Four Seasons Healthcare: Medication Consent Failures - CA
Resident 130 told inspectors at Four Seasons Healthcare & Wellness Center that staff "never explained the risk and benefits of the medication lorazepam and does not remember ever signing an informed consent form." The facility had been administering the anti-anxiety drug since March without proper authorization.
Licensed Vocational Nurse 3 acknowledged receiving the lorazepam order on March 23 but admitted missing the step of ensuring informed consent. "LVN 3 checked to ensure that informed consent was received for Trileptal, but LVN 3 missed ensuring informed consent was received for lorazepam," according to the April inspection report.
The 130-year-old facility serves residents with complex medical conditions. Resident 130 arrived in July 2024 with end-stage kidney disease requiring regular hemodialysis, plus paralysis of one arm from a stroke. His medical records showed he had the mental capacity to make his own healthcare decisions.
The Minimum Data Set Coordinator told inspectors that "psychotropic medications have a high risk for side effects potentially resulting in resident falls and injury." She found no documentation that staff or physicians had obtained consent before giving lorazepam to the mentally competent resident.
Facility policy requires written informed consent for psychotropic drugs, with renewal every six months. The policy states nurses must verify that physicians obtained consent before administering first doses of mood-affecting medications.
But the consent breakdown extended beyond medication. When Resident 130 complained that a nursing assistant refused to warm his breakfast after he returned from dialysis, no one offered him the chance to file a grievance.
Licensed Vocational Nurse 4 heard the complaint but never reported it to social services. "When a resident complains about a CNA refusing to provide care by not providing a warm meal, then a grievance should be offered and the grievance process should be started, but it wasn't," LVN 4 told inspectors.
The next day, administrators assigned the same aide to care for Resident 130 again. He became visibly upset, telling the Activities Director he didn't want that particular staff member caring for him.
Social Services Assistant 2 said the delay in addressing Resident 130's complaint "resulted in Resident 130 being assigned CNA 3 on 4/23/2024 potentially causing distress in the resident."
The Assistant Director of Nursing warned that giving lorazepam without consent "may be considered unnecessary medications resulting in a chemical restraint." She said the practice created "potential that the resident may have adverse effects of unnecessary medication resulting in a fall and injury."
Call lights presented another safety hazard. Inspectors found four residents unable to reach their emergency call devices during the April 22-25 survey.
Resident 489, who has seizure disorders and muscle weakness, had her call light on the floor beside her bed. The certified nursing assistant in her room acknowledged "residents can fall while reaching for the call light on the floor sustaining injury."
Resident 390, who has weakness in both arms and is at high risk for falls, had her specialized pad call light placed on her lap rather than positioned where she could actually activate it. Licensed Vocational Nurse 5 said the device "should have been placed next to either side of the resident's face so Resident 390 would be able to call for assistance when needed."
The most troubling case involved Resident 133, who has paralysis on his left side from a stroke. Inspectors watched a nursing assistant deliver water to his room at 8 a.m. without noticing his call light dangled from the bed rail, completely out of reach.
Resident 133 told inspectors he wanted water but "could not reach the pitcher" and "did not know where the call light was located."
The nursing assistant who delivered the water admitted she "should have noticed the call light was not within reach of the resident" but said she was "nervous." Another aide who had repositioned Resident 133 earlier said the call light "must have fallen off the bed, and CNA 2 must not have noticed."
Privacy violations compounded the care failures. Dietary staff threw away a report containing 13 residents' names, room numbers, allergies, and diet orders in a regular trash can in the kitchen. The document should have gone in a locked container for confidential disposal.
In a separate incident, nursing staff discarded handwritten notes about two residents' medications in a regular trash bin rather than shredding the protected health information.
Physical restraints raised additional concerns. The facility placed beds against walls for six residents but failed to complete proper assessments in multiple cases.
Resident 159's bed had "always been placed against the wall for the resident's safety," according to a nursing assistant, but the facility never obtained a physician's order or developed a care plan for the restraint.
The MDS Coordinator explained that proper procedure requires "an initial assessment should be completed to indicate the least restrictive measures attempted and indicate in the recommendation the type of restraint to be utilized for the resident's safety, obtain a physician's order and informed consent, and initiate a CP."
For Resident 73, staff completed restraint assessments three times over eight months but never accurately documented that his bed was positioned against the wall. The resident has right-side paralysis, and placing his bed against the left wall restricts movement from his functional side.
Care planning gaps extended to medications and medical devices. The facility failed to develop care plans for residents receiving antidepressants, antibiotics, and breathing machines.
Resident 489 received trazodone for depression and poor sleep but had no care plan addressing the medication's use or monitoring requirements. Resident 152 used a CPAP machine nightly for sleep apnea but lacked a care plan for managing the device or addressing compliance issues.
"When Resident 152 did not have a CP for CPAP use and noncompliance there was the potential that the resident's refusal would result in respiratory issues while sleeping and potentially heart issues," Licensed Vocational Nurse 2 told inspectors.
The Director of Nursing acknowledged multiple policy violations. She said informed consent protects residents' rights and prevents "unnecessary medications resulting in a chemical restraint." Regarding call lights, she noted "when the call light is not within reach it may result in an injury from sliding to the floor when the resident was not able to call for assistance."
The facility's own policies require call lights within residents' reach, informed consent for psychotropic medications, and comprehensive care plans addressing all aspects of resident care. Environmental safety checks occur Monday through Friday, but these systematic failures suggest the monitoring system isn't working.
Resident 130 continues to require dialysis three times weekly while managing anxiety without proper medication consent. His case illustrates how administrative shortcuts can leave vulnerable residents without basic protections they're legally entitled to receive.
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.
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
FOUR SEASONS HEALTHCARE & WELLNESS CENTER, LP in NORTH HOLLYWOOD, CA was cited for violations during a health inspection on April 25, 2025.
Licensed Vocational Nurse 3 acknowledged receiving the lorazepam order on March 23 but admitted missing the step of ensuring informed consent.
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.