Woodland Care Center
WOODLAND CARE CENTER in RESEDA, CA — inspection on April 11, 2025.
Found 30 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 141's admission Record, the admission Record indicated that the facility admitted the resident on [DATE] with diagnoses including encounter for palliative care (a specialized medical care that focuses on providing comfort and support to patients with serious, life-limiting illnesses) and end stage renal disease (ESRD-a condition in which the kidneys lose the ability to remove waste and balance fluids).
During a review of Resident 141`s Physician`s Certification for Hospice Benefit dated [DATE], the certification indicated that the resident has a life expectancy of six months or less, if the terminal illness runs its normal course with primary diagnosis of ESRD.
During a review of Resident 141`s Discharge summary dated [DATE], the Discharge Summary indicated that Resident 141 expired in the facility on [DATE].
During a review of Resident 141`s Inventory of Personal Effects (IPE) dated [DATE], signed by a facility representative, the IPE indicated that on admission, Resident 141 had a silver bracelet.
During concurrent interview and record review on [DATE] at 12:46 p.m., with the Social Services Director (SSD), the SSD stated that all personal belongings of a resident will be inventoried and documented in the IPE form.
The SSD stated that when a resident is discharged or expires in the facility, the personal belongings will be released to the family.
The SSD verified that Resident 141`s IPE indicated the resident had a silver bracelet on admission.
The SSD verified that there was no documentation that Resident 141`s silver bracelet was turned over to the facility and the facility has not been able to locate the bracelet.
The SSD stated that it was important Resident 141's personal belonging was accounted for and returned to Resident 141's resident's representative following the resident's death.
The SSD stated that personal belongings of a deceased resident may hold sentimental value for the resident's representative, and their (belongings) loss can cause emotional distress.
The SSD stated that it is the right of a resident that their personal belongings are safeguarded and protected from loss or misappropriation.
During a review of the facility`s policy and procedure titled Release of a Resident`s Personal Belongings, last reviewed by the facility on [DATE], the policy indicated that our facility protects the personal belongings of a resident who has been transferred or discharge from the facility .the personal belongings of a resident transferred or discharged from our facility will be released to the resident or authorized resident representative .
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
During a review of the facility's policy and procedure (P&P) titled, Resident Rights, last reviewed 1/16/2025, the P&P indicated: Federal and state laws guarantee certain basic rights to all residents of this facility.
These rights include the resident's right to: Exercise his or her rights as a resident of the facility Be informed of, and participate in, his or her care planning and treatment.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
shower or bathing facility, and from the floor.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
indicated that an individualized comprehensive care plan that includes measurable objectives and
care plans at least quarterly .
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
During a concurrent interview and record review on 4/11/2025 at 4:11 PM, with Administrator (ADM), the Administrator reviewed the Theft/Loss Report and stated that in 10/2024 the allegation of misappropriation of Resident 38's money was investigated and unsubstantiated, and no money was returned to Resident 38.
The ADM stated he did not report the allegation of misappropriation of Resident 38's money to CDPH, the ombudsman, or the local law enforcement agency.
During a review of the facility's recent policy and procedure titled Investigating Incidents of Theft and Loss last reviewed on 1/16/2025, the policy and procedure indicated: Should an alleged or suspected case of staff misappropriation of resident property be reported, the facility Administrator, or his/her designee, will notify the following persons or agencies within twenty-four (24) of such incidents, as appropriate: a.
State Licensing and Certification Agency. b.
Ombudsman. c.
Represent Representative. d.
Adult Protective Services. e.
Law Enforcement Officials .
The administrator or his or her designee will report the result of the investigation to the local police department, the ombudsman, and to the state survey and certification agency within five (5) working days of the incident.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
During a concurrent interview and record review on 4/10/2025 at 4:29 PM, with Social Services Assistant 1 (SSA 1), SSA 1 reviewed the Theft/Loss Report and Resident 38's Inventory and stated that she initiated the Theft/Loss Report in 10/2024 regarding Resident 38's missing money. SSA 1 stated that the amount of money the resident was missing varied, there was no documentation in the inventory the resident had money, and no money was observed by staff among the resident's belongings.
During an interview on 4/11/2025 at 10:14 AM with Restorative Nursing Assistant 1 (RNA 1), RNA1 stated that she was changing Resident 38's bed after he left to GACH 1 in October 2024 and noticed a wallet inside the bed side table drawer. RNA 1 stated that there was about $30 in the wallet, and she left the wallet inside the bedside table drawer. RNA 1 stated she did not give the wallet to the social services office for safekeeping until Resident 38 returned from the hospital.
During an interview on 4/11/2025 at 11:10 AM with the Director of Staff Development (DSD), the DSD stated that she interviewed staff in 10/2024 regarding Resident 38's report of missing money.
The DSD stated that the staff she interviewed did not see any money in Resident 38's room or in the laundry.
The DSD stated she did not interview RNA 1 in 10/2024.
During an interview on 4/11/2025 at 1:15 PM with the Director of Nursing (DON), the DON stated that staff should hand over any valuables to the social services office if a resident is transferred to hospital.
The DON stated a social services staff should have checked in with Resident 38 after he reported missing money in 10/2024 to monitor for any possible psychosocial effects on the resident.
The DON stated that the facility should have interviewed all staff involved in Resident 38's care to ensure a thorough investigation.
The DON stated this deficient practice had the potential to result in failure to protect Resident 38 from misappropriation of his property.
During concurrent interview and record review on 4/11/2025 at 4:11 PM, with the Administrator (ADM), the Administrator reviewed the Theft/Loss Report and stated that in 10/2024 the allegation of misappropriation of Resident 38's money was investigated and unsubstantiated, and no money was returned to Resident 38.
The ADM stated he did not report the allegation of misappropriation of Resident 38's money to CDPH, the ombudsman, or the local law enforcement agency.
The Administrator stated that he was not made aware until today that RNA 1 observed a wallet with $30 in it inside Resident 38 bedside table drawer.
During a review of the facility's recent policy and procedure titled Investigating Incidents of Theft and Loss last reviewed on 1/16/2025, indicated: All reports of theft or misappropriation of resident property shall be promptly investigated.
Residents have the right to be free from theft and loss.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
Assessment, last reviewed 1/16/2025, indicated the following:
minimal harm 1.
Any health care professional who participates in the assessment process is qualified to assess the medical, functional and/or psychosocial status of the resident that is relevant to the professional's
- Any person who completed any portion of the MDS assessment, tracking form, or correction
- The information captured on the assessment reflects the status of the resident during the
request form is required to sign the assessment certifying the accuracy of that portion of that assessment.
observation (look-back) period for that assessment.
Different items on the MDS may have different observation periods.
During a concurrent interview and record review on 4/9/2025 at 9:24 a.m., with Minimum Data Set Coordinator 2 (MDSC2), reviewed Resident 38 's care plans. MDSC 2 stated she could not find a care plan addressing Resident 38 use of side rails.
During an interview on 4/10/2025 at 1:30 p.m., with the Assistant Director of Nursing (ADON), the ADON stated it was important for the IDT to determine the specific care plan Resident 12 would need to ensure safe use of side rails.
During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 1/16/2025, the policy and procedure indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.
During a review of the facility's policy and procedure titled, Siderails last reviewed on 1/16/2025, the policy and procedure indicated: To ensure the safe use of side rails as an assistive device, to aid mobility, or to treat medical symptoms .The Licensed Nurse will complete the Bedrail Evaluation UDA and develop a care plan reflecting that evaluation.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
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 resident`s care plan to assess for any special needs of the resident.
During a review of the facility's Policy and Procedure (P&P) titled, Care Plan Comprehensive, last reviewed on 1/16/2025, the P&P indicated that a comprehensive care plan that includes measurable objectives and timetables to meet the resident`s medical, physical, mental and psychosocial needs shall be developed for each resident.
Assessments of residents are ongoing, and care plans are reviewed or revised as information about the resident and the resident`s condition change.
The IDT team is responsible for evaluation and updating of care plans when there has been a significant change in the resident`s condition, when the desired outcome is not met and when the resident has been readmitted to the facility from a hospital stay and at least quarterly.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
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.
During a review of the facility's Policy and Procedure (P&P) titled, Insulin Administration, last reviewed on 1/16/2025, the P&P indicated only appropriately licensed or certified personnel shall draw and administer insulin.
Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm).
During a review of the facility's recent policy and procedure titled, Administrating Medication, last reviewed on 1/16/2025, the P&P indicated, medications are administered in accordance with prescriber orders.
During a review of Information for the physician Humulin Regular dated 2011, it indicated that injection site should be rotated within the same region.
During a review of Highlights of prescribing medication Insulin Glargine injection, dated 11/2018, 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 provided FDA Label for Lantus, undated, it indicated to rotate injection sites to reduce the risk of lipodystrophy.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
hygiene.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
During an interview with the Director of Nursing (DON) on 4/11/2025 at 2:12 p.m., the DON confirmed that the weekly skin report was not done the week of 3/12/2025 but should have been completed by the licensed nurses.
The DON stated this was to ensure that the licensed nurses and physician can monitor the progress of Resident 37's wound.
The DON confirmed there was no completion of the daily wound treatment for 3/15/2025.
The DON stated this is important to ensure Resident 37's wound improves.
During a review of the facility's policy and procedure titled, Skin Integrity Management, last reviewed 1/16/2025, indicated the following: -Perform skin inspection on admission/re-admission and weekly.
Document on Treatment Administration Record (TAR) or in Point Click Care (PCC, a type of electronic medical record system). -Perform wound observations and measurements upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound. -Perform daily monitoring of wounds or dressings for presence of complications or declines and document if indicated. -Notify physician to obtain orders.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
During a review of Resident 125`s Interdisciplinary Team (IDT-a group of healthcare professionals
Conference notes dated 2/20/2025, the IDT notes indicated that the resident was readmitted back to facility on 2/19/2025.
The IDT notes indicated that Resident 125 was moved closer to the nursing station for close supervision and bilateral (both sides) landing pads were applied to both sides of his bed.
During a review of Resident 125`s Care Plan (a document outlining a detailed approach to care customized to an individual resident's need) for risk for falls initiated on 12/28/2024, the care plan indicated a goal that the resident will be free from falls for 90 days.
The care plan interventions were to place call light within resident`s reach while in bed, and to place all necessary personal items within his reach while in bed.
During an observation on 4/7/2025 at 10:19 a.m., inside Resident 125`s room, the resident was observed in his bed.
There was an unoccupied bed next to Resident 125. A landing pad was observed placed against the wall to the right side of Resident 125`s bed away from him.
There was another landing pad placed in front of the unoccupied bed also away from Resident 125.
During a concurrent observation and interview on 4/7/2025 at 10:24 a.m., inside Resident 125`s room the with Assistant Director of Nursing (ADON), the ADON stated that Resident 125`s landing pads were not placed on both sides of his bed as ordered by his physician and the potential outcome is injuries in the event of a fall.
During an interview on 4/11/2025 at 3:27 p.m., with the Director of Nursing (DON), the DON stated Resident 125 had a fall on 2/18/2025 and his physician ordered to place landing pads on both sides of his bed and check the placement of the pads during every shift.
The DON stated staff failed to monitor the placement of Resident 125`s landing pads and the potential outcome is insufficient care and increased risk for injuries in the event of a fall.
During a review of the facility`s Policy and Procedure (P&P) titled Safety of Residents, last reviewed on 1/16/2025, the P&P indicated that the purpose of this policy is to provide a safe environment for residents and facility staff.
During a review of the facility`s Policy and Procedure (P&P) titled Fall Management, last reviewed on 1/16/2025, the P&P indicated that the purpose of this policy is to reduce risk for falls, minimize the actual occurrence of falls, address the injury and to provide care for a fall. If a patient falls document accident/incident in the clinical record, update care plan to reflect new interventions and notify the physician and responsible party.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
During an interview on 4/11/2025 at 3:20 p.m., with the Director of Nursing (DON), the DON stated licensed staff are required to monitor the residents for complications associated with urinary catheter.
The DON stated licensed staff are required to provide catheter care to the residents who have indwelling catheter and document in the resident`s medical record.
The DON stated licensed nurses did not document anywhere in the Resident 49`s chart that they implemented the interventions of indwelling catheter care plan for the resident.
The DON stated the potential outcome of not providing care and monitoring for a resident`s indwelling catheter is the risk of infection and the inability to provide appropriate care and services to the resident.
During review of the facility`s Policy and Procedure (P&P) titled Urinary Catheter, last reviewed on 1/16/2025, the P&P indicated that the purpose of this policy is to decrease/eliminate difficulties associated with urinary catheter use.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
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 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 4/1/2025, 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.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
reviewed 1/16/2025, the P&P indicated, Medications included in the Drug Enforcement Administration
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.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
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.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
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. .
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
stored upright at controlled room temperature 68 to 77 degrees Fahrenheit and protected from light.
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.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
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.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
During a concurrent interview and record review on 4/10/2025 at 10:04 a.m., with the Registered
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.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
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.
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).
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
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.
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 hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid.
Food testing method: Spoon tilt test and Fork drip test.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
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.
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 substitutions of similar appeal and nutritional value.
Steps are taken to prevent resident exposure to the allergen(s).
Policy and Interpretation: (1) Food allergies are immune system responses to allergens (foods).
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, 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.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
F 0806 o
jeopardy to resident health or allergens does not occur. safety 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.
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 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.
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.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
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.
- During a review of Resident 96's admission Record, the admission Record indicated the resident
was admitted to the facility on [DATE], 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.
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 food prepared by the resident`s family brought into the Facility .when food items are intended for later 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 .
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
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.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
Based on observation, interview, and record review, the facility failed to:
- Ensure a resident's nasal cannula (a medical device that delivers supplemental oxygen therapy to
- Ensure a resident's urinal (a bottle for collecting urine) was labeled with a resident identifier for
people with low oxygen levels) oxygen tubing was not touching the floor for one of 12 sampled residents (Resident 71).
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
- 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.
056066 04/11/2025
Woodland Care Center 7120 Corbin Ave.
Reseda, CA 91335
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] 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.
056066
Form Approved OMB
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
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:
056066
Form Approved OMB
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
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:
056066
Form Approved OMB
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
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.