Four Seasons Healthcare & Wellness Center, Lp

F-F805

Findings:

a. During a review of Resident 173's Admission Record, the Admission Record indicated the facility initially admitted Resident 173 on 1/9/2025 and readmitted the resident on 2/17/2025 with diagnoses that included type two (2) diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD, irreversible kidney failure), and hypertensive heart and chronic kidney disease (heart and kidney problems that occur because of high blood pressure that is present over a long time).

During a review of Resident 173's Minimum Data Sheet (MDS - a resident assessment tool) dated 3/18/2025, the MDS indicated Resident 173 understood others and made self understood. The MDS indicated the resident required supervision and touching assistance (helper provides verbal cues and/or touching /steadying and or contact guard assistance as resident completes the activity) when eating.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 1 of 7 055932 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055932 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Four Seasons Healthcare & Wellness Center, LP 5335 Laurel Canyon Blvd. North Hollywood, CA 91607

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During a review of Resident 173's Physician Orders dated 3/30/2025, the Physician Orders indicated to provide CCHO, standard portion diet, mechanical soft texture (diet with soft, and chopped meats), regular, Level of Harm - Minimal harm or thin consistency. potential for actual harm

During an interview on 4/22/2025 at 11:42 a.m. with Resident 173, Resident 173 stated the food at the facility Residents Affected - Some was terrible as it was sometimes cold when it arrives. Resident 173 stated the food should be 165 F and wants steam coming from the food. Resident 173 stated he notified the facility staff as it was their responsibility to serve hot food. Resident 173 stated the facility used warmers, but it was not hot; hence, the food comes out cold. Resident 173 stated he has lost weight and did not want to eat in the facility.

During a review of the facility's daily spreadsheet (a list of food, amount of food that each diet would receive) titled Spring Cycle Menus, dated 4/22/2025, the spreadsheet indicated residents on CCHO renal diet would include the following foods on the tray:

Roast turkey 3 ounces (oz, a unit of measurement)

Gravy 1 oz

Seasoned peas 1/2 cup (c., household measurement

Wheat roll 1 piece

Margarine 1 teaspoon

Diet apple sauce 1/2 c

Milk 4 oz/ diet punch 8 oz

During a review of the facility's menu spreadsheet (a sheet containing the kind and amount of food each diet would receive) titled Spring Cycle Menus, dated 4/22/2025, the spreadsheet indicated residents on puree diet would include the following foods on the tray:

Puree roast turkey half (1/2) c

Puree cranberry-ginger-citrus sauce 1 oz

Puree bread dressing number 12 scoop (1/3 c)

Puree three bean salad 1/3 c

Vanilla mousse (no chocolate chips) 1/3 c.

Milk 4 fluid oz.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 7 055932 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055932 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Four Seasons Healthcare & Wellness Center, LP 5335 Laurel Canyon Blvd. North Hollywood, CA 91607

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During a puree test tray (a process of tasting, temping [using a thermometer to check its internal temperature to ensure it's cooked to a safe and desired level], and evaluating the quality of food) observation on Level of Harm - Minimal harm or 4/22/2025 at 12:51 p.m.with the Dietary Supervisor (DS), observed vanilla mousse temperature was at 46 F potential for actual harm when the DS took the temperature of the food using the facility thermometer.

Residents Affected - Some During a test tray observation on 4/22/2025 at 12:54 with the DS, observed the following temperatures when

the DS took the food temperatures using the facility thermometer:

Roast Turkey 125 F

Grape juice 46 F

Apple sauce 51 F

During an interview on 4/22/2025 at 12:57 p.m. with the DS and the Assistant Dietary Supervisor (ADS), the DS stated the temperatures of milk and milk products needed to be lower than 50 F. The ADS stated 130 F was standard they used for palatable temperature for hot food; however, the food was at 125 F. The DS stated 125 F for hot food was acceptable food temperature. The DS stated they have complaints in the facility regarding food temperatures and they talked to the residents and to the staff to ensure that they take

the tray to the residents right away as their action plan. The DS stated 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 DS stated residents may potentially lose weight because of not eating.

During an interview on 4/24/2025 at 4:05 p.m. with the Administrator (ADM), the ADM stated they do not have a policy regarding food preparation for palatability, flavor, appearance, and temperature.

During a review of the facility's standardized recipe titled Recipe: Roast Turkey dated 2024, the recipe indicated serve on trayline at a recommended temperature of 160 F-180 F.

During a review of the facility's standardized recipe titled Recipe: Vanilla Mousse, dated 2024, the recipe indicated (4) serve on trayline at a recommended temperature of 41 F or less.

During a review of the facility's policies and procedures (P&P) titled P-DS16 Food Temperatures dated 1/29/2025, the P&P indicated acceptable serving temperatures are follows for the following food:

Meat and entrees less more than 140 F

Hazardous salad, dessert less than 41 F

Milk, juice less than 41 F

b. During a review of Resident 157's Admission Record, the Admission Record indicated the facility initially admitted Resident 157 on 10/23/2024 and readmitted the resident on 1/8/2025 with diagnoses that included type 2 DM with foot ulcer (a small open sore or wound), ESRD, and hypertensive chronic kidney disease (kidney problems that occur because of high blood pressure that is present over a long time).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 7 055932 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055932 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Four Seasons Healthcare & Wellness Center, LP 5335 Laurel Canyon Blvd. North Hollywood, CA 91607

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During a review of Resident 157's MDS, dated [DATE REDACTED], the MDS indicated Resident 157 understood others and made self understood. The MDS indicated the resident required set-up or clean up assistance when Level of Harm - Minimal harm or eating. potential for actual harm

During a review of Resident 157's Physician Orders, dated 1/8/2025, the Physician Orders indicated to Residents Affected - Some provide renal diabetic diet (CCHO, renal diet) regular texture (texture with no restriction).

During an interview on 4/22/2025 at 10:28 a.m. with Resident 157, Resident 157 stated the food at the facility was too salty and he was already on special diet but the food the facility served was still too salty.

During a review of the facility's daily spreadsheet titled Spring Cycle Menus, dated 4/22/2025, the spreadsheet indicated residents on CCHO diet would include the following foods on the tray:

Roast turkey 3 oz

Gravy 1 oz

Bread dressing 1/3 c.

Seasoned peas 1/2 c.

Three bean salad - drain 1/2 c.

Vanilla mousse with no chocolate chips

Milk 4 oz

The spreadsheet further indicated residents on CCHO renal diet would include the following foods on the tray:

Roast turkey 3 oz

Gravy 1 oz

Seasoned peas 1/2 c

Wheat roll 1 piece

Margarine 1 teaspoon

Diet apple sauce 1/2 c

Milk 4 oz/ diet punch 8 oz

During an interview on 4/22/2025 at 12:03 p.m. with [NAME] 1, [NAME] 1 stated the regular and therapeutic diets got the same roast turkey meat and the only difference was the sauce as she prepared a cranberry-ginger citrus sauce for regular diet and gravy for residents on renal and diabetic diets.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 055932 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055932 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Four Seasons Healthcare & Wellness Center, LP 5335 Laurel Canyon Blvd. North Hollywood, CA 91607

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During a concurrent observation and interview on 4/22/2025 at 12:54 p.m. of the test tray of a renal CCHO diet with the DS and the ADS, tasted the roasted turkey with gravy and it was salty. The ADS stated renal Level of Harm - Minimal harm or diet should not be salty and the cook followed recipes and maybe the amount of base the cooks used made potential for actual harm it salty. The ADS stated [NAME] 1 prepared everything for lunch. The ADS stated it was important to follow

the recipe because if the food was salty the residents would not eat and enjoy their food. The DS stated Residents Affected - Some renal diet should not be salty as it would be contraindicated in the diet making them sick and retain water as

a potential outcome.

During an interview on 4/23/2025 at 8:46 p.m. with [NAME] 1, [NAME] 1 stated she did not follow the recipe for the gravy for renal CCHO diet because they do not have too many residents on it. [NAME] 1 stated she just guessed the ingredients and added the juice of the turkey, flour and some seasonings. [NAME] 1 stated

she did not follow the recipe of the gravy because it was not available in the recipe binder however it was important that they follow the exact recipe to ensure the food of the residents would taste good. [NAME] 1 stated the residents would not eat if the food did not taste good.

During an interview on 4/23/2025 at 9:46 a.m. with the DS, the DS stated they could not find the recipe for gravies, but all the food has standardized recipes, and it was important to follow the recipes to ensure residents would get the right amount of nutrition. The DS stated [NAME] 1 did not follow the recipe for gravy and residents on renal diet could get sick by not getting proper nutrition causing malnutrition if the recipes were not accurately followed. The DS stated [NAME] 1 should have not prepared gravy as all the diets gets

the same sauce and the spreadsheet was confusing as it was indicating gravy.

During a review of the facility's P&P titled Menus dated 1/29/2025, the P&P indicated, To ensure that the facility provides meals to residents that meet the requirements of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences.

During a review of the facility's P&P titled Standardized Recipes, dated 1/29/2025, the P&P indicated To provide the dietary department with guidelines for the use of standardized recipes. Food products prepared and served by the dietary department will utilize standardized recipes. I. Standardized recipes are provided with the menu cycle. III. Standardized recipes will have adjustments or separate recipes for therapeutic and consistency modifications. IV. Recipes will have diet modifications noted.

During a review of the facility's standardized recipe titled Gravies dated 2024, the recipe indicated, ingredients included salt 1 Tablespoon for 120 servings and Worcestershire sauce 3 tablespoon plus 2 1/4 tsp for 120 servings. The recipe further indicated turkey juice was not part of the ingredient.

During a review of the facility's product specification titled Turkey Breast boneless Raw Bag 15% undated,

the product specification indicated the turkey used for all the diets including renal and CCHO diets contained

the following ingredients: contains up to 15% solution of turkey broth, salt, sugar, sodium phosphate.

c. During a review of the facility's menu spreadsheet titled Spring Cycle Menus, dated 4/22/2025, the spreadsheet indicated residents on puree diet would include the following foods on the tray:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 055932 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055932 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Four Seasons Healthcare & Wellness Center, LP 5335 Laurel Canyon Blvd. North Hollywood, CA 91607

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Puree roast turkey 1/2 c

Level of Harm - Minimal harm or Puree cranberry-ginger-citrus sauce 1 oz potential for actual harm Puree bread dressing number 12 scoop (1/3 c) Residents Affected - Some Puree three bean salad 1/3 c

Vanilla mousse (no chocolate chips) 1/3 c.

Milk 4 fluid oz.

During an observation on 4/22/2025 at 11:49 p.m. of the puree mashed potato on the plate in trayline (an area where foods were assembled from the steamtable to resident's plate), observed the puree mashed potato did not hold its shape on the plate.

During an observation on 4/22/2025 at 11:54 a.m. of the puree roast turkey, observed puree roast turkey was flat on the plate when served.

During a concurrent test tray observation and interview on 4/22/2025 at 1:15 p.m. with the DS and the ADS,

the DS stated puree diet preparation and presentation were combination of form and smoothness of the food. The DS stated the puree food passed the spoon tilt test (a test used to determine the stickiness of the sample and the ability of the sample to hold together), meeting the proper texture of food, however it would not hold its shape on the plate when achieving the correct food texture. The DS stated if the puree food held its shape on the plate, then it would not pass the spoon tilt test; hence, they needed to follow the one thing which was the food texture. The ADS stated the International Dysphagia Standardization Initiative (IDDSI, is

a global standard with terminology and definitions to describe texture modified foods and thickened liquids used for individuals with difficulty of swallowing for all ages, in all care settings, and for all culture) standards was newly implemented, and puree diet should have baby foods, soft texture but not watery and should be able to pass a spoon tilt test. The ADS stated the puree mashed potatoes and puree roast turkey did not hold their shapes on the plate as they were a little bit flat on the plate and residents might not eat them causing poor food intake as a potential outcome.

During a review of the facility's diet manual (a manual containing all the diets the facility has for residents and its description, foods allowed and avoided in each diet) titled Regular Pureed Diet reviewed 1/29/2025, the diet manual indicated Description: The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be smooth and moist consistency and able to hold its shape. Portions given will account for the addition of fluids and be specified in the spreadsheet. Detailed recipes and procedures for pureeing foods maybe found in binder 1, under the food safety/miscellaneous section.

During a review of the facility's standardized recipe titled RECIPE: Pureed (IDDSI Level 4) dated 2024, the recipe indicated (5) The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed items must pass IDDSI level 4 testing requirements (i.e. the fork drip, fork pressure and spoon tilt test).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 055932 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055932 B. Wing 04/25/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Four Seasons Healthcare & Wellness Center, LP 5335 Laurel Canyon Blvd. North Hollywood, CA 91607

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 During a review of the facility's standardized recipe titled RECIPE: Mashed potato (Packaged) dated 2024,

the recipe indicated Dysphagia: smooth with no lumps. Puree if needed following the pureed recipes. Level of Harm - Minimal harm or potential for actual harm During a review of the IDDSI guideline website titled IDDSI, dated 7/2019, the IDSSI guideline indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to Residents Affected - Some hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 055932