Woodland Care Center

F 0711

resident's total program of care and appropriate documentation.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/08/2025

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 0800 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to provide a nutritional supplement drink per physician's order for one of three sampled residents (Resident 1).This deficient practice had the potential for Resident 1 to receive insufficient food intake which could result in weight loss and malnutrition (lack of sufficient nutrients in the body).Findings:During a review of Resident 1's admission Record, the admission

Record indicated the facility readmitted Resident 1 on 8/26/2025 with diagnoses that included other toxic encephalopathy (a broad term for any brain disease that alters brain function or structure), sepsis (a life-threatening blood infection), and pneumonia (an infection/inflammation in the lungs).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 8/27/2025, the MDS indicated Resident 1's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the sense) was severely impaired. The MDS indicated Resident 1 substantial/maximal assistance required from staff with eating, oral hygiene, toileting hygiene and personal hygiene.During a review of Resident 1's Order Summary Report, the Order Summary Report indicated an order for regular diet, pureed texture (a texture modified diet that consists of smooth, moist foods that are easy to swallow, food with soft pudding like consistency), thin consistency, nutritional supplement drink one (1) bottle with meals, breakfast and lunch, ordered 8/26/2025.During a review of Resident 1's care plan (a document that summarizes a resident's needs, goals, and care/treatment) for resident is at nutritional risk, revised on 8/27/2025, the care plan indicated an intervention for nutritional supplement drink with meals breakfast and lunch for supplement.During a review of Resident 1's Nutritional assessment dated [DATE REDACTED] timed 12:09 p.m., the Nutritional Assessment indicated nutritional supplement drink twice a day with meals with breakfast and lunch to provide additional calories and protein.During an observation on 9/5/2024 at 12:45 p.m., in Resident 1's room, observed Resident 1's lunch tray. Observed no nutritional supplement drink on Resident 1's lunch tray.During an interview on 9/5/2025 at 2:58 p.m., with the Assistant Dietary Supervisor (ADS), the ADS stated that nutritional supplement drinks are not provided by the kitchen and are given to residents by nursing staff.During an interview on 9/5/2025 at 3:10 p.m., with the Director of Nursing (DON), the DON stated that certified nursing assistants will ask the charge nurses for the nutritional supplement drink to provide to residents.During an interview on 9/5/2025 at 3:15 p.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated that he (CNA 1) did not provide a nutritional supplement drink to Resident 1 because CNA 1 did not assist Resident 1 with lunch. CNA 1 stated that he did not provide a nutritional supplement drink for breakfast.During an interview on 9/5/2025 at 3:18 p.m., with Restorative Nursing Assistant (RNA 1), RNA 1 stated that she (RNA 1) assisted Resident 1 with lunch.

RNA 1 continued to state that RNA 1 did not provide Resident 1 with a nutritional supplement drink during lunch or breakfast.During an interview on 9/5/2025 at 4:30 p.m., with the DON, the DON stated that nutritional supplement drinks should have been provided to Resident 1 because it is a physician's order.During a review of the facility's policy and procedure (P&P), Therapeutic Diets, last reviewed 1/16/2025, the policy indicated the therapeutic diets are prescribed by the attending physician to support

the resident's treatment and plan of care in accordance with his or her goals and preferences.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/08/2025

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

p.m., in Resident 2's room, observed Resident 2's lunch meal tray. Observed no coffee on Resident 2's lunch meal tray.During an interview on 9/8/2025 at 12:55 p.m., with Resident 2, in Resident 2's room, Resident 2 stated that Resident 2 is missing his coffee.During a concurrent observation, interview, and

record review on 9/8/2025 at 12:56 p.m., with the Director of Staff Development (DSD), reviewed Resident 2's noon meal ticket. Observed Resident 2's lunch meal tray and the DSD stated that Resident 2 is missing his coffee.During an interview on 9/8/2025 at 1:10 p.m., with the Director of Nursing (DON), the DON stated all meal tickets should be followed because the facility should be following residents' preferences. The DON stated it is the residents' right.During an interview on 9/8/2025 at 5:00 p.m., with the Registered Dietician (RD), the RD stated that it is important to honor residents' dietary preferences and follow residents' meal tickets because following preferences and meal ticket will help in increasing oral intake. The RD stated if the facility does not follow residents' preferences and/or meal ticket, there is a possibility for residents to have decrease oral intake, will not receive adequate nutritional needs, and may have weight loss. During a review of the facility's policy and procedure (P&P), Resident Food Preferences, last reviewed 1/16/2025, the policy 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 department will provide residents with meals consistent with their preferences as indicated on their tray card.During a review of the facility's policy P&P, Therapeutic Diets, last reviewed 1/16/2025, the policy indicated the therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care in accordance with his or her goals and preferences.

Event ID:

Facility ID:

If continuation sheet