Four Seasons Healthcare: Feeding Tube Safety Failure - CA
The pump was missing a dose limit setting.
That setting exists for a reason. Without it, a feeding pump has no ceiling, no automatic stop. The Director of Nursing, interviewed by inspectors on August 21, 2025, said the resident could experience unintended weight gain, an increased risk of regurgitation, and discomfort. She also said the resident could possibly develop fluid overload, a condition in which the body accumulates more fluid than it can process.
The facility's own enteral feeding policy, last reviewed on June 25, 2025, less than two months before the inspection, spelled out the required sequence: set pump settings according to the physician's order, set the dose limit on the machine, then start. The policy was current. The step was skipped anyway.
Four Seasons Healthcare & Wellness Center sits at 5335 Laurel Canyon Boulevard in North Hollywood. The complaint inspection that uncovered the feeding pump failure was completed on August 22, 2025. CMS assigned the deficiency under F0684, with a harm level of minimal harm or potential for actual harm, and noted that few residents were affected.
The classification matters less than what it describes. A resident who cannot eat on their own, who depends entirely on a tube and a machine to receive nutrition, had that machine set up wrong. The person responsible for their feeding did not complete the last required step before walking away.
The Director of Nursing did not dispute what happened. She confirmed the policy. She confirmed what the missing dose limit could cause. The inspection report does not record any explanation for why the step was skipped, or how long the pump had been running without it.
Enteral feeding, the process of delivering nutrition directly to the stomach or intestine through a tube, is used for residents who cannot swallow safely or reliably. It is not a passive process. The pump, the rate, the volume, the dose limit, all of it requires precise configuration because the resident has no way to signal that something is wrong the way a person eating normally might. They cannot push the plate away. They cannot stop drinking. The machine runs until someone stops it, or until the dose limit does.
There was no dose limit here.
The facility had reviewed its own policy on this procedure in June. Whoever conducted that review signed off on language that explicitly required the dose limit step. Six weeks later, a resident was on a pump where that step had not been taken.
Inspectors rated the violation as affecting few residents. The report does not specify how many, or for how long the pump operated without the limit set, or whether the resident experienced any of the consequences the Director of Nursing described as possible. Fluid overload in a frail nursing home resident is not a minor inconvenience. It can stress the heart and lungs. Regurgitation, for a resident already compromised enough to require tube feeding, carries its own serious risks.
None of that is speculation. The Director of Nursing said it herself, in the interview room, on the afternoon of August 21.
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 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
FOUR SEASONS HEALTHCARE & WELLNESS CENTER, LP in NORTH HOLLYWOOD, CA was cited for violations during a health inspection on August 22, 2025.
The pump was missing a dose limit setting.
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.