Four Seasons Healthcare: Medication Error Violations - CA
Four Seasons Healthcare & Wellness Center gave Resident 2 the drug Paxlovid outside the facility's required one-hour medication window on August 16, 2025. The patient had initially refused the medication earlier that day, then requested it in the early morning hours and again late at night.
Resident 2 was admitted to the facility in February with spondylosis with radiculopathy, a condition where age-related spine deterioration pinches nerves and causes pain, numbness, or weakness spreading to the limbs. The patient also suffered from chronic pain but maintained intact thinking and required only setup assistance for daily activities like bathing and dressing.
The physician had ordered Paxlovid — an oral antiviral that stops COVID-19 from multiplying in the body — to be given as three tablets by mouth twice daily for five days, beginning August 12.
Progress notes showed the unusual timing. At 3:30 a.m. on August 16, staff documented that Resident 2 had "refused Paxlovid earlier and now at 3:30 a.m. Resident 2 requested to take it and Paxlovid was given."
Nearly 20 hours later, at 11:10 p.m. the same day, notes indicated "Paxlovid was given to Resident 2 per Resident 2 request."
License Vocational Nurse 1 told inspectors during an August 20 interview that no documentation existed showing the physician was notified about Resident 2's request to take medication at those irregular times.
"The nurse should call the physician and ask for an order to change to administration time because if there were no changes in medication time the order could be missed or doubled dosed," LVN 1 explained.
Director of Nursing confirmed the medication error during an August 21 interview. She stated Paxlovid "must be given on scheduled time per physician's order and must be within one hour before or one hour after the scheduled time."
The nursing director acknowledged that "administering beyond the administration window time was considered a medication error according to facility policy." She found no record that staff had contacted the physician about changing the administration schedule.
"The nurse should call the physician to clarify the order if Paxlovid can be given at this certain time per Resident 2's request," the director told inspectors.
The timing violations potentially undermined the medication's effectiveness. The nursing director emphasized it was "important to follow physician's order to make sure Resident 2 will receive the full effectiveness of the medication."
Paxlovid requires precise timing to maintain therapeutic levels in the bloodstream and effectively combat COVID-19 viral replication. The drug's effectiveness depends on consistent dosing intervals, typically every 12 hours.
The facility's own medication administration policy, last reviewed June 25, 2025, requires that "all medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations."
The policy mandates that medications "must be administered within one hour before or one hour after" the prescribed time to ensure "residents receive the correct medications in a timely, safe, and documented manner."
By giving Paxlovid at 3:30 a.m. and 11:10 p.m. without physician approval, staff violated both the doctor's orders and the facility's own safety protocols. The 19-hour, 40-minute gap between doses also deviated significantly from the standard 12-hour interval for twice-daily medications.
Federal inspectors classified the violation as having "minimal harm or potential for actual harm," noting that the deficient practice had "the potential for Resident 2 to not receive the full benefit of the medication."
The August 22 inspection occurred in response to a complaint. Inspectors reviewed medication records for three residents and found the medication error affected one of the three sampled cases.
Resident 2 remains at Four Seasons Healthcare, where staff continue managing chronic pain from the degenerative spine condition that initially brought the patient to the facility six months earlier.
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: 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 August 22, 2025.
Four Seasons Healthcare & Wellness Center gave Resident 2 the drug Paxlovid outside the facility's required one-hour medication window on August 16, 2025.
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.