or designee will complete a random daily visual check of meal trays starting 4/9/2025 for residents with identified food allergies using the Daily Food Allergy Audit Form. This audit will remain on-going until the goal is achieved.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 15. The DON and or designee will review the change in conditions daily starting 4/10/2024 related to food allergies. Level of Harm - Immediate jeopardy to resident health or 16. The DON and or designee will complete a Monthly Food Allergy Interview Audit Tool to ensure that each safety residents allergies are current, and up to date starting 4/10/2025. This audit will remain ongoing until the goal is achieved. Residents Affected - Few 17. On 4/10/2025, the DON obtained an order from Medical Doctor (MD) for Tissue Transglutaminase ([tTG-igA], blood test to diagnose celiac disease, a disease in which the small intestine is hypersensitive to gluten, leading to difficulty in digesting food) to be drawn on 4/14/2025.

18. On 4/10/2025, the DON discussed with MD to update Resident 71's gluten intolerance to gluten allergy.

The DON updated allergy profile and care plan to reflect resident's gluten allergy. The DON provided dietary communication form to dietary staff on 4/10/2025 for gluten allergy update.

19. On 4/10/2025, Registered Nurse Supervisor obtained order from MD for Resident 71 for psychology consult for psychosocial support.

20. The RN Supervisor and or designee will update the Allergy report and special needs binder on the weekends (Saturday and Sunday) starting 4/12/2025 at each nursing station, and dining room.

21. The RD will check food inventory weekly based on the upcoming week's menu using the Inventory form. If any items are missing, the RD will notify the Dietary Manager/designee, and the RD will approve appropriate alternative with same nutritional value if necessary.

On 4/11/2025 at 3:51 p.m., while onsite and after verifying the facility's full implementation of the IJ removal plan, the SSA accepted the IJ Removal Plan and removed the IJ in the presence of the ADM and DON.

Findings:

During a review of Resident 71's Admission Record (or Face Sheet, placed at the front of the medical chart summarizing the patient's key details), the Admission Record indicated the facility initially admitted Resident 71 on 8/18/2022 and readmitted Resident 71 on 7/15/2025 with diagnoses including cachexia (a condition marked by a loss of more than 10% of body weight, including loose of muscle mass and fat, in a person who is not trying to lose weight), intestinal malabsorption (a disorder that prevents your body from effectively absorbing nutrients from your food), and non-celiac gluten sensitivity (when the digestive system cannot tolerate any form of the protein gluten).

During a review of Resident 71's Care Plan, initiated on 8/19/2022, revised 5/2/2024 and ongoing as of 4/8/2025, the Care Plan indicated Resident 71 had allergies to lactose (a sugar that is a normal part of milk products) and gluten. The Care Plan goal was for Resident 71 not to be exposed to allergen and not having adverse reactions daily for three months. Resident 71's Care Plan included the following interventions:

-Inform staff or caregivers of resident's allergy.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 -Resident is allergic to lactose and gluten and these allergies are listed in special needs binder.

Level of Harm - Immediate -Label physician's order sheet, MAR, treatment sheet, Face Sheet and diet sheet of resident's allergy. jeopardy to resident health or safety -Notify pharmacy of resident's allergy.

Residents Affected - Few -Observe for any signs and symptoms of allergic reaction to drugs/food administered and notify MD immediately.

During a review of Resident 71's Allergy List, dated 5/2/2024, the Allergy List indicated Resident 71 was allergic to lactose and gluten.

During a review of Resident 71's Dietary Profile, dated 5/21/2024, the Dietary Profile indicated Resident 71 was allergic to gluten and milk.

During a review of Resident 71's H&P, dated 8/21/2024, the H&P indicated Resident 71's past medical history included significant for presumed gluten enteropathy (an autoimmune inflammatory disease of the small intestine that is precipitated by the ingestion of gluten) with chronic cachexia.

During a review of Resident 71's IDT Care Conference notes, dated 10/11/2024, the IDT Care Conference notes indicated Resident 71 to receive gluten and lactose free diet.

During a review of Resident 71's Physician's Order, dated 11/4/2024, the Physician's Order indicated to provide gluten free, no lactose, regular texture consistency with thin liquids diet.

During a review of Resident 71's Nutritional assessment dated [DATE REDACTED], the Nutritional Assessment indicated Resident 71 was allergic to gluten and lactose. The assessment indicated Resident 71 should not have gluten due to the diagnosis of gluten enteropathy.

During a review of Resident 71's Minimum Data Sheet (MDS -- a standardized assessment and care planning tool), dated 2/25/2025, the MDS indicated Resident 71's understood others and could make himself understood. The MDS indicated the resident required set-up or clean up assistance when eating.

During a review of Resident 71's MAR for the month of 4/2025, the MAR indicated Resident 71 was allergic to lactose and gluten.

During a review of Resident 71's Physician's Order Summary Report, dated 4/8/2025, the Physician's Order Summary Report indicated Resident 71 had allergy to lactose and gluten.

During an interview on 4/8/2025 at 7:37 a.m. with Dietary District Manager 1 (DDM 1) during the tray line in

the kitchen, DDM 1 stated the cook prepared for breakfast two hot cereals, oatmeal and cream of wheat.

During a review of Resident 71's breakfast meal tray ticket, on 4/8/2025 at 8:10 a.m., Resident 71's meal ticket indicated Resident 71 was on gluten restricted diet, was allergic to gluten and lactose, liked no salt on

the tray and small portion entree.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 During a concurrent observation and interview, on 4/8/2025 at 8:17 a.m., in Resident 71's room, Resident 71 had the breakfast tray on the bedside table. The tray contained a bowl of hot creamy cereal with a smooth Level of Harm - Immediate texture. Resident 71 stated the hot cereal on his tray looked like oatmeal or cream of wheat and he would not jeopardy to resident health or eat it. Resident 71 stated he was allergic to gluten and lactose and could not eat cream of wheat or oatmeal safety because it caused him to have loose bowel movements and lots of gas. Resident 71 stated he has been given oatmeal and regular bread, despite having informed the nursing staff about his allergies. Resident 71 Residents Affected - Few stated he had requested that someone from the kitchen came to talk to him, but nobody came.

During an interview with [NAME] 1, on 4/8/2025 at 8:26 a.m., [NAME] 1 stated she prepared oatmeal and cream of wheat for breakfast. [NAME] 1 stated the hot cereal bowl on Resident 71's tray was cream of wheat.

During an interview with the RD, on 4/8/2025 at 8:28 a.m., the RD stated cream of wheat had gluten and the software (programs used to operate computers and execute specific tasks) the facility use for their menus should have adjusted Resident 71's meal ticket to indicate cream of rice was the choice instead of oatmeal or cream of wheat but it did not. The RD stated Resident 71 had a gluten allergy diagnosis and should not receive cream of wheat or oatmeal because of his possible allergic reaction such as having diarrhea, loose bowel movement, shortness of breath, and swallowing problems. The RD stated she needed to find out the reason Resident 71's meal ticket did not indicate No Wheat.

During an interview with the DS, on 4/8/2025 at 8:35 a.m., the DS stated she told [NAME] 1 to serve cream of rice (instead of oatmeal or cream of wheat) and that she saw [NAME] 1 preparing it earlier that morning.

During an interview with [NAME] 1, on 4/8/2025 at 8:40 a.m., [NAME] 1 stated she only cooked oatmeal and cream of wheat for breakfast and did not cook cream of rice because it was not available in stock in the facility.

During an interview the RD, on 4/8/2025 at 8:44 a.m., the RD confirmed the cream of rice was out of stock.

During a concurrent observation inside the dry storeroom (a designated area used for storing food that do not require temperature control or refrigeration) and interview with Dietary Aide 1 (DA 1), on 4/8/2025 at 10:22 a.m., there was no cream of rice observed available in the facility. DA 1 stated the last time he placed

an order for cream of rice was in 3/2025.

During a review of the facility's purchase order dated 1/28/2025, the purchase order indicated that the most recent order for cream of rice was placed on 1/28/2025.

During an interview with DA 2, on 4/8/2025 at 10:31 a.m., DA 2 stated she was responsible for checking the accuracy of the tray for breakfast by making sure the food on the tray matched the food listed on the meal ticket. DA 2 stated she checked for allergies, likes, dislikes and other special request of each resident in the tray line. DA 2 stated she also checked for gluten-free diet to provide gluten-free bread and other foods that were safe to give to residents with gluten free diet. DA 2 stated Resident 71 had water, orange juice, lactose free milk, and cream of wheat in his tray that morning. DA 2 stated a previous DS told her cream of wheat was okay to give to residents with gluten-free diet. DA 2 stated they served cream of wheat to residents on gluten free diet every day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 During an interview with the DS, on 4/8/2025 at 10:47 a.m., the DS stated there were three staff assigned on

the tray line. The first was the starter, responsible for setting up the trays and tray tickets. The second staff Level of Harm - Immediate placed the drinks, desserts, salads, and breakfast cereals. The third staff was the caller, whose role involved jeopardy to resident health or calling residents' diet texture, allergens, diets and any missing items on the tray, as well as ensuring the safety accuracy of each tray. The DS stated she expected DA 1 to remove cream of wheat from trays for residents with allergies to gluten. The DS stated no training on gluten free diets had been provided to the kitchen staff Residents Affected - Few since she assumed the position in 3/ 2025.

During an interview with LVN 3, on 4/8/2025 at 10:57 a.m., LVN 3 stated that earlier in the morning during

the breakfast meal, she checked Nursing Station 3 tray for any allergies, intolerances, diet texture and verified that what had been served on the resident's tray matched the information in the diet report. LVN 3 stated it was important to have accurate trays especially for residents with allergies to prevent complications. LVN 3 stated she checked Residents 71's breakfast meal trays but could not remember what was on Resident 71's tray. LVN 3 stated she lifted the lid of Resident 71's hot cereal and it appeared to be cream of rice. LVN 3 stated since the ticket indicated hot or cold cereals, LVN 3 felt it was appropriate to serve the cream of wheat to Resident 71. LVN 3 stated if she knew the hot cereal was cream of wheat, she would not have allowed it to be served to Resident 71.

During an interview with the ADM, on 4/8/2025 at 11:41 a.m., the ADM stated Resident 71's physician informed them that Resident 71 had gluten intolerance because if his symptoms of diarrhea and gas upon gluten consumption.

During an interview with the DON, on 4/8/2025 at 11:45 a.m., the DON stated the licensed nurse checks the meal trays for allergies before giving it to the residents but would not know if the product was or not gluten-free. The DON stated it was the kitchen staff's responsibility to provide the correct food on the resident's tray as it could potentially cause diarrhea, dehydration and weight loss to Resident 71.

During an interview with the RD, on 4/8/2025 at 2:17 p.m., the RD stated she spoke and conducted a nutritional assessment with Resident 71 on 10/14/2024 but did not talk to Resident 71 on 2/7/2025 as there were no reports from nursing and kitchen staff indicating any dietary issues.

During a revie of the facility's P&P titled Nutritional Assessment, dated 1/16/2025, the P&P indicated, (6) The dietitian will determine whether food allergies or intolerances are interfering with the resident's overall nutrition status and make recommendations regarding appropriate food substitutions and/or dietary supplements.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 During a review of the facility's P&P titled, Food Allergies and Intolerances, dated 1/16/2025, the P&P indicated Residents with food allergies and/or intolerances are identified upon admission and offered food Level of Harm - Immediate substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the jeopardy to resident health or allergen(s). Policy and Interpretation: (1) Food allergies are immune system responses to allergens (foods). safety Immunoglobulin E ([[NAME]] antibodies produced by immune system) attach to mast cells (a type of white blood cells that is found in connective tissue all through the body) in the body tissue (e.g. skin, nose, throat, Residents Affected - Few lungs and gastrointestinal tract) and basophils (white blood cells in the immune system) in blood. When allergens are eaten, the [NAME] antibodies attach to mast cells and basophils in certain sites and those cells produce histamine, an inflammatory compound. (2) Food intolerances are unpleasant reactions to specific foods that are not life threatening it can necessitate avoidance of the triggering foods. Assessment and interventions:

o Resident are assessed for a history of food allergies and intolerances upon admission and as part of the comprehensive assessment.

o All resident reported food allergies and intolerances are documented in the assessment notes and incorporated into the resident's care plan.

o Meals for resident with severe food allergies are specially prepared so that cross-contamination with allergens does not occur.

o Residents with food intolerances and allergies are offered appropriate substitutions or food that they cannot eat.

During a review of the facility's P&P titled, Diet Manual dated 1/16/2025, the P&P indicated, the diet manual has been developed to provide explanation of the diets used in the development of the menu program. The diets have been developed using current scientific research, information from best practices, and recommendations from Position Papers of Professional Associations. The menu is developed to meet the Recommended Daily Allowances (RDAs) of the National Academies for persons 51 and over. Diet should be adjusted to meet the needs and preferences of the individual resident. The diet manual is intended as a guide for the physician or other qualified healthcare professional to use in prescribing modified diets and for

the healthcare personnel in following the diet orders.

During a review of the facility's diet manual titled, Gluten Restricted Diet dated 2/2025, the diet manual indicated Intended Use: This diet is used in the treatment of gluten-induced enteropathy (non-tropical sprue, celiac disease). The diet aims to eliminate symptoms, such as flatulence, diarrhea, steatorrhea, weight loss, indigestion and bloating, caused by sensitivity to gluten and gluten-containing products. The tropical sprue is not responsive to a gluten restricted diet. Adequacy: The Gluten restricted diet eliminates all foods containing wheat, rye, and barley. Grains not allowed on a gluten restricted diet: wheat, einkorn, [NAME], wheat starch, wheat bran, wheat germ, cracked wheat, barley, rye, graham flour, plain flour, white flour. Gluten free foods are made from the recommended grains listed above. There are many gluten-free substitutions to wheat-containing foods. You must read labels, as many products contain wheat ingredients where it is not obvious.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 During a review of the facility's P&P titled, Tray Identification dated 1/16/2025, the P&P indicated, The food service manager or supervisor will check trays for correct diets before the food carts are transported to their Level of Harm - Immediate designated areas. Nursing staff shall check each food tray for the correct diet before serving the residents. If jeopardy to resident health or there is an error, the nurse supervisor will notify the dietary department immediately by phone so that the safety appropriate food tray can be served.

Residents Affected - Few During a review of the facility's P&P titled, Resident Food Preferences dated 1/16/2025, the P&P indicated,

The dietary manager will complete a dietary profile for residents to reflect current food preferences and nutritional needs upon admission, readmission, quarterly, annually or as needed. The dietary manager will complete the dietary profile for residents to capture and update the information regarding nutritional needs and food preferences (b) allergies.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47441

Residents Affected - Some Based on observation, interview, and record review, the facility failed to:

1. Ensure safe and sanitary food storage and food preparation practices in the kitchen when:

a. Kitchen equipment and utensils were not maintained in its proper condition, smooth and easy to clean.

1. Three (3) of four (4) racks were corroded with amber discoloration in the walk-in refrigerator.

2. Four (4) of seven (7) racks were corroded with amber discoloration in the dry storage room.

3. Fifty (50) of 50 resident's cracked trays.

b. Kitchen equipment and kitchen areas were not cleaned and sanitized.

1. Walk-in refrigerator floors had food such as orange, piece of bread, piece of cream cheese, sandwich spread and dirt debris.

2. Walk-in freezer had food debris on the floor.

3. Chest freezer ledge opening had dust buildup and door was sticky to touch.

4. Walk-in refrigerator gasket had dirt buildup.

c. Three (3) of 3 dietary aides were wearing gold, leather and rubber bracelets during food preparation and pot washing.

These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 97 of 149 medically compromised residents who received food and ice from the kitchen.

2. Ensure leftover food brought from outside by a resident or family member was labeled with resident identifier and use by date for one of one (Resident 96) sampled resident.

This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) to Resident 96.

Findings:

1.a. During an observation on 4/7/2025 at 8:22 a.m., of the walk-in refrigerator, 3 of 4 racks had rust and corroded.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 b.During an observation on 4/7/2025 at 8:33 a.m., of the dry storage room, observed 4 of 7 racks were corroded with amber discoloration. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 4/7/2025 at 11:23 a.m. with the Registered Dietitian (RD),

the RD stated the racks in the walk-in refrigerator and dry storage were dusty, dirty and it needed Residents Affected - Some replacement as it was rusted. The RD stated the food racks must be rust free to prevent food borne illnesses

it could potentially cause the residents.

During an interview on 4/7/2025 at 11:43 a.m. with the Dietary Supervisor (DS), the DS stated the racks in

the walk-in refrigerator and dry storage area were rusty and needed to be replaced. The DS stated the racks needed to be smooth to prevent bacterial contamination as these racks were hard to clean if they are not smooth.

During a review of the facility's policies and procedures (P&P) titled Refrigerators and Freezers dated 1/16/2025, the P&P indicated, (9) Supervisors will inspect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed.

During a review of the facility's P&P titled Equipment dated 1/16/2025, the P&P indicated, All food service equipment will be clean, sanitary, and in proper working order. (3) All food contact equipment will be cleaned and sanitize after every use. (4) All non-foods contact equipment will be clean and free of debris.

c. During an observation on 4/7/2025 at 12:12 p.m. of the resident's tray used for lunch service, observed 50 of 50 trays were cracked and chipped.

During an interview on 4/9/2025 at 2:09 p.m. with the DS, the DS stated she was aware of the chipped and cracked resident's tray and it was not okay as it could collect germs and bacteria causing cross contamination to food of the residents. The DS stated it would also not look presentable to residents if food trays were cracked and chipped.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints.

b.1. During an initial kitchen tour observation on 4/7/2025 at 8:25 a.m., of the walk-in refrigerator, observed orange, piece of bread, piece of cream cheese, sandwich spread and dirt debris on the floor.

b.2. During an observation of 4/7/2025 at 8:28 a.m. of the walk- in freezer, observed food debris on the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During a concurrent observation and interview on 4/7/2025 at 11:18 a.m. with the RD, of the walk-in refrigerators, walk-in freezer, the RD stated there were food and dirt debris in both the walk-in refrigerator Level of Harm - Minimal harm or and freezer and it was not okay as the floor should have been cleaned. The RD stated she did not see the potential for actual harm dirt during her rounds this morning. The RD stated walk-in refrigerator, and freezers were part of the cleaning schedule, and it should have been swept and mopped. The RD stated maintaining the walk-in refrigerators Residents Affected - Some and freezers cleanliness were important for infection control to prevent residents from getting sick of food borne illness.

b.3. During an initial kitchen tour observation on 4/7/2025 at 8:44 a.m. of the chest freezer, observed dust, dirt buildup around the ledge opening of the chest freezer and door was too sticky to touch.

During an interview on 4/7/2025 at 11:42 a.m. with the DS, the DS stated the staff needed to clean the chest freezer every day for infection control and to prevent contamination. The DS stated the potential outcome of cross-contamination of food include stomach issues, diarrhea and vomiting.

b.4. During an observation on 4/7/2025 at 8:51 a.m. of the walk-in refrigerator, observed the refrigerator gasket had dirt buildup.

During a concurrent observation and interview on 4/7/2025 at 11:28 a.m. of the walk-in refrigerator gasket and the chest freezer with the RD, the RD stated, the walk-in refrigerator gasket had dust and dirt debris and

the chest freezer ledge opening had dirt and dust debris. The RD stated the walk-in refrigerator and chest freezer were cleaned last Tuesday and once a week cleaning might not be enough. The RD stated it was important to maintain the cleanliness of the food storage to prevent cross-contamination to food and food borne illnesses to residents.

During a review of the facility's P&P titled Refrigerators and Freezers, dated 1/16/2025, the P&P indicated,

This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. (10) Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.

1.c. During an observation on 4/7/2025 at 11:07 a.m., of the food preparation, observed Dietary Aide 4 (DA 4) was wearing a black leather bracelet and gold bracelet while preparing food.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During an observation 4/7/2025 at 11:14 a.m. of the food preparation, Dietary Aide 3 was wearing a gold bracelet while dishing out orange slices. Level of Harm - Minimal harm or potential for actual harm During an observation on 4/7/2025 at 11:42 a.m. of the food preparation process, DA 4 was wearing gold and black bracelet while scooping apple sauce, Dietary Aide 5 was wearing rubber bracelet while Residents Affected - Some dishwashing and DA 3 was wearing gold bracelet while scooping pineapple.

During an interview on 4/7/2025 at 11:48 a.m. with the DS, the DS stated their policy in the kitchen was not allowing staff to wear jewelries as the jewelries could contaminate the food as a potential outcome to the residents.

During a review of the facility's P&P titled Infection Control for Dietary Employees, dated 1/16/2025, the P&P indicated, (1) Personal cleanliness that the dietary department is maintained in a sanitary condition in order to prevent food contamination and the growth of disease producing organisms and toxins. (g) Watches and bracelets: Food handlers should not wear watches or bracelets on their wrists, including smart watches, fitness trackers, and medical bracelets. If you have a medical alert bracelet, you can work with your manager to find an alternative, like wearing it around your neck or ankle.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated 2-303.11 Prohibition. Except for a plain ring such as wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands.

38469

2. During a review of Resident 96's Admission Record, the Admission Record indicated the resident was admitted to the facility on [DATE REDACTED], with diagnoses including weakness and history of falling.

During a review of Resident 96`s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/10/2025, the MDS indicated the resident`s cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact. The MDS also indicated that the resident required assistance on staff for toileting hygiene, shower, lower body dressing and putting on/taking off footwear.

During a concurrent observation and interview with Resident 96 on 4/07/2025 at 9:09 a.m., observed Resident 96 in bed. Observed a plastic a plastic bag containing two Styrofoam containers placed on top of

the over-bed table. Resident 96 stated the Styrofoam containers contained burritos and tortilla chips with salsa that she had ordered from a restaurant last night. Resident 96 stated that after she ate the burritos, she had requested the certified nurse assistant to place the leftover food in the refrigerator and had it brought back to her (Resident 96) this morning. The plastic bag was not dated and labeled with Resident 96's identifier.

During an interview and follow up observation on 4/07/2025 at 9:23 a.m., with the Director of Staff Development (DSD), at Resident 96's bed side, the DSD stated the plastic bag containing two Styrofoam containers was not dated and labeled with Resident 96's identifier. The DSD stated that any left-over food brought from outside must be labeled with the resident's room number and use-by date. The DSD stated residents ingesting left-over food items beyond its use by date placed the residents at risk for contracting foodborne illnesses.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During a review of the facility`s policy and procedures titled Food Brought by Family/Visitors, last reviewed

on 1/16/2025, the policy and procedure indicated a purpose to provide residents with the option of having Level of Harm - Minimal harm or food prepared by the resident`s family brought into the Facility .when food items are intended for later potential for actual harm consumption, the responsible staff member will label foods with resident`s name, and the current date and use by date .items will be thrown out after 72 hours . Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 47441 potential for actual harm Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly Residents Affected - Some when there were 15 soiled gloves, an empty bottle spray, plastic, and other trash on the floor and one (1) of three (3) dumpsters (a movable waste container designed to be brought and taken away by a special collection vehicle, or to a bin that a specially designed garbage truck lifts) had dirt and brown food spills.

These failures had a potential to result in attracting birds, flies, insects, pest and possibly spread infection to 142 of 149 facility residents.

Findings:

During a concurrent observation and interview on 4/9/2025 at 2:13 p.m., with the Dietary Supervisor (DS), observed 15 soiled gloves, a spray bottle, plastic, and other trash on the ground. Observed one (1) of three dumpsters had brown dried up food spills and dirt. The DS stated there were soiled gloves on the floor and it was not okay. The DS stated it was important to maintain the cleanliness of the dumpster and its surroundings to prevent pest and insect spreading infection to the residents.

During a concurrent observation and interview on 4/9/2025 at 2:17 p.m., with the Environmental Services Supervisor (EVS), observed the dumpster. The EVS stated the trash area had soiled gloves and other trashes were on the floor and the dumpster had dirt or food spills and was not acceptable because it could attract flies, mosquitos, and other animals that could spread infection to the residents. The EVS stated she expected the area to be clean every day and the dumpster should be washed every week.

During a review of the facility's policy and procedure (P&P) titled, Food-Related Garbage and Refuse Disposal, dated 1/16/2025, the P&P indicated, Food-related garbage and refuse are disposed of in accordance with current state laws (7) Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38469 potential for actual harm Based on observation, interview, and record review, the facility failed to: Residents Affected - Some 1. Ensure a resident's nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was not touching the floor for one of 12 sampled residents (Resident 71).

2. Ensure a resident's urinal (a bottle for collecting urine) was labeled with a resident identifier for two of 12 sampled residents (Resident 94 and 2) investigated for infection control.

These deficient practices had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection.

Findings:

1. During a review of Resident 71's Admission Record, the Admission Record indicated the facility originally admitted the resident on 8/18/2022 and readmitted the resident on 7/15/2024 with diagnoses including cachexia (a general state of ill health involving great weight loss and muscle loss) and atelectasis (complete or partial collapse of a lung or a section (lobe) of a lung).

During a review of Resident 71's Minimum Data Set (MDS - a resident assessment tool) dated 2/25/2025,

the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was intact and required partial/moderate assistance with shower, dressing, and required supervision with toileting and personal hygiene.

During a review of Resident 71's physician orders dated 11/9/2024, the physician order indicated an order to administer oxygen at two (2) liters per minute (LPM- unit of measurement for oxygen) via nasal cannula as needed for low oxygen.

During a concurrent observation and interview on 4/7/2025 at 11:15 a.m., with the Infection Preventionist (IP), observed Resident 71's nasal cannula oxygen tubing on the floor. The IP stated that the nasal cannula tubing is already contaminated and can potentially introduce bacteria to Resident 71 which can lead to infection and had to be replaced immediately.

During a review of the Centers for Disease Control and Prevention (CDC, national public health agency) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, updated 7/2019, indicated floors can become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances.

47883

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 2.a. During a review of Resident 94's Admission Record, the Admission Record indicated the facility admitted

the resident on 1/27/2023 with diagnoses including hypertension (high blood pressure [the force of the blood Level of Harm - Minimal harm or pushing on the blood vessel walls is too high]) and spinal stenosis (the spaces inside the bones of the spine potential for actual harm get too small).

Residents Affected - Some During a review of Resident 94's MDS dated [DATE REDACTED], the MDS indicated the resident's cognitive skills for daily decision making was intact and required supervision or touching assistance with shower, dressing, and putting on/taking off footwear.

During a concurrent observation and interview on 4/7/2025 at 10:52 a.m., with the IP, observed with the IP, Resident 94 lying in bed and a plastic urinal bottle at Resident 94's bedside. Observed the plastic urinal bottle had no written identifier indicating that it belonged to Resident 94. The IP stated that the urinal bottle should be labeled with name and room number to prevent the roommates from accidentally using the urinal bottle.

During a review of the facility's policy and procedure titled, Standard Precautions, last reviewed on 1/16/2025, the policy and procedure indicated that standard precautions will be used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Handle used resident-care equipment soiled with blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of other microorganisms to other residents and environments.

2.b. During a review of Resident 2's Admission Record, the Admission Record indicated the facility admitted

the resident on 5/12/2017 with diagnoses including a history of urinary tract infections (UTI - an infection in

the bladder/urinary tract), chronic pulmonary disease (a lung diseases that block airflow and make it difficult to breathe), and schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves) .

During a review of Resident 2's MDS dated [DATE REDACTED], the MDS indicated that the resident had moderately impaired cognition. The MDS further indicated that Resident 2 needed moderate assistance with all activities of daily living (ADLs - activities related to personal care).

During a concurrent observation and interview on 4/7/2025 at 10:00 a.m., with Certified Nursing Assistant 2 (CNA 2), observed two unlabeled urinals at Resident 2's bedside. CNA 2 verified by stating that the urinal was not labeled with a resident identifier.

During an interview on 4/9/2025 at 8:45 a.m., with the IP, the IP stated that resident urinals should be labeled with their last name and first initial to ensure infection control. The IP stated it was important to label urinals with a resident identifier in order to ensure that only one resident is using it and there is no cross contamination amongst residents.

During an interview on 4/11/2025 at 1:15 a.m., with the Director of Nursing (DON), the DON stated the facility had no specific policy addressing the labeling of urinals for infection control.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of 89 056066 Department of Health & Human Services Printed: 08/29/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056066 B. Wing 04/11/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of the facility's policy and procedure titled, Standard Precautions, last reviewed on 1/16/2025, the policy and procedure indicated that standard precautions will be used in the care of all Level of Harm - Minimal harm or residents regardless of their diagnoses or suspected or confirmed infection status. Standard Precautions potential for actual harm presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Handle used resident-care equipment soiled with Residents Affected - Some blood, body fluids, secretions, and excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of other microorganisms to other residents and environments.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of 89 056066