Valley Village Care: Medication Errors & Safety Fails - CA
The February inspection revealed a cascade of medication safety failures affecting multiple residents at the 13000 Victory Boulevard facility. Licensed Vocational Nurse 1 admitted that Resident 32's insulin injection sites "were not rotated" and "should have been rotated per standards of practice to prevent pain, redness, irritation, bruising, and pits on the resident's skin."
Inspection records show nurses gave Resident 32 both types of insulin — long-acting Lantus and short-acting Novolog — in the same abdominal areas repeatedly over weeks. From February 11 through February 16, staff injected Novolog into the left upper quadrant of the resident's abdomen five consecutive times.
The manufacturer's guidelines explicitly warn against this practice. The Lantus instructions state: "Change (rotate) the injection sites within the area chosen with each dose to reduce the risk of getting lipodystrophy (pitted or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites."
For Novolog, the manufacturer warns: "Do not give into skin that is thickened, or has pits, or has lumps."
The Assistant Director of Nursing acknowledged the violations could cause "adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin."
A separate medication error involved Licensed Vocational Nurse 1 administering Norco, a powerful pain medication, to Resident 32 despite the resident reporting a pain level of zero. The physician's order specified Norco should only be given "for severe breakthrough" pain with levels "seven to ten."
The Director of Staff Development told inspectors "Norco should not be given to Resident 32 when pain level is zero. Zero means Resident 32 had no pain."
Safety violations extended beyond individual medication errors. Licensed Vocational Nurse 4 left two acetaminophen tablets and an enoxaparin injection on top of a medication cart "unattended and out of her sight" while she walked to the nurses station.
"Should not be leaving medications unattended as there can be a potential for someone to take the medications," the nurse admitted to inspectors.
The facility's own policy requires medication carts remain "closed and locked when out of sight of the medication nurse" with "no medications kept on top of the cart."
Another resident faced different risks when Licensed Vocational Nurse 3 gave potassium medication with only two ounces of water instead of the required "full glass of water." The physician's order specified the medication should be taken "with food and full glass of water or juice of four ounces."
The nurse acknowledged the error: "Two ounces is not full glass of water. She should have followed the physician's order."
The Director of Nursing explained that "taking potassium with a full glass of water helps lessen upsetting the stomach."
Perhaps most concerning was a medication given 102 times without proper authorization. Resident 2 received heparin injections twice daily from December 28, 2024, through February 16, 2025, even though the physician's order failed to specify the route of administration.
The order read "heparin sodium injection solution 5000 units hemodialysis two times a day," but Resident 2 was not on dialysis. The medication label indicated subcutaneous administration for blood clot prevention, contradicting the physician's order.
Registered Nurse 1 told inspectors "the medication should have been held and clarified with the physician prior to administration." The Assistant Director of Nursing called it "a significant medication error" because "the five rights of medication administration includes the right route."
The inspection also revealed systemic failures in monitoring residents on blood-thinning medications. Resident 2 had no physician's order requiring staff to monitor for bleeding symptoms despite receiving heparin daily. The facility's own policy requires staff to "assess for evidence of effects related to the subtherapeutic or greater than therapeutic drug level" and monitor for "excessive bruising, or other evidence of bleeding."
Feeding assistance failures compounded medication problems. Resident 67, who had a physician's order for "feeding assistance at all times," was repeatedly observed without staff help during meals. On February 16, inspectors found the resident "sitting up with tray in front of him" with "no staff assisting Resident 67 with his meal."
A treatment nurse estimated the resident "may have eaten two bites of his breakfast." The resident's family member told inspectors staff "do not help him to eat."
Licensed Vocational Nurse 4 explained that without assistance, "if CNAs are not assisting Resident 67 with meals, he will not eat and will have his tray in front of him untouched."
The facility also failed to notify physicians when residents ate poorly. Licensed Vocational Nurse 4 reviewed records showing Resident 67 consumed less than 50% of consecutive meals on February 10, February 13, and February 14, but "should have been reported to the MD" according to the care plan.
Environmental hazards added to resident risks. Inspectors found Resident 23's path to the bathroom blocked by his roommate's wheelchair on multiple occasions. Licensed Vocational Nurse 4 acknowledged "the area leading to the bathroom should be clear for Resident 23 to be able to use the restroom and the resident can fall trying to get into the bathroom."
The resident told inspectors "staff place his roommate's wheelchair locked and blocking the bathroom door making him unable to use the bathroom."
Two residents had overbed tables placed on top of their fall-prevention floor mats, creating unstable surfaces. Certified Nursing Assistant 5 noted the table "wheels left an indentation on the floor mat and was unstable when she tried to move it." She warned "the overbed table can fall on Resident 297 and cause injury to the resident."
Kitchen operations violated food safety standards. Inspectors found expired items including corn flakes, breadcrumbs, beans, and cheese past their use-by dates. Multiple food items lacked proper labeling with received dates, open dates, or use-by dates.
The facility failed to record storage room temperatures on February 13 evening and February 14 morning and evening, despite policies requiring twice-daily monitoring to prevent bacterial growth.
Infection control lapses included medication bottles covered in "light brown drippings" that nurses described as "sticky" but continued using without cleaning. Licensed Vocational Nurse 4 acknowledged "the importance of cleaning the Prostat bottle was for infection control."
The violations affected residents with complex medical conditions including diabetes, dementia, heart failure, and stroke recovery. Many lacked capacity to understand their care or advocate for themselves.
Federal inspectors classified the violations as causing "minimal harm or potential for actual harm" but noted the practices could lead to medication errors, falls, malnutrition, and infections among the facility's vulnerable population.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Valley Village Care Center from 2025-02-17 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
VALLEY VILLAGE CARE CENTER in NORTH HOLLYWOOD, CA was cited for violations during a health inspection on February 17, 2025.
The February inspection revealed a cascade of medication safety failures affecting multiple residents at the 13000 Victory Boulevard facility.
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.