Four Seasons Healthcare & Wellness Center, Lp

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

interview and record review on 10/24/2025 at 11:08 a.m., with the Director of Nursing (DON), facility's policy and procedure (P&P), titled, Change of Condition Notification, dated 8/25/2022, was reviewed. The P&P indicated, The facility will promptly inform the resident, consult with the resident's Physician, and notify

the residents legal representative or an interested family member, if known, when the resident endures a significant change in their condition caused by, but not limited to:A. An accidentB. A significant change in

the resident's physical, mental or psychosocial status (how factors like emotions, thoughts, and behaviors are influenced by social elements such as family, relationships, and culture), and orC. A significant change

in treatment.II. Change in Condition related to the Physician notification is defined as when the Physician must be notified when any sudden and marked adverse (unfavorable, harmful or negative) change in the residents condition which is manifested by signs and symptoms different that usual denote a new problem, complication or permanent change in status and require a medical assessment, coordination and consultation with the Physician and a change in the treatment plan. The DON stated RN 1 should have called the Conservator. The DON stated conservators are the decision makers of the Residents. The DON stated Conservator should have been notified to inform them of the alleged sexual interaction. The DON stated their policy indicated notification should be prompt. The DON stated Conservator should have been called on 10/22/2025. The DON stated there was a delay in notification.During an interview on 10/24/2025, at 11:38 a.m., with the MDS Nurse (MDSN), the MDSN stated Conservator acts on Resident 1's behalf and was appointed to make healthcare decisions for Resident 1. The MDSN stated that attempts to notify the conservator should have been made.

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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

10/24/2025

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based on interview and record review the facility failed to maintain an accurate and complete medical

record for one of three sampled residents (Resident 2) by failing to ensure accurate time of notification was documented in Resident 2's medical record.This failure had the potential to cause confusion in care and the medical records containing inaccurate documentation.Findings:During a review of Resident 2‘s admission Record, the admission Record indicated the facility admitted Resident 2 on 2/6/2025, with diagnoses that included unspecified (unconfirmed) epilepsy (repeatedly uncontrolled electrical activity in the brain, which may produce a jerking movement of a part or the entire body), chronic pain syndrome (a condition where persistent pain lasts for at least three months) and unspecified depression (a serious mood disorder that goes beyond temporary sadness, causing a persistent feeling of emptiness, hopelessness, and loss of interest in life).During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a Resident's medical history, performing a physical exam, and documenting their findings), dated 2/7/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions.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 cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.During a review of Resident 2's eInteract Change in Condition Evaluation, dated 10/22/2025, timed at 5:16 p.m., the eInteract Change in Condition Evaluation indicated alleged sexual interaction. The eInteract Change in Condition Evaluation indicated the Physician was notified on 10/22/2025, at 7:16 p.m., and the Responsible Party (party responsible for making health care decisions when the principal party is unable to) was notified on 10/22/2025, at 1:18 a.m.During a concurrent interview, and record review on 10/24/2025, at 11:08 a.m., with the Director of Nursing (DON), Resident 2's eInteract Change in Condition Evaluation, dated 10/22/2025, was reviewed.

The eInteract Change in Condition Evaluation indicated Resident 2's Responsible Party was notified on 10/22/2025 at 1:18 a.m. The DON stated the alleged sexual encounter happened on 10/22/2025, at 5 p.m.

The DON stated the documentation for the Responsible Party notification was wrong. The DON stated they could not call ahead before the incident happened. The DON stated wrong documentation can create confusion at the time of the incident.During an interview on 10/24/2025, at 11:31 p.m., with the Administrator (ADM), the ADM stated the incident happened on 10/22/2025, at 5 p.m., The ADM stated he (ADM) was in his (ADM) office when he (ADM) was notified of the alleged sexual encounter.During a review of facility's policy and procedure (P&P), titled, Change in Condition dated 8/25/2022, was reviewed. The P&P indicated, Documentation:a. Licensed Nurse will document the following: .iii. the time the family/responsible person was contacted and name of individual notified.

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