NORTH HOLLYWOOD, CA - A state inspection at Four Seasons Healthcare & Wellness Center revealed multiple serious medication safety violations involving insulin administration and storage, placing diabetic residents at risk for potentially life-threatening complications. The April 25, 2025 inspection documented expired insulin being administered to residents, improper injection site rotation, and inadequate medication labeling practices.
Expired Insulin Administered to Diabetic Resident
The most concerning violation involved Resident 90, who received four doses of expired insulin between two dates in 2025. During the inspection, surveyors discovered an opened Lispro Kwikpen insulin pen in Medication Cart Station 2 that had expired but remained in active use. The pen, which had been opened and should have been discarded after 28 days according to manufacturer guidelines, was found with a label indicating it had exceeded its usable timeframe.
Licensed Vocational Nurse 3 acknowledged during the inspection that "administering expired insulin will not be effective in treating residents blood sugar levels and can harm Resident 90 by causing high blood sugar levels leading to coma, hospitalization, and death." The nurse confirmed that the expired pen should have been removed from the medication cart to prevent further administration but had not been discarded as required.
The facility's Director of Nursing confirmed that "several LVNs failed to remove the expired insulin Lispro Kwikpen" and that this resulted in "significant medication errors." The DON acknowledged the serious risks, stating that expired insulin would not effectively control blood sugar levels and could lead to diabetic ketoacidosis (DKA), a potentially fatal condition where acid builds up in the blood due to insufficient insulin.
Repeated Injection Site Violations Affecting Multiple Residents
Inspection records revealed systematic failures in rotating insulin injection sites for at least four residents with diabetes. Resident 52's medical records showed insulin was repeatedly administered to the same body areas, with multiple injections given to the left arm and right lower quadrant of the abdomen without proper rotation between doses.
Similarly, Resident 159, who had severely impaired cognition and required total assistance with daily activities, received multiple insulin injections in the same locations. Records showed the resident received consecutive injections to the left lower quadrant and left arm without the required site rotation. Resident 390's administration records demonstrated the same pattern, with six consecutive insulin injections administered to the left lower quadrant.
The facility's MDS Coordinator confirmed these violations, stating that "the administration sites for insulin should be rotated per standards of practice, manufacturer's guideline, and per physician's order to prevent hardening or lumps in the skin." The coordinator acknowledged that failure to rotate sites constituted medication errors and violated both physician orders and professional standards.
Medical Risks of Improper Insulin Administration
Failure to rotate injection sites causes lipodystrophy, a condition where fatty tissue under the skin either breaks down or builds up abnormally. This creates hardened areas or lumps that significantly impair insulin absorption. When insulin is injected into these damaged areas, the medication cannot be properly absorbed into the bloodstream, leading to unpredictable blood sugar levels.
Lipodystrophy develops gradually when the same injection sites are used repeatedly. The damaged tissue becomes less vascular, meaning fewer blood vessels are available to carry the insulin into circulation. This can result in delayed or incomplete absorption, causing blood sugar to remain dangerously high even after insulin administration. Conversely, if insulin eventually absorbs unpredictably from these sites, it can cause sudden drops in blood sugar (hypoglycemia), which can lead to confusion, seizures, loss of consciousness, and death.
The risks are particularly severe for residents with cognitive impairment who cannot communicate symptoms of blood sugar fluctuations. Resident 159, with severely impaired cognition, and Resident 52, with moderate cognitive impairment and metabolic encephalopathy, were especially vulnerable to these complications as they could not alert staff to symptoms of improper blood sugar control.
Expired Insulin Creates Life-Threatening Risks
Insulin is a protein hormone that begins degrading once exposed to temperature variations and time. After 28 days at room temperature, insulin molecules break down and lose their ability to effectively lower blood sugar. Using expired insulin is essentially the same as administering a diluted or ineffective dose, leaving residents' diabetes uncontrolled.
For diabetic residents in long-term care facilities, uncontrolled blood sugar can rapidly progress to diabetic ketoacidosis (DKA), where the body starts breaking down fat for energy instead of glucose, producing toxic ketones. This condition can develop within hours in insulin-dependent diabetics and requires immediate hospitalization. Early symptoms include excessive thirst, frequent urination, and confusion - symptoms that cognitively impaired residents may be unable to report.
The facility's own policies required that "outdated, contaminated, or deteriorated medications are immediately removed from stock" and that staff must "check expiration date on package/container before administering any medication." These safety protocols exist because expired medications can range from ineffective to toxic, depending on how the chemical compounds break down over time.
Additional Issues Identified
The inspection also revealed improper medication labeling practices. Artificial tears eye drops for Resident 68 were found without proper labeling in Medication Cart Station 3, violating regulations requiring all medications be labeled according to professional standards. This creates risks for medication errors, as unlabeled medications can be confused with other drugs or administered to the wrong resident.
The facility's medication storage practices also came under scrutiny. Manufacturer guidelines clearly specified that opened insulin pens must be stored at room temperature not exceeding 86 degrees Fahrenheit and discarded after 28 days. The inspection found that while the expired insulin was stored at appropriate temperatures, the critical step of removing expired medications was repeatedly overlooked by multiple staff members across different shifts.
Documentation reviews showed that multiple licensed nurses had opportunities to identify and remove the expired insulin during medication passes but failed to do so. This indicates systemic problems with medication management protocols rather than an isolated incident. The facility's policy requiring staff to place dates on multi-dose containers when opened was apparently followed, as the expired insulin pen was labeled with opening and expiration dates, yet staff continued administering from the expired pen.
Industry Standards and Required Protocols
Professional nursing standards and manufacturer guidelines universally require insulin injection site rotation to preserve tissue integrity and ensure consistent absorption. Best practices mandate rotating through at least four different injection areas: the abdomen, thighs, upper arms, and buttocks. Within each area, injections should be spaced at least one inch apart from previous injection sites.
For residents requiring multiple daily insulin injections, facilities should implement systematic rotation schedules. Many facilities use body maps or rotation charts to track injection sites, ensuring no area is used more frequently than once per week. This is particularly critical for residents receiving multiple daily injections, as tissue damage accumulates more rapidly with frequent use.
Regarding medication expiration, Centers for Medicare & Medicaid Services regulations require facilities to follow manufacturer storage requirements explicitly. For insulin, this means maintaining strict temperature controls and adhering to 28-day limits for opened vials or pens. Facilities should implement daily medication cart checks, with designated staff responsible for identifying and removing expired medications before each shift.
The violations at Four Seasons Healthcare represent fundamental breakdowns in medication safety protocols that placed vulnerable residents at serious risk for preventable complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Four Seasons Healthcare & Wellness Center, Lp from 2025-04-25 including all violations, facility responses, and corrective action plans.
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