Federal inspectors found that staff administered insulin shots to one resident 11 times in February, with nine of those injections going into the same left lower quadrant of the abdomen. Another resident received multiple insulin and blood thinner injections in identical locations despite doctor's orders specifically requiring site rotation.
The violations occurred even though the facility's own policy, last reviewed in December 2024, states that injection sites should be rotated to reduce the risk of damaging skin tissue.
Resident 65, a diabetic with moderately impaired cognition who required substantial assistance with daily activities, received insulin lispro injections according to a sliding scale based on blood sugar levels. The resident's physician had ordered the medication be administered "before meals and at bedtime" with explicit instructions to "rotate injection site."
But Licensed Vocational Nurse 3 told inspectors that injection sites were not rotated, despite the physician's order and standards of practice. The nurse acknowledged that proper rotation prevents "pain, redness, irritation, bruising, and pits on the resident's skin."
Records showed a pattern of repeated injections in the same locations. On February 2, 3, 8, and 15, nurses gave shots in the left lower quadrant of the abdomen. When they did switch sides, they clustered injections in the right lower quadrant on February 6, 8, 12, and 13.
The Director of Nursing confirmed that administration sites should have been rotated to prevent "adverse effects such as bruising, skin irritation, skin pits, lipodystrophy and amyloidosis which can affect absorption of the insulin."
Manufacturer guidelines for insulin lispro warn users to "change (rotate) your injection sites within the area you choose for each dose to reduce your risk of getting lipodystrophy (pits in skin or thickened skin) and localized cutaneous amyloidosis (skin with lumps) at the injection sites."
The guidelines specifically instruct not to inject where skin has pits, is thickened, has lumps, is tender, bruised, scaly, hard, or into scars or damaged skin.
Similar violations occurred with Resident 29, who had type 2 diabetes and was receiving both insulin and heparin injections. The resident received heparin shots for blood clot prevention and insulin according to a sliding scale, with both medications ordered to have injection sites rotated.
Records showed heparin injections on January 24 and 25 both went into the left lower quadrant of the abdomen. Insulin shots on January 29 were administered twice in the same location. Later injections on February 14 and 15 were both given in the left upper quadrant.
Registered Nurse 1 told inspectors there were "multiple instances where the licensed staff did not rotate the subcutaneous administration of heparin and Humulin R on the resident." The nurse said rotation was important to prevent "excessive bruising and lipodystrophy on residents."
The Director of Nursing said staff should have rotated sites to prevent "adipose tissue buildup on the frequented site, discoloration, and hardening of the skin which can affect absorption of the medication." She noted there was no excuse for repeating sites since the electronic health record shows where the last injection was given.
Heparin manufacturer guidelines state that "a different site should be used for each injection to prevent the development of massive hematoma."
A third resident, Resident 52, experienced similar problems with insulin NPH injections. Despite having severely impaired cognitive skills and requiring the medication twice daily for diabetes, staff repeatedly used the same injection sites.
On January 5, both morning and evening insulin shots went into the left lower quadrant of the abdomen. The same pattern repeated on January 19. When staff did change locations, they switched to clustering injections in the right lower quadrant on February 7 and 8.
The facility also failed to properly administer thyroid medication to another resident. Resident 197, who was admitted on February 17 with hypothyroidism, told inspectors she had "only received her thyroid medication only two to three times this week" and had not received it that morning.
The resident was prescribed levothyroxine sodium 75 micrograms once daily. Her care plan specified the need for daily thyroid replacement therapy with monitoring by licensed nurses for side effects and effectiveness.
Licensed Vocational Nurse 1 confirmed that three doses had not been administered from a 15-tablet supply. The nurse told inspectors that when the thyroid medication is not given, "the resident could have confusion."
The Director of Nursing called this "a medication error" that required notifying the doctor and family. She said missed thyroid medication "could affect Resident 197's thyroid functioning" and constituted a change in the resident's condition.
The facility's medication error policy requires staff to notify the resident's representative and physician to obtain further instructions when medication reaches a resident in error, and to monitor the resident according to the prescriber's instructions.
Inspectors found these medication administration failures during a February 28 survey of the 93534-bed facility on 10th Street West. The violations were classified as causing minimal harm or potential for actual harm to residents.
The repeated injection site failures occurred despite the facility having clear policies and access to manufacturer guidelines warning about the risks of not rotating sites. Staff acknowledged knowing the requirements but failed to follow them consistently across multiple residents requiring regular injections.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Ellison John Transitional Care Center from 2025-02-28 including all violations, facility responses, and corrective action plans.
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