STUDIO CITY, CA - A federal inspection of Studio City Rehabilitation Center completed on August 23, 2024, revealed a pattern of medication management failures, including an error rate that exceeded the federally allowed threshold and a widespread failure to rotate insulin injection sites for multiple residents.
Medication Error Rate Exceeds Federal Limit
Federal regulations require that nursing homes maintain a medication error rate below 5 percent. During the August 2024 survey, inspectors documented two medication errors out of 31 total opportunities, producing an overall error rate of 6.45% — well above the acceptable ceiling.
Both errors involved a single resident, identified as Resident 56, a patient with diagnoses including Type 2 diabetes and gastritis. On the morning of August 21, 2024, a Licensed Vocational Nurse (LVN) was observed administering metformin — a blood sugar management medication — at approximately 9:06 AM. The physician's order specified that metformin should be given at 7:30 AM with meals.
Metformin is specifically prescribed with meals for a medically important reason: taking it on an empty stomach significantly increases the risk of gastrointestinal side effects, including nausea, cramping, and stomach irritation. For a resident already diagnosed with gastritis — inflammation of the stomach lining — receiving this medication nearly 90 minutes late and without food compounds that risk considerably.
During the same medication pass, the LVN also failed to prepare or administer docusate, a stool softener prescribed for bowel management that was due at 9 AM. The omission of docusate places a resident at risk for constipation, which in elderly nursing home residents can escalate to fecal impaction, a potentially serious medical condition.
The LVN acknowledged both errors during a subsequent interview with inspectors. "LVN 2 stated that Resident 56 was at risk of having stomach irritation from not administering metformin with meals at 7:30 AM, and at risk of having constipation from not administering docusate," the inspection report noted.
The facility's own policy, titled Administering Medications and dated April 2019, clearly states that medications must be administered within one hour of their prescribed time and in accordance with prescriber orders. The metformin administration fell outside that window, and the docusate was omitted entirely — both meeting the facility's own definition of medication errors.
Insulin Injection Site Rotation Failures Across Five Residents
Perhaps more concerning in scope was the facility's systematic failure to rotate subcutaneous insulin injection sites. Inspectors found that five of seven sampled residents receiving insulin — identified as Residents 12, 38, 49, 56, 116, and 125 — were not having their injection sites properly rotated.
Injection site rotation is a fundamental component of safe insulin administration. When insulin is repeatedly injected into the same area of tissue, it can cause lipodystrophy — an abnormal redistribution of fat beneath the skin that creates hardened lumps or indentations. These tissue changes are not merely cosmetic; they directly affect how insulin is absorbed into the bloodstream. Insulin injected into lipodystrophic tissue absorbs unpredictably, which can lead to dangerous blood sugar fluctuations — both hyperglycemia (dangerously high blood sugar) and hypoglycemia (dangerously low blood sugar).
Repeated same-site injections can also lead to cutaneous amyloidosis, a condition where clumps of abnormal proteins accumulate in the skin. This further degrades the injection site and compounds absorption problems.
The standard of care for insulin administration in long-term care facilities requires that nursing staff document the injection site used for each administration and systematically rotate between areas — typically the abdomen, thighs, upper arms, and buttocks. Proper rotation protocols ensure each site has adequate time to recover between injections, preserving tissue integrity and maintaining consistent medication absorption.
The fact that this failure was identified in five out of seven residents sampled suggests a facility-wide practice issue rather than an isolated incident. This pattern points to gaps in staff training, documentation protocols, or clinical oversight regarding injection administration.
Blood Thinner Injection Also Affected
One of those residents, Resident 38, faced an additional risk. In addition to insulin, Resident 38 was receiving enoxaparin — an anticoagulant medication used to prevent and treat blood clots — also administered via subcutaneous injection. Inspectors found that injection site rotation was not being performed for the enoxaparin either.
Failure to rotate enoxaparin injection sites carries its own set of risks. Repeated injection in the same location increases the likelihood of localized bruising, hematoma formation, and tissue damage. Because enoxaparin itself is a blood thinner, bruising and bleeding complications at the injection site can be more pronounced, and compromised tissue from repeated same-site administration can create additional complications.
Unmonitored Sleep Medication Raises Unnecessary Drug Concerns
A separate but related deficiency involved the facility's management of Resident 126, a patient with a diagnosis of depression who was prescribed melatonin 5 mg at bedtime since March 2022 — more than two years before the inspection.
The resident's care plan, initiated July 8, 2024, established a goal of six hours of sleep per night. However, inspectors could find no documentation that the facility was actually monitoring how many hours the resident slept. Without that monitoring, there was no way to determine whether the melatonin was effective, whether the dosage needed adjustment, or whether the medication could be reduced or discontinued altogether.
The facility's own consultant pharmacist had flagged this issue in a Medication Regimen Review dated June 26, 2024. The pharmacist recommended updating the indication for melatonin to specify "for supplement to regulate circadian rhythm" and suggested implementing monitoring for hours of sleep during evening and nighttime shifts. The follow-through column on the pharmacist's review was completely empty — no documentation, no dates, no signatures indicating anyone had reviewed or acted on these recommendations.
The Director of Nursing confirmed during an interview that "without monitoring hours of sleep it was unknown if non-pharmacological interventions and/or Melatonin were effective in reaching the goal of 6 hours of sleep and when to make changes to medications such as lowering the dose or discontinuing."
Under federal regulations, a resident's drug regimen must be free from unnecessary medications. A drug is considered unnecessary when it is administered without adequate monitoring or without adequate indication for its use. The failure to track sleep hours while continuing to administer melatonin for over two years, combined with the ignored pharmacist recommendations, placed this medication squarely in that category.
What These Violations Mean for Resident Safety
The deficiencies identified at Studio City Rehabilitation Center reflect breakdowns at multiple levels of the medication management process. The "five rights" of medication administration — right patient, right drug, right dose, right time, and right route — represent the most basic safety framework in nursing care. The errors involving Resident 56 violated two of those rights in a single medication pass.
The injection site rotation failures represent a more systemic concern. Insulin-dependent residents in long-term care facilities rely entirely on nursing staff to manage their injections safely. When rotation protocols are not followed across a majority of sampled residents, it indicates a gap in clinical practice that extends beyond individual staff performance.
The melatonin monitoring failure illustrates a different but equally important problem: the breakdown of the pharmacist review process, which exists specifically as a safety check to ensure medications remain appropriate and necessary over time. When pharmacist recommendations go unreviewed and unsigned, that safety net ceases to function.
Facility Response and Regulatory Context
Studio City Rehabilitation Center, located at 11429 Ventura Boulevard in Studio City, California, was required to submit a plan of correction addressing each identified deficiency. The violations were classified at the level of minimal harm or potential for actual harm, affecting few to some residents depending on the specific deficiency.
Federal nursing home regulations under 42 CFR Part 483 establish the standards against which these deficiencies were measured. The medication error rate threshold of 5% is a firm federal benchmark, and facilities exceeding it are cited regardless of whether individual errors resulted in documented harm. The standard exists because medication errors, even when they do not cause immediate observable harm, create cumulative risk — particularly in elderly residents who are often managing multiple chronic conditions simultaneously.
Families of residents at Studio City Rehabilitation Center can access the full inspection report, including the facility's plan of correction, through the Centers for Medicare and Medicaid Services Care Compare website or by contacting the California Department of Public Health.
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.
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