CANOGA PARK, CA — Federal health inspectors documented a 24% medication error rate at Canyon Oaks Nursing and Rehabilitation Center during a February 2025 survey — nearly five times the maximum 5% rate permitted under federal regulations. The inspection uncovered a pattern of medication safety failures affecting multiple residents, including the administration of expired insulin, unaccounted controlled substances, and repeated insulin injection site violations.
The 73-page inspection report, completed on February 27, 2025, identified deficiencies across pharmaceutical services, medication administration, pain management, wound care, respiratory care, and resident safety at the Canoga Park facility located at 22029 Saticoy Street.
Medications Crushed Without Physician Authorization
The most alarming finding centered on a licensed vocational nurse who was directly observed crushing six medications for a resident with dementia without any physician order to do so. On February 24, 2025, inspectors watched as the nurse crushed aspirin, calcium with Vitamin D, iron supplements, docusate sodium, memantine hydrochloride, and Tylenol together into a single bag, mixed the combined powder with applesauce, and administered it to the resident.
The resident then swished water in her mouth and spit the medications into a basin. The nurse acknowledged she could not determine how much of the dose — or which specific medications — the resident actually received.
When contacted about the practice, the resident's primary care physician stated the resident did not have difficulty swallowing and that he was unaware medications were being administered in crushed form. Six medication errors out of 25 total opportunities during the observation produced the 24% error rate, documented under F-tag 759.
Crushing medications without a physician's order is classified as a medication error because it changes the form of the drug from what was prescribed. Some medications are specifically designed not to be crushed — certain formulations rely on intact tablet coatings for proper absorption, timed release, or to protect the stomach lining. Combining multiple crushed medications together further compounds the risk, as drug interactions can occur when medications are mixed outside of their intended delivery form.
Expired Insulin and Eye Drops Administered to Residents
Inspectors found that staff administered expired insulin to a diabetic resident and expired glaucoma eye drops to another resident, both stored in the same medication cart.
A Fiasp insulin pen for one resident had been opened on January 28, 2025, giving it a 28-day use window that expired on February 24. Records confirmed a nurse administered a dose from the expired pen on February 25 at 6:30 a.m. Expired insulin loses its potency, meaning it may not effectively lower blood sugar levels. Uncontrolled blood sugar can lead to hyperglycemia, which in severe cases can progress to diabetic ketoacidosis or diabetic coma.
Similarly, a latanoprost eye drop bottle for a resident with glaucoma had been opened on January 12, 2025, and was administered on both February 23 and February 24 — well beyond its recommended use period. Expired eye drops pose a dual risk: diminished effectiveness in controlling eye pressure and potential contamination, since the preservative system in the medication degrades over time.
"Administering expired insulin will not be effective in treating residents' blood sugar levels and can harm the resident by causing high blood sugar levels," one licensed nurse told inspectors during the survey.
Insulin Injection Sites Not Rotated for Weeks
Two diabetic residents received insulin injections at the same anatomical site for extended periods, in direct violation of manufacturer guidelines, physician orders, and the facility's own policies.
One resident, who lacked the cognitive capacity to make decisions, received insulin glargine injections in the left upper quadrant of the abdomen on at least 16 documented occasions between February 1 and February 19, 2025, with no rotation to alternative sites.
A second resident received Humulin R insulin injections in the left lower quadrant of the abdomen on five occasions in December 2024, again without any site rotation.
Repeated injections at the same site can cause lipodystrophy — the formation of pits, lumps, or thickened areas in the skin and fatty tissue beneath the injection site. These tissue changes can alter insulin absorption rates unpredictably, making blood sugar management unreliable even when the correct dose is administered. The manufacturer's guidelines for both insulin products specifically instruct users to rotate injection sites with each dose to prevent these complications.
A registered nurse confirmed during the inspection that the failure to rotate sites constituted a medication error under the facility's own policies.
Controlled Substance Accountability Gaps
The inspection revealed multiple failures in tracking controlled medications — substances with potential for abuse that require strict documentation under federal and state law.
Inspectors found a one-dose discrepancy in pregabalin, a controlled pain medication, between what the accountability log showed and what was physically present in the medication cart. A nurse acknowledged she had administered a dose to a resident that morning but failed to document it on the controlled drug record. The facility's policy requires immediate documentation when any controlled substance is removed from storage.
Additionally, two emergency medication kits containing controlled substances in one medication cart had no accountability log for the entire month of February 2025. Without shift-by-shift reconciliation, there is no way to verify whether controlled substances were used appropriately, went missing, or were diverted.
An emergency medication kit in another medication room had been opened on February 13 and remained unreplaced for more than 11 days at the time of inspection — well beyond the facility's 72-hour replacement requirement. This gap meant critical emergency medications may not have been available if a resident required urgent treatment.
Wound Care Interrupted for Nine Days
A resident admitted with a Stage 2 pressure ulcer on the sacral region went nine consecutive days without prescribed wound treatment. The physician had ordered daily wound care — cleansing with normal saline, applying zinc oxide, and covering with a dry dressing — for 21 days. The treatment order expired on February 10, 2025, but the treating nurse failed to contact the physician before the stop date to continue the order.
No wound treatment was provided between February 11 and February 19. The same treatment was eventually resumed on February 20 after the lapse was identified.
"The wound could have worsened and could have resulted in infection when no treatment was provided," the treatment nurse acknowledged to inspectors. Pressure ulcers that go untreated can deteriorate rapidly, progressing from superficial skin damage to deep tissue involvement that can reach muscle and bone, with associated risks of systemic infection.
Antipsychotic Medication Continued Despite Discontinuation Order
A psychiatric nurse practitioner ordered the discontinuation of aripiprazole, an antipsychotic medication, for a resident with schizophrenia on January 24, 2025, noting the resident's psychosis symptoms had stabilized. However, medication records showed the facility continued administering the drug daily through February 18, 2025 — 25 days after the discontinuation order.
When the nurse practitioner followed up on February 7, the clinical note indicated no apparent distress after discontinuing the medication — suggesting the prescriber believed the drug had already been stopped. The resident's own assessment showed no behavioral symptoms such as screaming, supporting the decision to discontinue.
Antipsychotic medications carry significant risks for elderly nursing home residents, including tardive dyskinesia, tremors, dizziness, excessive sedation, and increased fall risk. Federal regulations require facilities to attempt gradual dose reductions of psychotropic medications unless clinically contraindicated.
Additional Violations Documented
The inspection also identified failures in:
- Oxygen therapy: A resident with respiratory failure and hypoxia was found with oxygen tubing disconnected and tucked under his gown while the concentrator ran, meaning he received no supplemental oxygen despite a physician's order to maintain saturation above 90%. - Pain management: A cancer patient with bone metastases went without documented pain monitoring on multiple shifts, and staff failed to complete required pain assessments after two changes in condition. - Hearing aid maintenance: A resident's broken hearing aid went unreported and unrepaired, leaving her unable to communicate her care needs to staff. - Medication availability: A resident's bladder medication was unavailable for nine days, while nurses falsely documented in electronic records that the medication had been administered on days it was not in stock. - Pharmacist recommendations ignored: A consultant pharmacist's recommendation to start iron supplements for a resident with anemia was never communicated to the physician.
Facility Response
Canyon Oaks Nursing and Rehabilitation Center is required to submit a plan of correction addressing each deficiency. The Director of Nursing acknowledged multiple failures during the inspection and indicated the facility would implement corrective measures, including staff in-services on medication ordering procedures and new accountability logs for controlled substance tracking.
All deficiencies were classified at the level of "minimal harm or potential for actual harm," with the medication error rate and several pharmaceutical service violations affecting multiple residents.
The full inspection report is available through the Centers for Medicare & Medicaid Services and provides additional details on each cited deficiency.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Canyon Oaks Nursing and Rehabilitation Center from 2025-02-27 including all violations, facility responses, and corrective action plans.
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