LOS ANGELES, CA - Federal inspectors found significant medication administration failures and safety violations at Brier Oak on Sunset nursing home during a January 2025 inspection, including the administration of expired insulin to diabetic residents and improper injection site rotation practices.
Critical Insulin Administration Failures
The most serious violations centered on the facility's mishandling of insulin therapy for diabetic residents. State inspectors discovered that multiple residents received expired insulin over several days, creating dangerous health risks for vulnerable patients with diabetes.
Resident 63 received expired Lantus insulin from December 20-30, 2024, administered by six different licensed nurses. The insulin pen had been opened on November 21, 2024, and should have been discarded after 28 days on December 19, 2024, according to manufacturer guidelines. Similarly, Resident 71 received expired insulin from December 27-30, 2024, after the medication had exceeded its 28-day room temperature storage limit.
During the inspection, Licensed Vocational Nurse 1 acknowledged that "administering expired insulin has lost its potency will not be effective in keeping the blood sugar levels stable" and could harm residents by causing hyperglycemia and diabetic ketoacidosis, potentially leading to hospitalization or death.
The Director of Nursing confirmed that multiple licensed staff members failed to remove expired insulin from medication carts as required by facility policies. The facility also lacked replacement insulin pens, creating a gap in essential diabetes care.
Improper Injection Site Rotation Practices
Inspectors identified a systematic failure to rotate injection sites for insulin and blood-thinning medications, affecting multiple residents over extended periods. This practice violates established medical protocols designed to prevent tissue damage and ensure proper medication absorption.
Resident 29, who received both insulin and heparin injections, experienced repeated injections in the same body areas. Records showed insulin administered consistently in the left arm over multiple days, with only occasional rotation to other sites. The facility's heparin administration records revealed similar clustering of injection sites in specific abdominal quadrants.
Resident 42 received insulin injections predominantly in abdominal areas without proper rotation between different body regions. Medical administration records documented consecutive injections in the same abdominal quadrants, contrary to best practices for subcutaneous medication delivery.
The facility's registered nurses acknowledged these failures during interviews, stating that "the standard of practice is to rotate the administration site of heparin and insulin to prevent the development of lipodystrophy and bruising."
Medical Consequences of Injection Site Violations
Failure to rotate injection sites creates multiple health risks for nursing home residents. When the same area receives repeated injections, fatty tissue under the skin can become damaged, leading to lipodystrophy - permanent changes in fat distribution that create lumps or depressions in the skin.
These tissue changes significantly impact medication absorption rates. Insulin injected into damaged tissue may not absorb properly, leading to unpredictable blood sugar control. For diabetic residents who rely on precise insulin dosing, this can result in dangerous fluctuations between high and low blood sugar levels.
Repeated injections in the same location also increase the risk of bruising, pain, and tissue scarring. In elderly residents with fragile skin, these complications can be particularly severe and slow to heal.
The medical standard requires rotating injection sites across different body areas - arms, thighs, and abdomen - and within each area to ensure healthy tissue and consistent medication absorption. Proper rotation also prevents the development of amyloidosis, a serious condition where abnormal proteins accumulate in tissues.
Delayed Critical Medication Administration
The inspection revealed concerning delays in administering time-sensitive medications. Resident 495, a kidney transplant recipient, experienced significant delays in receiving tacrolimus, an immunosuppressive medication crucial for preventing organ rejection.
The resident was scheduled to receive tacrolimus at 8 AM and 8 PM daily, with facility policy allowing only one hour variance. However, records showed the medication was consistently administered well outside this window - sometimes more than three hours late.
The resident herself reported the delays, stating "she has not been getting her medications for her kidneys on time" and that "she was the one reminding the staff to give her kidney medications."
Tacrolimus requires precise timing to maintain therapeutic blood levels. Irregular administration can lead to organ rejection, a life-threatening complication for transplant recipients. The medication works by suppressing the immune system's response to the transplanted organ, and consistent blood levels are essential for its effectiveness.
Expired Medication Storage and Emergency Kit Failures
Beyond insulin, inspectors found multiple instances of expired medications remaining in active storage areas. An emergency medication kit in the facility's medication room had expired in December 2024 but remained available for potential use during medical emergencies.
The facility also stored an expired Aplisol tuberculosis testing vial that had been opened on November 25, 2024, and should have been discarded after 30 days. Using expired tuberculosis testing materials can produce inaccurate results, potentially leading to missed diagnoses or inappropriate treatment decisions.
These storage violations indicate systematic failures in medication monitoring and inventory management. The facility's own policies required daily checks of medication storage areas and immediate removal of expired items, but staff clearly were not following these procedures consistently.
Additional Issues Identified
The inspection documented several other safety violations beyond medication administration errors:
Waste Management Problems: Garbage dumpsters in the facility parking lot were repeatedly observed overflowing with refuse bags stacked on top of open containers. This creates conditions that attract pests and potentially spread infections to the facility's 138 residents.
Hospice Care Coordination Failures: The facility failed to ensure proper documentation and visit scheduling for a hospice patient, with missing progress notes and cancelled visits that could delay necessary end-of-life care.
Infection Control Lapses: Staff were observed placing pillows from the floor onto clean linens, and resident equipment showed signs of damage that could harbor bacteria and complicate cleaning procedures.
The violations represent multiple breakdowns in the facility's quality assurance systems, from medication management to basic sanitation practices. While classified as causing minimal immediate harm, these deficiencies create cumulative risks for residents who depend on the facility for comprehensive healthcare services.
The facility must submit a plan of correction addressing each violation and demonstrate sustained compliance with federal nursing home standards to ensure resident safety and quality care.
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.
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