Sherman Oaks Health & Rehab: Insulin Site Failures - CA
Resident 107, who was admitted on February 17, 2025, with type 2 diabetes, chronic kidney disease, and coordination problems, received multiple insulin injections in identical body locations over several days in February. The resident was alert, oriented, and had intact cognition according to medical assessments.
The resident required two types of insulin. Doctors ordered Insulin Aspart, 6 units before meals, starting February 17. Three days later, they added Insulin Glargine, 15 units every 12 hours.
Records show nurses administered the long-acting insulin in dangerously repetitive patterns. On February 22, they gave both the morning and evening doses in the left lower quadrant of the resident's abdomen. Later that same day, they switched to the left upper quadrant but gave two more injections there within six hours.
The pattern continued for days. February 24: left lower quadrant. February 25: left lower quadrant again. February 27: left upper quadrant. February 28: left upper quadrant once more.
Registered Nurse 1 acknowledged the violations during a March 13 interview while reviewing the injection records. "There were multiple times where the insulin administration sites were not rotated from 2/2025 to 3/2025 for Resident 107," the nurse told inspectors.
The nurse explained why rotation matters: "Licensed nurses should rotate insulin administration sites to prevent phlebitis, hematoma, pain, and lipodystrophy on residents."
Phlebitis causes blood clots to form in veins. Hematomas are collections of blood that leak from broken vessels. Lipodystrophy involves changes to fat tissue that can affect insulin absorption.
The Director of Nursing confirmed the violations the next day. During a March 14 interview, the DON said 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 policy, last reviewed September 27, 2024, explicitly requires site rotation. The policy states insulin "may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen," while avoiding areas within two inches of the navel.
More importantly, the policy requires that "injection sites should be rotated, preferably within the same general area."
The facility also provided inspectors with prescribing information for Lantus, the brand name for insulin glargine that Resident 107 received. The manufacturer's guidance, approved by federal regulators in 2000, specifically instructs medical providers to "rotate injection sites to reduce the risk of lipodystrophy."
But nurses ignored both the facility policy and manufacturer instructions, creating unnecessary medical risks for a resident whose diabetes already made wound healing difficult.
The violations occurred despite Resident 107's vulnerability. The resident's medical history showed type 2 diabetes, a condition that impairs blood sugar control and slows healing. The resident also had stage 3 chronic kidney disease, meaning the kidneys had mild to moderate damage and reduced ability to filter waste from blood.
These conditions made proper insulin administration even more critical. Yet nurses repeatedly chose convenience over safety, injecting medication into familiar spots rather than following established rotation protocols.
The inspection also uncovered a separate violation involving another resident's end-of-life care. Resident 115 had a Do Not Resuscitate order on file, a legal document signed by the patient or their representative and physician indicating wishes to withhold resuscitation efforts.
Despite this clear directive, staff performed CPR on Resident 115 when the resident's heart stopped. The inspection report notes this "violated the resident's preferred treatment wishes" but provides no additional details about the circumstances or outcome.
Federal regulations require nursing homes to honor advance directives and provide basic life support only when appropriate under physician orders and resident preferences. The facility failed to follow both the legal document and the resident's expressed wishes about end-of-life care.
Both violations reflect broader problems with following established medical protocols. In the insulin case, nurses had clear written guidance from multiple sources but chose to ignore it. In the resuscitation case, staff had a legal document specifying the resident's wishes but performed unwanted medical interventions anyway.
The inspection classified both violations as causing "minimal harm or potential for actual harm." However, the consequences of repeated insulin injections in the same sites can include permanent tissue changes, reduced insulin effectiveness, and increased infection risk for diabetic patients who already heal poorly.
For Resident 107, the improper injection technique created unnecessary medical risks during a vulnerable period. The resident had been in the facility for only about a month when inspectors documented the pattern of unsafe insulin administration.
The facility's failure to follow its own policies and manufacturer guidelines demonstrates a gap between written procedures and actual practice. Staff had access to proper training materials and clear instructions but failed to implement basic safety measures for a diabetic resident's daily medical care.
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.
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
SHERMAN OAKS HEALTH & REHAB in SHERMAN OAKS, CA was cited for violations during a health inspection on March 14, 2025.
The resident was alert, oriented, and had intact cognition according to medical assessments.
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.