Federal inspectors found multiple medication safety failures at Brier Oak on Sunset during a January 3 inspection, including three residents who received a combined 22 doses of expired insulin over several weeks in December.
Resident 63 received 10 doses of expired Lantus insulin from five different licensed nursing staff between mid-December and the end of the month. Resident 71 got three doses of the same expired insulin from two staff members during the same period. Resident 141 received nine doses of expired Humulin insulin from four different nurses.
The expired medications came from medication cart 4, which multiple licensed nurses used without checking expiration dates.
Licensed Vocational Nurse 1 told inspectors that administering expired insulin "was not in accordance with manufacturer guidelines, standards of practice and facility policy and procedures." The Director of Nursing confirmed the violations could lead to "improper management of blood sugar resulting in a possible coma, hospitalization and/or death."
The facility's overall medication error rate hit 14.81 percent during the inspection observation period — nearly three times the federal five percent threshold. Inspectors observed four medication errors out of 27 opportunities, affecting two residents.
Resident 71, admitted with difficulty walking and gastrointestinal bleeding, was prescribed oyster shell calcium with vitamin D and psyllium husk powder for bowel management. During the 9:10 a.m. medication pass on December 31, LVN 1 gave the resident plain oyster shell calcium without vitamin D and polyethylene glycol solution instead of the prescribed psyllium husk powder.
"Not receiving vitamin D can harm Resident 71 by not only decreasing the absorption of the calcium but also leading to osteoporosis," LVN 1 told inspectors. The nurse said failing to give psyllium husk powder "would not help with passing stool easily."
Resident 88, admitted with a fractured left femur and iron deficiency, received the wrong forms of multivitamin and calcium supplements. The resident was prescribed a specific multivitamin tablet and calcium carbonate-vitamin D with minerals in a 600-400 mg-unit dose. Instead, LVN 1 administered a multivitamin with minerals and calcium with only 5 micrograms of vitamin D.
"Administering multivitamin with minerals to Resident 88 may not be beneficial to their health and may cause adverse effects," LVN 1 said. The wrong calcium dosage could "lead to fragile bones and potentially cause breakage of bones."
The Director of Nursing told inspectors that one medication order for Resident 88 was "unclear and confusing" and should have been clarified with the physician before administration.
Beyond expired medications and wrong doses, inspectors found nurses weren't rotating injection sites for insulin and blood thinner medications. Four residents receiving subcutaneous insulin injections had the same sites used repeatedly, which can cause lipodystrophy and abnormal protein buildup in the skin.
Resident 495's anti-rejection medication for a kidney transplant was consistently given late, potentially risking organ rejection.
The medication safety problems extended to controlled substance tracking. Inspectors found two accountability logs for controlled drugs awaiting disposal in the Director of Nursing's office that lacked required verification signatures from either the DON or a registered nurse.
The Director of Nursing admitted to inspectors that there was "no consistent process to sign & date the logs by the RN/DON" and acknowledged failing to sign the logs when receiving controlled substances from licensed vocational nurses. The DON said proper verification was "important to prevent medication diversions and accidental exposure of harmful substances to residents."
Meanwhile, RN 1, who became a registered nurse in August 2024 and was hired in October, was caring for residents with urinary catheters without completing required clinical competency training. The Director of Staff Development couldn't locate any documentation that the newly licensed nurse had completed catheter care assessments.
During interviews, the Director of Staff Development said she "was not sure if it was required to complete a FC skills competency assessment during the registered nurse's orientation." But the Director of Nursing said catheter care competency was required for all licensed nurses and should be included in the Competency Completion Log.
The DON told inspectors that RN 1's lack of catheter care training "could have potentially resulted in FC complications like trauma" causing "damage to the urinary track resulting in bleeding and pain" for residents with catheters.
The facility's own policies require nursing staff to demonstrate "the skills and techniques necessary to care for resident needs including basic nursing skills." The registered nurse job description states nurses must "demonstrate nursing skills utilized in direct patient care" and ensure staff complete required training programs.
Facility policy also mandates that "medications are administered as prescribed" and requires nurses to verify "the right medication, dose, route, and time of administration" before giving any medication to residents.
The inspection found that multiple licensed nurses failed to follow basic medication administration protocols, from checking expiration dates to rotating injection sites to verifying controlled substance accountability. The compounding failures affected at least eight residents and created risks ranging from organ rejection to diabetic coma.
The facility's medication error rate of 14.81 percent was nearly triple the federal five percent limit, indicating systemic problems with medication management that extended far beyond individual nurse mistakes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brier Oak On Sunset from 2025-01-03 including all violations, facility responses, and corrective action plans.