Health inspection·January 23, 2026

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a resident's comprehensive care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) for one of nine sampled residents (Resident 2) when Licensed Vocational Nurse 3 (LVN 3) failed to accurately document the administration of pyridoxine hydrochloride (a form of vitamin B6, used to treat and prevent vitamin B6 deficiency) in the medication list sheet (created by the facility to validate that Resident 2 received medications at the scheduled times).This deficient practice had the potential to create confusion among licensed staff regarding the administration of pyridoxine which could result in ineffective delivery of care and services to the resident.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/24/2025 and readmitted on [DATE] with diagnoses that included Parkinson's disease (a movement disorder of the nervous system that worsens over time), hypotension (low blood pressure), and bipolar disorder, (mental disorder that causes unusual shifts in mood, energy, activity levels, concertation, and the ability to carry out day-to- day tasks).During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 11/3/2025, the MDS indicated Resident 2's cognition (ability to think and make decisions) was intact and was able to make self-understood and understand others. The MDS further indicated that Resident 2 was independent with activities of daily livings (ADLs- activities such as bathing, dressing and toileting a person performs daily).During a review of Resident 2's Physician Order Summary Report dated 1/22/2026, the Order Summary Report indicated the following orders:- Pyridoxine hydrochloride (Pyridoxine HCL - a form of vitamin B6, used to treat and prevent vitamin B6 deficiency), or pyridoxine, oral tablet 25 milligram (mg- unit of measurement), give half (0.5) tablet by mouth one time a day every seven (7) days for vitamin B6 deficiency. Monitor for neuro (nerve, used to describe anything related to the nervous system) symptoms of too much of vitamin B6, tingling evolving to pain in feet and legs below knee. Order Date 9/24/2025.During a review of Resident 2's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications given to a resident) for pyridoxine administration history for 12/2025, the MAR indicated, pyridoxine was scheduled and administered on 12/4/2025, 12/11/2025, 12/18/2025, and 12/25/2025. During a review of Resident 2's untitled medication list dated 12/17/2025, the medication list sheet indicated that pyridoxine 25 mg to be given half (0.5) tablet every seven days on Thursday at 9 a.m. was marked with a check.During a review of Resident 2's Care Plan Report, with an initiated date of 5/14/2025, last revised on 8/21/2025, the Care Plan Report indicated Resident 2's power of attorney (POA legal authorization for a designated person to make decisions about another person's property, finances, or medical care) had episodes of denying/forgetting requests made (i.e. requesting orders for medications/supplements). The interventions included having licensed nurses discuss Page 1 of 2 056066 056066 01/23/2026 Woodland Care Center 7120 Corbin Ave. Reseda, CA 91335

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with the resident and to validate and initial in the medication sheets the medications and time of administration.During a concurrent interview and record review on 1/22/2026 at 2:40 p.m., with Licensed Vocational Nurse 3 (LVN 3), Resident 2's medication list dated 12/17/2025 and Resident 2's physician order for pyridoxine were reviewed. LVN 3 stated he mistakenly documented in the medication list sheet that pyridoxine was administered to Resident 2 but confirmed that the resident did not receive the medication. During a concurrent interview and record review on 1/23/2026 at 1:10 p.m., with the Director of Nursing (DON), the DON reviewed Resident 2's untitled medication list dated 12/17/2025. The DON stated that the medication list was created to validate that Resident 2 received medications at the scheduled times. The DON stated that LVN 3 checked pyridoxine as administered on Wednesday 12/17/2025, although it was scheduled to be given every Thursday. The DON reviewed Resident 2's care plan that indicated that the license nurses were to discuss medications with the resident and validate and initial in the medication list sheet the medications and administration times.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, An individualized comprehensive care plan that includes measurable objective and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident. Each resident's comprehensive care plan is designated to. Build on the resident's individualized needs, strengths, and preferences. 056066 Page 2 of 2