SHERMAN OAKS, CA - State health inspectors identified significant medication administration errors and staffing deficiencies at Sherman Oaks Health & Rehab during a March 2025 inspection, including failures to properly rotate insulin injection sites and ensure proper medication labeling that placed residents at risk for serious complications.
Critical Insulin Administration Errors Documented
The facility failed to follow basic insulin administration protocols for a diabetic resident, repeatedly using the same injection sites over multiple days in February and March 2025. Medical records revealed that Resident 107, who had Type 2 diabetes and chronic kidney disease, received insulin injections at identical abdominal locations on consecutive administrations, violating fundamental diabetes care standards.
Between February 22 and February 28, 2025, documentation showed multiple instances where nurses administered insulin glargine to the same abdominal quadrants without proper rotation. For example, the left lower quadrant was used for injections on February 22 at both 9:40 a.m. and 9 p.m., and again on February 24 and February 25. The left upper quadrant received repeated injections on February 22 at 10:41 a.m. and 4:30 p.m., and subsequently on February 27 and 28.
Repeated injection site use without rotation can cause lipodystrophy - an abnormal distribution of fat tissue that creates hardened or indented areas under the skin. These tissue changes interfere with insulin absorption, making blood sugar control unpredictable and potentially dangerous for diabetic patients. The condition also increases risks for phlebitis (vein inflammation with blood clot formation), hematomas (pooled blood under the skin), and chronic pain at injection sites.
The facility's Director of Nursing acknowledged during the inspection that "the licensed nurses should have rotated the insulin administration sites of Resident 107 to prevent bleeding, thinning of the skin, injury to the site, and lipodystrophy." The facility's own insulin administration policy explicitly required site rotation within general body areas to prevent these complications.
Dangerous Medication Labeling Oversight
Inspectors discovered a potentially life-threatening medication labeling violation when observing the administration of intravenous antibiotics to Resident 109. The IV bag containing meropenem, a powerful antibiotic used to treat the resident's urinary tract infection, lacked proper patient identification labeling.
On March 11, 2025, surveyors observed the medication being administered with only a handwritten label showing the drug name, dose, time, and nurse's initials - but no patient name. This critical omission occurred because the pharmacy had not yet delivered the resident's prescribed medication following their hospital return, forcing staff to use emergency supplies without following proper labeling protocols.
The absence of patient identification on IV medications creates severe risks. Without proper labeling, medications can be administered to wrong patients, potentially causing allergic reactions, drug interactions, or unnecessary medication exposure. For antibiotics like meropenem, administration to the wrong patient could trigger severe allergic responses including anaphylaxis, or contribute to antibiotic resistance when given unnecessarily.
The administering nurse admitted this was "an oversight" and confirmed that proper labeling ensures "the right resident gets the right medication at the right time." The facility's medication labeling policy clearly required all medications to display the resident's name to prevent administration errors.
Failure to Follow Up on Critical Diabetic Lab Results
The facility demonstrated inadequate management of abnormal laboratory results for Resident 77, who had multiple serious conditions including diabetes with neuropathy, congestive heart failure, and chronic kidney disease. When lab results from November 8, 2024, showed an elevated hemoglobin A1C level of 9 percent - significantly above the normal range of 4.0 to 6.0 percent - staff failed to ensure proper physician follow-up.
An A1C level of 9 percent indicates poor blood sugar control over the previous two to three months. This level places patients at substantially increased risk for diabetic complications including progressive kidney damage, accelerated neuropathy, poor wound healing, and increased infection susceptibility. For a resident already experiencing diabetic neuropathy and chronic kidney disease, this elevated level required immediate medical attention and likely medication adjustments.
Although progress notes indicated the attending physician was notified with instructions to relay results to the resident's endocrinologist, no follow-up documentation existed showing whether the specialist received the information or provided new treatment orders. The MDS Nurse reviewing the case stated there should have been follow-up documentation the next day, November 9, 2024, to confirm the endocrinologist received the results and determine if medication adjustments were needed.
Without proper follow-up on abnormal A1C results, residents face continued exposure to dangerously elevated blood sugar levels. Chronic hyperglycemia accelerates damage to blood vessels and nerves, worsens kidney function, and impairs the immune system's ability to fight infections. The MDS Nurse specifically noted risks including "hyperglycemia, uncontrolled blood sugar levels, symptoms would include polyuria (excessive urination), polyphagia which is excessive/uncontrollable eating and excessive drinking can affect the resident's kidneys."
Additional Issues Identified
Beyond these major violations, inspectors documented several other deficiencies affecting resident care and safety. The facility failed to properly date food items in the kitchen refrigerator, including an undated pitcher of cranberry juice that could potentially cause foodborne illness if consumed past its safe use date. This basic food safety violation demonstrated broader quality control issues in dietary services.
The inspection also revealed inadequate facility-wide staffing assessments. The facility failed to maintain a current staffing plan that accurately evaluated resources needed for resident care during all shifts, including nights and weekends. This deficiency directly contributed to medication administration delays for multiple residents, as referenced in the inspection findings showing Residents 21 and 77 received medications later than scheduled due to staffing issues.
Medical Context and Industry Standards
These violations represent fundamental breakdowns in basic nursing home care standards. Proper insulin site rotation has been standard diabetes care practice for decades, with manufacturer guidelines and medical literature consistently emphasizing its importance. The prescribing information for Lantus insulin, which the facility had access to, explicitly states to "rotate injection sites to reduce the risk of lipodystrophy."
Similarly, medication labeling requirements exist as primary safeguards against potentially fatal administration errors. The Joint Commission and Centers for Medicare & Medicaid Services consider proper medication identification a critical element of patient safety, requiring multiple verification steps before any medication administration.
The failure to follow up on abnormal lab results violates basic clinical care coordination expected in skilled nursing facilities. With diabetic residents comprising a significant portion of nursing home populations, facilities must have robust systems for tracking and responding to abnormal glucose control indicators.
These systemic failures suggest inadequate staff training, poor quality assurance mechanisms, and insufficient administrative oversight at Sherman Oaks Health & Rehab. The pattern of violations across multiple care areas - medication administration, laboratory follow-up, food safety, and staffing - indicates organizational deficiencies requiring comprehensive corrective action to ensure resident safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sherman Oaks Health & Rehab from 2025-03-14 including all violations, facility responses, and corrective action plans.
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