Four Seasons Healthcare: Seizure Records Incomplete - CA
The resident, identified in inspection records only as Resident 1, has lived at the facility since May 2019. She carries diagnoses of type 2 diabetes, convulsive disorder, and other specified disorders of the brain. As of October 2025, her ability to make decisions for herself was assessed as moderately impaired. Her physician had ordered staff to monitor and document seizure activity every shift and to notify her attending doctor whenever one occurred.
On December 18, 2025, she seized three times. The first episode hit at 8:45 in the morning and lasted ten seconds. The second came at 11:11 a.m. and ran for a full minute. The third arrived at noon and lasted two minutes. The progress notes logged the times and durations. What they did not contain was any documented nursing assessment of what her condition looked like after each one, and no one had filled out the standardized form the facility uses to communicate a change in condition to physicians and the care team.
That form, called an SBAR, for Situation, Background, Appearance, and Review, is the mechanism nurses use to tell a doctor what they found when they evaluated a patient after something went wrong. For Resident 1's three seizures on December 18, not one SBAR existed.
A registered nurse who reviewed the records with inspectors on December 23 confirmed the documentation was incomplete. She said licensed nurses are expected to document their assessments after a change in condition. She said the SBAR forms had not been created. She said the change-of-condition documentation was incomplete. She offered no explanation for why.
Four minutes later, inspectors spoke with the Director of Nursing. The director said the nurse who witnessed the seizures, or the supervising RN on duty, was responsible for documenting both the episodes and the assessments that followed. The director said complete documentation mattered because it was how the care team and attending physician understood what was happening with a resident. Then the director said plainly that the facility had failed to make sure the documentation was done.
That admission is notable. The facility's own policies, last reviewed just three months before the inspection, in September 2025, spell out that nurses will record the date, time, and pertinent details of any event and the assessment that follows, the time the physician was contacted, and the time the family or responsible person was reached. The policies also require that entries be recorded promptly as events occur, that they be complete, descriptive, and accurate, and that anyone who makes an observation or provides care to a resident documents it in the record.
None of that happened for Resident 1 on December 18.
Inspectors classified the violation as causing minimal harm or potential for actual harm, which is the lower end of the federal harm scale. But the specific concern they flagged was delayed medical intervention, the risk that a physician, not knowing what a resident looked like after a two-minute seizure, might miss a deterioration that warranted treatment.
A two-minute seizure in an elderly person with a documented brain disorder and moderately impaired cognition is not a minor event to observe and then leave unrecorded. The body after a seizure can show signs that matter: confusion beyond baseline, injuries from muscle contractions, changes in responsiveness, oxygen levels, heart rate. The nursing assessment exists precisely to catch those things and get them to the doctor. Without it, the doctor is working from a timestamp and a duration, not from a clinical picture.
The inspection covered three sampled residents. The documentation failure was found in one of them.
Four Seasons Healthcare and Wellness Center is a long-term care facility operating in North Hollywood. The inspection was conducted December 23, 2025, as a complaint survey. The Director of Nursing, who acknowledged the failure directly to inspectors, did not offer a timeline for when or whether the documentation gap for December 18 would be addressed.
Resident 1's records show she has been a patient at the facility for more than six years. On the morning of December 18, she seized at 8:45, then again at 11:11, then again at noon. Somewhere in the facility, a nurse watched each of those episodes end. What that nurse found when she checked on her afterward was never written down.
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 2025-12-23 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 19, 2026 · Our methodology
FOUR SEASONS HEALTHCARE & WELLNESS CENTER, LP in NORTH HOLLYWOOD, CA was cited for violations during a health inspection on December 23, 2025.
The resident, identified in inspection records only as Resident 1, has lived at the facility since May 2019.
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.