Health inspection·December 23, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 ensure the medical records of one of three sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to ensure licensed nurses documented Resident 1's change of condition (COC) in Resident 1's medical records. This deficient practice resulted in incomplete and inaccurate information on Resident 1's medical records and had the potential for delayed medical interventions.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 5/22/2019 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), other specified disorders of the brain, and convulsions (a medical event involving sudden, violent, involuntary muscle contractions and relaxations, causing uncontrollable shaking or stiffening of the body linked to unusual brain activity). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/22/2025, the MDS indicated Resident 1's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were moderately impaired. During a review of Resident 1's Physician Orders, dated 12/16/2025, the Physician Orders indicated to monitor and document for episodes of seizure activity every shift and notify the attending physician of seizure presence. During an interview on 12/23/2025 at 3:51 p.m. and concurrent record review of Resident 1's Progress Notes, dated 12/18/2025, reviewed with Registered Nurse (RN) 1, the Progress Notes indicated Resident 1 experienced three consecutive seizure episodes . at 8:45 a.m. for ten seconds, at 11:11 a.m. for one minute, and at 12 p.m. for two minutes. RN 1 stated licensed nurses should document the assessment done on Resident 1 after the resident's COC. RN 1 stated there was no documented evidence that a Situation, Background, Appearance, and Review (SBAR) Form was created for the three seizure episodes of Resident 1 on 12/18/2025. RN 1 stated Resident 1's COC documentations were incomplete. During an interview on 12/23/2025 at 3:55 p.m. with the Director of Nursing (DON), the DON stated the licensed nurse that witnessed Resident 1's seizure or the RN supervisor should document the seizure episodes and the assessment done on the resident. The DON stated complete documentation was important for communicating Resident 1's condition to the attending physician and the resident's care team. The DON stated the facility failed to ensure proper documentation of Resident 1's assessment was completed. During a review of the facility's policy and procedure (PnP) titled, Change in Condition, last reviewed on 9/25/2025, the PnP indicated the licensed nurse will document the following . i. date, time, and pertinent details of the event and the subsequent assessment in the medical record. ii. The time the Physician was contacted. iii. The time the family or responsible person was contacted. During a review of the facility's policy and procedure (PnP) titled, Completion and Correction, last reviewed on 9/25/2025, the PnP indicated the purpose to ensure that medical records are complete and accurate. The PnP indicated . entries will be Page 1 of 2 055932 055932 12/23/2025 Four Seasons Healthcare & Wellness Center, LP 5335 Laurel Canyon Blvd. North Hollywood, CA 91607

F 0842 Level of Harm - Minimal harm or potential for actual harm recorded promptly as the events or observations occur. Entries will be complete, legible, descriptive, and accurate. any person making observations or rendering services to the resident will document in the record. The PnP indicated documentation will reflect medically relevant information concerning the resident and will be documented in a professional manner. Residents Affected - Few 055932 Page 2 of 2