Four Seasons Healthcare & Wellness Center, Lp

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

possibly have fluid overload.During an interview on 8/21/2025 at 12:48 p.m. with the Director of Nursing (DON), the DON stated that according to facility policy and procedure it indicates to set dose limit on the machine before starting it. The DON stated that Resident 1 could possibly have an unintended weight gain, increase risk of regurgitation, and discomfort.During a review of the facility-provided policy and procedure titled, Enteral Feeding, last review date 6/25/2025, the policy and procedure indicated, Set pump setting according to the physician order. Set dose limit on machine and start, if applicable.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

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 0760

Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or potential for actual harm

Based on interview and record review the facility failed to ensure that medication was administered according to the physician order for one of three sample resident (Resident 2).This deficient practice had

the potential for Resident 2 to not receive the full benefit of the medication. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/4/2025 with a diagnosis of spondylosis with radiculopathy (age-related wear and tear in your spine is pinching a nerve, which causes pain, numbness, or weakness to spread from your back to your limbs) and chronic pain.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 8/14/2025, the MDS indicated Resident 2's thought process was intact and required set-up assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 2's Physician's Orders, dated 8/12/2025, the Physician's Order indicated to give Paxlovid (oral antiviral medication for COVID-19 {infectious disease} that helps stop the virus from multiplying in your body) 3 tablets by mouth two times a day for 5 days.During a review of Resident 2's Progress Notes, dated 8/16/2025 at 3:30 a.m., the Progress Notes indicated Resident 2 refused Paxlovid earlier and now at 3:30 a.m. Resident 2 requested to take it and Paxlovid was given at 3:30 a.m.During a review of Resident 2's Progress Notes, dated 8/16/2025 at 11:10 p.m., the Progress Notes indicated that Paxlovid was given to Resident 2 per Resident 2 request.During a concurrent interview and record review on 8/20/2025 at 11:13 a.m. with License Vocational Nurse (LVN) 1, Resident 2 progress notes dated 8/16/2025 were reviewed. LVN 1 stated that there was no documentation from the nurse that physician was notified that Resident 2 wants to take her medication on 8/16/2025 at 3:30 a.m. and 11:10 p.m. LVN 1 stated that 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.

During a concurrent interview and record review on 8/21/2025 at 3:32 p.m. with the Director of Nursing (DON), Resident 2's progress notes dated 8/16/2025 were reviewed. The DON stated Resident 2's medication (Paxlovid) was administered at 3:30 a.m. and 11:10 p.m. The DON stated that Resident 2's 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 DON stated that 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 DON stated administering beyond

the administration window time was considered a medication error according to facility policy and procedure indicating to administer the medication within one hour before or one hour after the scheduled time. The DON stated upon reviewing Resident 2's medical record the DON did not find any documentation that the physician was notified of the change of administration time. The DON stated that it was important to follow physician's order to make sure Resident 2 will receive the full effectiveness of the medication (Paxlovid).During a review of the facility policy and procedure titled, Medication Administration, last review date of 6/25/2025, the policy and procedure indicated, All medications shall be administered by licensed nursing staff according to physician orders, current best practices, and federal and state regulations. The facility shall ensure residents receive the correct medications in a timely, safe, and documented manner.

Medications must be administered within one hour before or one hour after.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet