STUDIO CITY, CA - Federal inspectors discovered Studio City Rehabilitation Center allowed an unlicensed occupational therapy assistant to continue treating residents for at least three months after their California license expired, according to a federal inspection report released in August 2024.
Unlicensed Therapy Services Expose Residents to Risk
The most serious violation involved a Certified Occupational Therapy Assistant (COTA) whose California Board of Occupational Therapy license expired yet continued providing rehabilitation services to vulnerable residents. Federal inspectors found the COTA was still scheduled to work as late as the day before the inspection, despite having an expired license.
The facility's Director of Rehabilitation confirmed that according to the state licensing board's website, the COTA's license had expired, yet acknowledged the assistant was still working at the facility. When inspectors reviewed the facility's credentialing policy, they found it clearly stated that any employee with expired credentials should not be scheduled to work and should have their access deactivated immediately upon license expiration.
Professional licensing requirements exist to ensure healthcare workers maintain current competency and meet ongoing education standards. When facilities permit unlicensed individuals to provide therapy services, residents may receive inadequate or potentially harmful care from practitioners who have not maintained their professional credentials.
Occupational therapy plays a critical role in nursing home care, helping residents maintain independence, prevent falls, and preserve functional abilities. The therapy focuses on activities of daily living such as dressing, eating, and mobility - essential skills that directly impact residents' quality of life and safety.
Widespread Medication Safety Failures
Inspectors identified multiple medication errors that placed residents at risk of serious complications. The facility failed to follow basic medication administration protocols for insulin injections, a critical medication for diabetic residents.
For at least five residents, nursing staff repeatedly failed to rotate insulin injection sites as required by physician orders, facility policy, and manufacturer guidelines. Proper injection site rotation prevents lipodystrophy - a condition that causes pits, lumps, or thickened skin at injection sites. When injection sites develop these abnormalities, insulin absorption becomes unpredictable, making blood sugar control more difficult.
One registered nurse interviewed by inspectors stated that not rotating injection sites "constitutes a medication error" and could cause "bruising and swelling of the skin." The Director of Nursing confirmed that failing to rotate sites was considered a medication error due to not following physician orders and manufacturer guidelines.
Insulin management requires precise protocols because blood sugar fluctuations can cause serious complications including coma, seizures, and death. The facility's own insulin administration policy specifically required site rotation "preferably within the same general area" such as the abdomen, thigh, or upper arm.
Inspectors also found expired medications stored in refrigerators where they could be accidentally administered to residents. Two lorazepam vials - a controlled substance used to treat seizures and anxiety - were found expired or without proper dating labels. One vial for tuberculosis testing was also found without required date labeling.
Licensed nurses told inspectors that expired medications lose potency and sterility, potentially causing infections or treatment failures. For seizure medications like lorazepam, ineffective treatment could result in uncontrolled seizures, hospitalization, or death.
Infection Control Breakdowns Create Disease Risk
The facility demonstrated multiple failures in infection control practices that could facilitate the spread of dangerous pathogens among medically vulnerable residents.
Licensed nursing staff failed to properly wear protective gowns when caring for residents on enhanced barrier precautions. These special infection control measures are implemented for residents with open wounds, invasive medical devices, or multidrug-resistant bacterial infections. During the inspection, a Licensed Vocational Nurse was observed providing care to three such residents while wearing an improperly secured gown.
Enhanced barrier precautions require gowns to be fully fastened at both the neck and waist to prevent contamination from splashes, sprays, and contact with contaminated surfaces. The Centers for Disease Control and Prevention specifically requires gowns to "fully cover torso from neck to knees" and be "fastened in back of neck and waist."
Water temperature monitoring revealed another serious infection risk. The facility's water system frequently operated below 113 degrees Fahrenheit - the minimum temperature required to prevent Legionella bacteria growth. Legionella causes a severe form of pneumonia that can be fatal, particularly in elderly or immunocompromised individuals like nursing home residents.
Temperature logs showed multiple days where water temperatures fell to 110-112 degrees Fahrenheit, creating conditions where Legionella thrives. The facility's Infection Preventionist confirmed these temperature failures "predisposed the growth of Legionella in the water system" that could cause residents to become seriously ill.
Additional infection control failures included oxygen tubing touching floors, catheter drainage bags placed on floors instead of proper holders, and inadequate supplies of surgical masks - having only a one-week supply when two weeks minimum is recommended for outbreak preparedness.
Food Safety and Quality Concerns
Kitchen inspections revealed multiple food safety violations that could lead to foodborne illness outbreaks. Inspectors found dented canned goods stored with undamaged cans, creating contamination risks. Food Code regulations classify certain damaged cans as potentially hazardous because dents can compromise the container's seal and allow bacterial contamination.
Essential food safety equipment was missing or inadequate. Walk-in refrigerators and freezers lacked independent thermometers separate from built-in units, making it impossible to verify proper food storage temperatures if the primary systems failed. Kitchen equipment including mixers and pans showed food residue buildup, while overhead ventilation systems had dust accumulation that could contaminate food preparation areas.
Residents reported receiving unappetizing, overcooked food that affected their appetite and nutritional intake. During inspection, vegetables were observed to be "mushy and overcooked," salads appeared "wilted," and desserts looked "soggy." One resident stated the food "did not look appetizing" and refused to eat portions of their meal.
Poor food quality creates nutritional risks, particularly for residents already experiencing weight loss or malnutrition. The facility's own dietary policies required food to be "attractively served at the proper temperature" and prepared to "maximize flavor, appearance, and nutritional value."
Resident Safety and Quality of Life Impact
These violations collectively demonstrate systemic failures in resident care and safety oversight. When nursing homes fail to maintain proper licensing, medication protocols, infection control, and food safety standards, residents face increased risks of injury, infection, malnutrition, and inadequate treatment.
The unlicensed therapy services particularly concern patient advocates because occupational therapy directly impacts residents' functional abilities and fall prevention - critical factors for maintaining independence and preventing serious injuries in elderly populations.
Federal regulations require nursing homes to provide services only by qualified, properly licensed professionals to ensure residents receive appropriate care from competent practitioners. When facilities circumvent these requirements, they compromise both care quality and legal protections for residents and families.
Studio City Rehabilitation Center must now develop and implement correction plans addressing all identified violations to regain compliance with federal nursing home standards. The facility faces potential financial penalties and increased oversight until corrective measures are verified through follow-up inspections.
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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