Federal inspectors documented the injection site failures during an August 23 survey, finding that nurses violated physician orders to rotate injection locations for five residents receiving diabetes medications.
Resident 116, who arrived in May with diabetes, kidney failure, and a urinary tract infection, received 20 insulin injections in nearly identical abdominal locations between June and August. Records show 15 of the 20 shots went into the left lower quadrant of the abdomen, with nurses clustering injections in the same small area rather than rotating sites as ordered.
The resident lacked capacity to understand decisions or communicate effectively, according to assessment records.
Resident 125 experienced similar treatment failures. Between June and August, nurses gave the resident 26 insulin injections, with 19 shots concentrated in the left lower abdominal quadrant. The resident had bilateral above-knee amputations and severe cognitive impairment.
Nurses also failed to rotate injection sites for blood thinner medications. Resident 38, diagnosed with quadriplegia and brain damage, received an anticoagulant called enoxaparin that required site rotation to prevent complications. Inspection records show seven consecutive injections in the left upper abdominal quadrant during May and June.
When confronted with the evidence, Registered Nurse 4 acknowledged the violations during an August 22 interview. "There were multiple instances where the insulin administration sites was not rotated," the nurse told inspectors, explaining that rotation prevents "bruising and swelling of the skin and to prevent lipodystrophy."
Lipodystrophy causes pitted or thickened skin at injection sites and can interfere with insulin absorption.
The facility's own policy, last reviewed in April 2024, explicitly requires site rotation "preferably within the same general area (abdomen, thigh, upper arm)." Manufacturer guidelines provided by the facility warn against using the same injection spot repeatedly, stating it increases "risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps)."
Director of Nursing confirmed the policy violations during an August 23 interview, stating "insulin injection sites should be rotated to prevent skin irritation and lipodystrophy."
The problems extended beyond individual oversights. Registered Nurse 7 told inspectors that "several licensed nurses failed to rotate the insulin administration sites" and placed residents "at risk of harm from lipodystrophy."
Two additional residents faced similar injection site failures. Resident 12 received consecutive insulin doses in the right upper abdominal quadrant on August 13 and 14. Resident 56's records showed multiple instances where nurses used the same injection locations repeatedly, including four consecutive shots in the right lower abdomen and three straight injections in the left lower quadrant.
The inspection revealed broader medication safety issues beyond injection site rotation. Nurses left controlled medications unaccounted for in five cases, with missing doses of hydrocodone, Ativan, and other controlled substances. The facility failed to properly document disposal of expired controlled medications, creating opportunities for drug diversion.
One nurse removed a diabetic resident's urinary catheter without a physician's order, then failed to monitor for urinary retention. When the catheter required reinsertion, the nurse used clean gloves instead of sterile technique, violating infection control protocols.
The facility also failed to provide prescribed rehabilitation equipment. Three residents with contracture risks did not receive ordered splints and hand rolls for weeks or months, with staff documenting that equipment was provided when it was not.
Resident 138, who could communicate, told inspectors he "used to wear a left elbow splint, but they stopped putting it on" and that his hand roll "got lost and he never received another one."
Safety hazards throughout the facility placed residents at additional risk. Inspectors found heavy oxygen equipment placed on fall mats, rendering them ineffective. Beds remained in elevated positions after care, increasing fall risks for high-risk residents. Alarm cords were too long, creating entanglement hazards.
The medication administration failures particularly endangered residents who could not communicate their needs. All five residents with injection site violations had severe cognitive impairments or communication difficulties, making them unable to report pain or skin problems from repeated injections in the same locations.
Federal regulations require nursing homes to ensure residents receive medications safely and according to physician orders. The repeated injection site violations represent a fundamental failure to follow basic medical protocols for vulnerable residents dependent on staff for all aspects of care.
The inspection found the facility's policies were adequate but staff consistently failed to follow them. The Director of Nursing acknowledged that proper injection site rotation was "common knowledge for licensed nurses" but that "several licensed nurses failed to rotate the insulin administration sites."
Studio City Rehabilitation Center, located at 11429 Ventura Boulevard, serves residents with complex medical needs including diabetes, respiratory failure, and neurological conditions. The August inspection documented violations across multiple areas of care, from medication administration to rehabilitation services.
The injection site failures represent more than documentation problems. For diabetic residents requiring daily insulin, repeated injections in the same locations can cause permanent skin changes that interfere with medication absorption and blood sugar control. The facility's own policies and manufacturer guidelines explicitly warn against these practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Studio City Rehabilitation Center from 2024-08-23 including all violations, facility responses, and corrective action plans.
Additional Resources
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