NORTH HOLLYWOOD, CA - A recent state inspection at Four Seasons Healthcare & Wellness Center revealed significant violations in food safety, dietary services, and infection control protocols that affected dozens of vulnerable residents.
Critical Food Temperature and Safety Failures
The April 2025 inspection uncovered serious deficiencies in food preparation and temperature control that put residents at risk of foodborne illness. Inspectors documented multiple instances where meals failed to meet established safety standards for serving temperatures.
During food temperature testing, investigators found roasted turkey served at 125°F instead of the required 160-180°F range. Cold items also exceeded safe temperatures, with cottage cheese measured at 51.8°F and mocha mix at 48°F, both above the required 41°F maximum for dairy products.
The Dietary Supervisor acknowledged that 125°F was below their standard of 130°F and confirmed the facility had received resident complaints about food temperatures. "The residents might not eat the food or enjoy it if the food was not hot or cold as they expect them to be," the supervisor stated during the inspection.
Food temperature violations create significant health risks for nursing home residents, who often have compromised immune systems and underlying health conditions. Proper hot food temperatures (above 140°F) prevent bacterial growth, while cold foods must remain below 41°F to inhibit harmful microorganisms. When foods remain in the "danger zone" between these temperatures, bacteria can multiply rapidly, potentially causing serious foodborne illnesses in medically vulnerable populations.
Unsafe Food Cooling Procedures Documented
Inspectors identified improper cooling procedures for cooked meats that violated federal food safety guidelines. Documentation showed roasted turkey and beef were cooled for eight hours instead of the required six-hour maximum, creating conditions favorable for bacterial growth.
According to facility cooling logs, roasted turkey prepared on multiple dates exceeded safe cooling timeframes. One instance showed turkey taking eight hours to cool properly, with staff acknowledging the violation. Food safety regulations require cooked foods to cool from 135°F to 70°F within two hours, then reach 41°F within an additional four hours.
The Dietary Supervisor explained the proper protocol: "The roast turkey needed to further cool down to 40°F within four hours for a total of six hours of the cooling process. If the roast turkey did not cool down to 40°F in a total of 4 hours then they needed to reheat the roast turkey to 165°F for 15 seconds or throw it away."
Staff admitted to not following standardized recipes for therapeutic diets, particularly for residents requiring low-sodium renal diets. One cook stated she "just guessed the ingredients" when preparing gravy for residents with kidney disease, rather than following prescribed recipes designed to manage their medical conditions.
Therapeutic Diet Management Failures
The facility failed to provide proper therapeutic diets as prescribed by physicians. One diabetic resident with kidney disease received large portion meals instead of the regular portions ordered by their doctor, potentially affecting blood sugar control and kidney function.
Residents on specialized renal diets complained that food was "too salty," despite being prescribed low-sodium meals essential for managing their kidney disease. The facility's own staff acknowledged during taste testing that renal diet foods were inappropriately salty, with the Assistant Dietary Supervisor stating: "renal diet should not be salty and the cook followed recipes and maybe the amount of base the cooks used made it salty."
Therapeutic diets are medically necessary for residents with conditions like diabetes, kidney disease, and heart problems. These specialized meal plans control sodium, protein, carbohydrates, and other nutrients to prevent complications and support treatment. When facilities fail to follow prescribed diets, residents face increased risks of hospitalization, disease progression, and other serious health consequences.
Kitchen Sanitation and Equipment Deficiencies
The inspection revealed widespread sanitation problems throughout the kitchen facility. Investigators found all 50 meal trays in use were cracked, refrigerator shelves had chips and rust damage, and a broken thermometer was discovered in the vegetable freezer.
Equipment cleanliness violations included food residue on mixer shafts, dirt debris in clean plate storage areas, and food containers with adhesive residue that could contaminate meals. Staff were observed using cleaning cloths during food preparation and leaving them near uncovered salads, creating cross-contamination risks.
The facility also stored damaged canned goods alongside safe products, including one can with bulging that could indicate botulism contamination. The Dietary Supervisor acknowledged these violations could lead to serious health consequences for residents.
Pureed Food Preparation Concerns
For residents requiring texture-modified diets due to swallowing difficulties, the facility failed to meet International Dysphagia Diet Standardisation Initiative (IDDSI) guidelines. Pureed foods did not maintain proper shape on plates, potentially creating choking hazards for residents with dysphagia.
The Assistant Dietary Supervisor acknowledged that improperly prepared pureed foods "might not eat them causing poor food intake as a potential outcome." Residents requiring pureed diets often have serious swallowing disorders, making proper food texture critical for preventing aspiration pneumonia and ensuring adequate nutrition.
Medical Documentation and Infection Control Gaps
Beyond food service violations, inspectors found significant deficiencies in medical record keeping and infection prevention protocols. The facility failed to document change-of-condition reports for residents who required hospitalization, including one resident transferred for gastrostomy tube placement and another for seizure management.
Infection control violations included failing to implement enhanced barrier precautions for a resident with a urinary catheter. Required protective equipment stations and warning signs were not posted outside the resident's room, potentially allowing infections to spread among the facility's vulnerable population.
The facility also failed to properly monitor antibiotic use under their stewardship program, overlooking one resident's prophylactic antibiotic therapy in surveillance tracking.
Additional Issues Identified
The inspection documented several other concerning practices, including inaccurate wound documentation that could affect treatment planning, inadequate equipment maintenance throughout the kitchen, and failure to separate damaged food containers from safe inventory.
Staff training gaps were evident in multiple areas, with kitchen personnel admitting to not following established recipes and protocols designed to ensure resident safety and proper nutrition.
Industry standards require nursing facilities to maintain comprehensive food safety programs, accurate medical documentation, and robust infection control measures to protect residents who are often among society's most vulnerable populations. The violations at Four Seasons Healthcare & Wellness Center highlight systemic failures across multiple critical care areas that directly impact resident health and safety.
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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