Four Seasons Healthcare & Wellness Center, Lp
FOUR SEASONS HEALTHCARE & WELLNESS CENTER, LP in NORTH HOLLYWOOD, CA — inspection on September 15, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
called Lab 1 for STAT H/H.
Per conversation at 12 a.m. with MD, no transfer to the hospital to recheck for H/H.During a review of Resident 1's Progress Notes dated 10/4/2023 at 8:46 a.m., the Progress Notes indicated received a call from MD that resident (Resident 1) will not have a blood transfusion if HGB result was above 7 g/dL.
The Progress Notes indicated that staff notified MD re STAT order for H/H phlebotomist was still pending.During a review of Resident 1's COC dated 10/4/2023 at 2:44 p.m., the COC indicated Resident 1 was transferred to the General Acute Care Hospital (GACH) per Resident 1's request.
The COC indicated Resident 1 was noted with episode of blood in stool, MD was made aware and ordered STAT H/H.
The COC indicated Family Member (FM) 2 was made aware and persistently requested to send out Resident 1 to the GACH at 10:05 a.m.During a review of Resident 1's Lab 1 results dated 10/4/2023, the Lab 1 results indicated test for H/H, Resident 1 was in the hospital.
The Lab 1 results were reported on 10/4/2023 at 9:19 p.m.During a review of Resident 1's Lab 1 results dated 10/4/2023, the Lab 1 results indicated lab results were reported on 10/4/2023 at 11:01 p.m. and the labs result was Resident 1 was positive for occult blood.During a concurrent interview and record review with Director of Nursing (DON) on 9/15/2025 at 4:15 p.m., Resident 1's COC, Progress Notes, and Physician Orders dated 10/31/2023 were reviewed.
The DON stated the MD ordered FOBT one time which includes occult blood and CBC.
The DON reviewed progress note dated 10/4/2023 and stated indicates Lab 1 phlebotomist did not come on 10/4/2023.
The DON reviewed Resident 1's orders and the DON stated there was no order for the repeat H/H MD ordered on 10/4/23.
The DON stated when MDs order STAT labs it is to ensure the results are done within four hours.
The DON stated if a STAT lab is ordered the nurses need to call the lab and get a timeframe and should then follow up until the labs have been collected.
The DON stated the night nurse should have called Lab 1 but not sure if Lab 1 gave the nurse a timeframe of when they were coming to the facility as there was no documentation.
The DON reviewed Resident 1's COC dated 10/4/2023 at 2:44 p.m. the DON stated the COC indicated Resident 1 was discharged per resident's request.
The DON stated there were no notes indicating the STAT labs were done.
The DON stated if STAT labs are not done as ordered by MD there is a potential for a delay in care.During a review of the facility's Policy and Procedures (P&P) titled, Collection of Laboratory Specimens- Phlebotomy Procedures, last reviewed on 6/25/2025, the P&P indicated STAT lab test orders must be called into the laboratory customer service and mentioned as STAT.
All attempts will be made to expedite the turnaround time for lab test ordered as STAT.
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