NORTH HOLLYWOOD, CA - Federal inspectors identified multiple serious safety violations at Four Seasons Healthcare & Wellness Center that put residents at risk, including the administration of expired insulin to a diabetic resident and improper food handling practices that could lead to foodborne illness among the facility's medically vulnerable population.
Critical Medication Errors Put Diabetic Resident at Risk
The most serious violation involved the repeated administration of expired insulin to a diabetic resident over several days. According to the inspection report, Licensed Vocational Nurse staff administered four doses of expired insulin Lispro to one resident between specific dates in April 2025.
The insulin pen was found stored in a medication cart with a label showing it had expired according to manufacturer guidelines. Insulin Lispro, commonly used to control blood sugar levels in diabetic patients, must be discarded 28 days after opening according to manufacturer specifications. The medication loses its potency beyond this timeframe, rendering it ineffective for blood sugar control.
The facility's Director of Nursing acknowledged that "several LVN's failed to remove the expired insulin Lispro pen from the medication cart" and confirmed that the resident received the ineffective medication multiple times. This represents a significant breakdown in the facility's medication management protocols.
Medical Consequences of Expired Insulin Administration
When diabetic residents receive expired insulin, their blood glucose levels can become dangerously elevated due to the medication's reduced effectiveness. Uncontrolled high blood sugar can lead to diabetic ketoacidosis (DKA), a life-threatening condition where the body produces dangerous levels of blood acids called ketones.
DKA occurs when the body doesn't have enough effective insulin to allow blood sugar to enter cells for energy production. Without intervention, this condition can result in hospitalization, coma, or death. For nursing home residents who often have multiple health complications, such medication errors pose particularly serious risks to their health and safety.
The inspection also revealed that eye drops for another resident were stored without proper labeling to indicate when they were first opened. Eye medications typically expire 28 days after opening, and using expired drops can lead to eye infections since the medication is no longer sterile beyond its expiration date.
Food Safety Failures in Kitchen Operations
Inspectors documented serious food safety violations in the facility's kitchen that affected all 176 residents receiving meals. Kitchen staff demonstrated a lack of understanding of proper food cooling procedures, which are critical for preventing bacterial growth that can cause foodborne illness.
According to the inspection findings, two kitchen staff members were unable to properly explain the correct cool-down process for cooked foods. The facility's cooling logs showed that roast turkey, roast beef, and roast pork were not cooled according to food safety standards on multiple occasions.
Food safety regulations require that cooked foods be cooled from 135°F to 70°F within two hours, then from 70°F to 41°F or lower within an additional four hours - a total of six hours maximum. The facility's records showed cooling times that exceeded these safety parameters, with some items taking up to eight hours to reach safe storage temperatures.
Kitchen staff Cook 2 stated during the inspection that roast turkey took "a total of eight hours cooling," which violates food safety protocols. The Dietary Supervisor confirmed that staff "did not properly cool the meats" on multiple dates and acknowledged that on one occasion "the food should have been discarded."
Understanding Food Safety Temperature Controls
Proper food cooling is essential in institutional kitchens because bacteria multiply rapidly in the "danger zone" between 41°F and 135°F. When cooked foods remain in this temperature range for extended periods, harmful bacteria like Salmonella, E. coli, and Clostridium perfringens can grow to dangerous levels.
For nursing home residents, who often have compromised immune systems due to age and medical conditions, foodborne illness can be particularly serious. Symptoms can include severe diarrhea, vomiting, dehydration, and in extreme cases, hospitalization or death.
The facility's written policies correctly outlined proper cooling procedures, including transferring food to containers no deeper than two inches, labeling with dates, and monitoring temperatures at specific intervals. However, the inspection revealed a disconnect between written procedures and actual kitchen practices.
Dietary Compliance Issues Affect Special Diet Residents
Beyond food safety concerns, inspectors found that kitchen staff failed to follow standardized recipes for residents requiring therapeutic diets. One cook admitted to "guessing" ingredients when preparing gravy for residents on renal and diabetic diets rather than following established recipes.
A resident on a renal diabetic diet told inspectors that "the food at the facility was too salty" despite being on a special diet. When supervisory staff tested the food during the inspection, they confirmed it was indeed too salty for residents requiring low-sodium diets.
Residents with kidney disease and diabetes require carefully controlled sodium intake. Excessive salt can cause water retention, elevated blood pressure, and worsen kidney function. For residents with end-stage renal disease, improper diet management can accelerate the need for dialysis or cause dangerous fluid buildup.
The cook stated she "did not follow the recipe for the gravy because it was not available in the recipe binder," highlighting gaps in the facility's recipe management and staff training systems. The Dietary Supervisor emphasized that following standardized recipes is "important to ensure residents would get the right amount of nutrition" and that deviations could lead to malnutrition if recipes are not followed accurately.
Temperature Control Problems Throughout Meal Service
Food temperature monitoring during the inspection revealed multiple items served below safe temperatures. Roast turkey was measured at 125°F, well below the required 140°F minimum for hot foods. Cold items including applesauce (51°F), vanilla mousse (46°F), and grape juice (46°F) were found above the maximum safe temperature of 41°F for cold foods.
These temperature violations create additional food safety risks, as foods held at improper temperatures provide ideal conditions for bacterial growth. Hot foods must be maintained at 140°F or higher, while cold foods should be kept at 41°F or below to prevent pathogen multiplication.
Additional Issues Identified
The inspection revealed several other concerning practices that compromised resident care and safety. Food texture problems were documented for residents requiring pureed diets, with both mashed potatoes and roast turkey failing to hold their shape on plates, indicating improper preparation techniques.
Staff training deficiencies were evident throughout the kitchen operations, with orientation checklists lacking topics about proper food cooling procedures. The facility's competency verification processes for dietary staff did not adequately ensure understanding of critical food safety practices.
The combination of medication management failures and food safety violations represents a pattern of insufficient oversight and training that placed vulnerable residents at unnecessary risk. These violations underscore the importance of rigorous staff training, competency verification, and ongoing monitoring of critical safety procedures in long-term care facilities.
Federal regulations require nursing homes to maintain strict standards for both medication administration and food safety to protect their vulnerable populations. The violations identified at Four Seasons Healthcare & Wellness Center demonstrate the serious consequences when these essential safety systems fail to function properly.
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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