WOODLAND HILLS, CA - Motion Picture and T.V. Hospital skilled nursing facility was cited by state inspectors for multiple medication administration violations that put residents at risk, including giving medications outside prescribed timeframes and failing to follow proper safety protocols.
Critical Medication Timing Violations
Inspectors documented serious violations of medication administration protocols during an April 2025 survey at the 23388 Mulholland Drive facility. Multiple residents received medications significantly outside their prescribed schedules, with nurses unable to properly document the actual administration times due to system limitations.
The most concerning incident involved a Licensed Vocational Nurse (LVN) administering seizure medications to a resident with dementia, paraplegia, and seizure disorders nearly two hours before the 9 a.m. scheduled time. The nurse gave critical anti-seizure medications lacosamide and levetiracetam at 7:31 a.m., stating "she cannot sign Resident 66's MAR with the actual time she gave the medications because the system will not allow her until 8 a.m."
Medical protocols require strict timing for seizure medications because inconsistent blood levels can trigger breakthrough seizures or cause dangerous side effects. Anti-seizure drugs like lacosamide and levetiracetam must maintain steady concentrations in the bloodstream. When given too early, the medication may wear off before the next scheduled dose, creating gaps in seizure protection that could result in life-threatening seizures.
The same nurse exhibited identical timing violations with another resident who had dementia, depression, and diabetes. Despite being scheduled for 9 a.m. administration, medications including diabetes drug metformin and dementia medication donepezil were given at 7:43 a.m., again with documentation issues preventing accurate record-keeping.
Dangerous Feeding Tube Medication Practices
Inspectors identified severe protocol violations in feeding tube medication administration that could have resulted in serious complications. A resident with epilepsy, muscle spasm, and brain injury who received medications through a gastrostomy tube experienced multiple safety protocol breaches.
The investigating nurse failed to follow established facility policy requiring water flushes between each medication. Instead of administering gabapentin, quetiapine, and baclofen separately with water flushes between each drug, the nurse mixed all medications together without proper separation protocols.
This practice creates significant medical risks. When medications are mixed in feeding tubes without proper flushing, they can interact chemically, reducing effectiveness or creating dangerous combinations. The drugs can also crystallize and block the feeding tube, potentially requiring surgical replacement. Most critically, without proper flushing, patients may not receive complete doses of their prescribed medications.
Gabapentin treats nerve pain, quetiapine manages brain injury-related agitation, and baclofen controls muscle spasticity. These medications require complete absorption for optimal therapeutic effect. When mixed without proper protocols, their effectiveness becomes unpredictable, potentially leaving the resident with uncontrolled seizures, increased agitation, or painful muscle spasms.
The facility's own policy clearly states medications must be "administered separately (Do not mix medication) and flush with 15 ml to 30 ml of water between each med" to prevent air from entering the tube and ensure proper medication delivery.
Insulin Administration Site Rotation Failures
A diabetic resident experienced improper insulin administration practices that violated both manufacturer guidelines and nursing standards. Documentation revealed the same injection sites were used repeatedly instead of rotating locations as required for safe insulin therapy.
Records showed the resident received Victoza (liraglutide) injections in identical locations on consecutive days, with the left middle thigh used repeatedly on March 19-20, 2025, and the right lower arm used consecutively on January 27-28, 2025. This pattern continued throughout the documented period, demonstrating systematic failure to follow rotation protocols.
Proper injection site rotation prevents lipodystrophy, a condition where fatty tissue under the skin becomes lumpy or pitted from repeated injections in the same area. These tissue changes can significantly impair insulin absorption, leading to unpredictable blood sugar control. Poor blood sugar management in diabetic patients increases risks of serious complications including diabetic ketoacidosis, cardiovascular problems, and delayed wound healing.
The manufacturer's guidelines explicitly state injections should "rotate injection sites within the same region in order to reduce the risk of cutaneous amyloidosis" and warn that adverse reactions include injection site rash and skin redness when proper rotation is not followed.
Discontinued Medication Storage Problems
The facility failed to properly remove discontinued medications from treatment areas, creating potential for dangerous medication errors. A topical antibiotic called mupirocin remained accessible in treatment carts after being discontinued on February 12, 2025, leading to inappropriate administration to a resident with pressure injuries.
This storage failure violates fundamental medication safety principles requiring immediate removal of discontinued drugs. When expired or discontinued medications remain accessible, nurses may inadvertently administer them, potentially causing adverse reactions or interfering with current treatment plans.
Medical Context and Industry Standards
These violations represent serious departures from established nursing home medication management standards. The Centers for Medicare & Medicaid Services requires facilities to follow the "Six Rights" of medication administration: right medication, right dose, right patient, right route, right time, and right documentation.
Medication timing protocols exist because many drugs require precise scheduling to maintain therapeutic blood levels. Seizure medications, diabetes drugs, and psychiatric medications often have narrow therapeutic windows where early or late administration can compromise treatment effectiveness.
Feeding tube medication administration requires specialized training because of the unique risks involved. The digestive system processes medications differently when delivered directly to the stomach, and improper technique can cause aspiration, tube blockage, or incomplete drug absorption.
Insulin injection site rotation has been a nursing standard for decades because repeated use of the same sites causes tissue damage that impairs drug absorption. This is particularly critical for elderly nursing home residents who may already have compromised circulation and slower healing.
Additional Issues Identified
Inspectors documented several other concerning practices during the survey. The facility's electronic medication administration record system prevented nurses from documenting actual administration times when medications were given outside prescribed windows, creating accuracy problems in medical records.
Staff acknowledged giving medications outside scheduled timeframes approximately three times weekly for certain residents, suggesting these timing violations were routine rather than isolated incidents.
The facility's policies appeared adequate on paper, clearly outlining proper medication administration procedures, but implementation and oversight were insufficient to ensure compliance with safety protocols.
Documentation revealed communication gaps between nursing staff and healthcare providers regarding medication timing adjustments, with nurses uncertain about proper procedures for addressing resident preferences for earlier medication administration.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Motion Picture and T.v. Hosp D/p Snf from 2025-04-11 including all violations, facility responses, and corrective action plans.
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