Sherman Village HCC: Expired Insulin Violations - CA
Federal inspectors found the expired Humulin R vial during a September 6 inspection of Sherman Village HCC on Riverside Drive. The insulin had been stored at room temperature since a date that made it expire days before nurses continued drawing doses from it.
Licensed Vocational Nurse 5 told inspectors the multi-dose vial for Resident 85 was labeled with a date indicating use began weeks earlier. The nurse said most insulin vials expire within 30 days of opening, and this Humulin R vial had expired days before the inspection.
"Humulin R doses administered to Resident 85 after [the expiration date] came from that expired vial, and no other vial was opened or used," LVN 5 told inspectors.
The nurse explained that expired insulin loses its potency and effectiveness. When administered, it cannot properly control blood sugar levels, potentially causing hyperglycemia or hypoglycemia that could result in coma, hospitalization, or death.
The manufacturer's labeling requires opened Humulin R vials to be stored at room temperature below 86 degrees and used or discarded within 31 days of opening. The facility's own policy states that outdated medications "are immediately removed from stock" and disposed of properly.
Director of Nursing acknowledged that several licensed vocational nurses failed to remove the expired insulin from the medication cart, leading to what she called a "significant medication error." She said expired insulin has lost its strength and effectiveness, and when given by mistake, it won't control blood sugar levels effectively.
The violation forced Resident 85 to undergo additional laboratory testing and required a change of condition notification due to the medication error's adverse effects.
But medication errors were just one problem inspectors documented during their visit to the 100-bed facility.
In the kitchen, dietary staff ignored portion control requirements for residents on life-sustaining renal diets. Two residents with end-stage kidney disease received incorrect portions because staff used tongs instead of measuring scoops when serving pasta.
Residents 29 and 39, both diabetics with severe kidney problems requiring dialysis, needed precise half-cup portions of wheat pasta. The facility's menu spreadsheet specifically called for renal diet residents to receive exactly half a cup of the seasoned wheat pasta.
During the lunch service observation, a dietary worker used tongs to portion the pasta instead of the required gray scoop. The Dietary Supervisor told inspectors that staff "needed to use the right utensils" and follow the spreadsheet exactly.
"If residents received more, they could gain weight and if less they could lose weight without trying," the supervisor explained.
The Registered Dietitian said staff couldn't get exact measurements using tongs, and incorrect scoop sizes meant residents wouldn't get appropriate portions. This could cause weight gain or loss and prevent residents from getting adequate calories and protein for their specific dietary needs.
For residents with kidney failure, portion control becomes critical. Too much potassium, sodium, or phosphorus can overwhelm damaged kidneys and worsen their condition.
Infection control violations spread throughout the facility, putting vulnerable residents at risk of disease transmission.
A restorative nursing aide removed his mask and blew on hot food for Resident 6 during lunch, then alternated between feeding two residents without washing his hands between them. The aide told inspectors he lowered his mask and blew on the resident's meat to cool it off, and didn't sanitize his hands because "he didn't have anything to sanitize his hands with."
The Infection Preventionist said blowing on food could transfer contaminated droplets that residents would then ingest. Staff are required to wash hands immediately before and after providing feeding assistance to each resident.
Unlabeled urinal bottles created cross-contamination risks in shared bathrooms. Inspectors found used urinals hanging from railings in restrooms shared by Residents 42 and 83, with no labels identifying which resident they belonged to.
Licensed Vocational Nurse 3 found the unlabeled urinal and said he didn't know which resident it belonged to because it wasn't labeled. "All urinals should be labeled to make sure they are used for only one resident and to prevent multiple residents from using the same urinal," he said, then threw the urinal away.
Similar labeling failures affected respiratory equipment. The suction tubing for Resident 84, who depends on a ventilator, carried an unreadable date label. Respiratory Therapist 4 couldn't determine when the equipment was last changed, creating infection risks.
"It was important to label the suction with a readable date to ensure it was not too old as it tends to grow bacteria and viruses when used for a longer period of time that can cause the resident to get respiratory infections," the therapist explained.
Oxygen tubing for two residents touched the floor, violating infection control standards. Staff acknowledged the tubing should remain off the floor to prevent what the Director of Nursing called "ascending infection."
Enhanced Barrier Precautions, designed to protect residents with medical devices from drug-resistant infections, were routinely ignored. Licensed Vocational Nurse 3 started tube feeding for Resident 80 without wearing the required gown, despite the resident's care plan specifically calling for gown and glove use during any gastrostomy tube access.
The nurse incorrectly believed he only needed a gown when giving medications through the tube, not when starting nutritional feedings. The Director of Nursing confirmed that accessing any gastrostomy tube requires full protective equipment, and failure to follow protocols "could potentially result in the spread of infection and may cause cellulitis."
Kitchen sanitation problems compounded the infection risks. Refrigerator fans accumulated dust, walk-in cooler shelves showed rust and amber discoloration, and dietary workers wore multiple rings, watches, and gold bracelets while handling food.
The Dietary Supervisor acknowledged that jewelry "contained germs and could cause cross-contamination" but continued allowing staff to wear prohibited accessories during food preparation.
Outside the building, trash scattered around dumpsters created additional contamination risks. The Housekeeping Supervisor said maintaining the area was difficult because "there were too many people throwing trashes and it was hard to maintain."
Vaccination protocols failed for multiple residents during the 2023-2024 flu and COVID-19 seasons. Three residents never received required education about vaccine risks and benefits, and staff failed to document consent or refusal decisions.
The Infection Preventionist admitted he "could have done more" to ensure residents received proper vaccination education and administration. He said the vaccines were critical because "vulnerable residents were the highest risk for hospitalization and death" from these diseases.
Even basic safety systems failed residents. Resident 70's call light activated inside his room but didn't trigger the alert light outside his door, meaning staff couldn't see when he needed help. The resident said he'd experienced response delays of up to two hours due to the malfunctioning system.
The Director of Nursing said a broken call light system meant "facility staff would not be able to meet the needs of the resident" and could affect "the resident's dignity and safety."
The inspection revealed a facility where basic safety protocols had broken down across multiple departments, from medication management to food service to infection control, putting residents at risk of preventable harm.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sherman Village Hcc from 2024-09-06 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
SHERMAN VILLAGE HCC in NORTH HOLLYWOOD, CA was cited for violations during a health inspection on September 6, 2024.
Federal inspectors found the expired Humulin R vial during a September 6 inspection of Sherman Village HCC on Riverside Drive.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.