Other·April 6, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of two Facility-Reported Incidents (FRIs) during an annual recertification visit conducted 02/18/2020. FRI number: CA00670629 FRI number: CA00674839 Representing the Department of Public Health: Health Facilities Evaluator Nurse ID: 38552 Health Facilities Evaluator Nurse ID: 38469 Health Facilities Evaluator Nurse ID: 38601 Health Facilities Evaluator Nurse ID: 40081 Health Facilities Evaluator Nurse ID: 40732 Health Facilities Evaluator Nurse ID: 41987 Health Facilities Evaluator Nurse Trainee ID: 43040 Health Facilities Evaluator Nurse Trainee ID: 43103 Health Facilities Consultant Pharmacist ID: 40994 No deficiencies were issued for FRIs number CA00670629 and CA00674839. Highest Severity and Scope: K Total Census: 191 Sample Size: 60 On 2/20/2020 the Department of Public identified an Immediate Jeopardy situation (IJ) a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. Resident 291 was not administered 17 doses of LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 1 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Flovent (an inhalation medication used to treat breathing problems), and did not receive monitoring for oxygen saturation levels (a measure of how much oxygen is in the blood), to maintain the oxygen level at 92 % (percent) as required by the physician's order from 2/11/2020 to 2/20/2020. Resident 17 was not administered eight doses of Lantus insulin (a medication used to treat high blood sugar, as required by the physician's order between 2/14/2020 and 2/22/2020. These failures had the potential for Residents 291 and 17 to experience significant harm including respiratory arrest (the inability to breathe) Resident 291, or coma (a prolonged period of unconsciousness brought on by illness or injury) Resident 17, likely resulting in hospitalization or death. On 2/20/2020, at 3:30 p.m. the Administrator (ADM), and the Director of Nursing (DON) were verbally notified of an Immediate Jeopardy (IJ) situation. On 2/22/2020 at 5:48 p.m., after receipt of acceptable plan of action (POA) and verification of POA implementation, the IJ was lifted in the presence of the ADM and the DON.

F558 SS=D Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3)

F558 03/24/2020 §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 2 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on observation, interview and record review, the facility failed to provide reasonable accommodation of resident needs for one (1) of three (3) residents investigated under reasonable accommodation of resident needs and preferences, by failing to ensure Resident 77's call light is within reach. This deficient practice had the potential to result in the delay of the provision of necessary care and services for Resident 77. Findings: A review of Resident 77's Admission Record indicated the resident was originally admitted to the facility on 09/11/18 and readmitted on 04/4/19, with diagnoses that included muscle weakness, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and osteoarthritis (inflammation of one or more joints). A review of Resident 77's Minimum Data Set (MDS- an assessment and screening tool) dated 12/05/19, indicated that Resident 77's cognitive skills (cognition refers to conscious mental activities, and includes thinking, reasoning, understanding, learning, and remembering) for daily decision making is intact. The MDS also indicated that Resident 77 required supervision from staff for bed mobility, transfer, dressing and personal hygiene. On 02/17/20 at 10:30 a.m., during the Initial Tour, Resident 77 was observed lying in bed sleeping. Upon closer inspection, the resident's call light was observed to be on the floor with the call button at the far end of the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 3 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE bedside drawer. During the observation, Licensed Vocational Nurse 9 (LVN 9) came into the room. After pointing out the call light to LVN 9, she then removed the call light from the floor and placed the call light on the resident's bed, with the cord on top of the bed siderail. LVN 9 stated part of her tasks include to make sure there is water in the resident's pitcher and to ensure the call light is within reach of the resident. LVN 9 explained that, the purpose of the call light is for a resident to call the nurses' when they need anything. On 02/20/20 at 09:16 a.m., during an interview the Assistant Director of Nursing (ADON), stated that the purpose of the call light is for the resident to call staff if they need assistance, and when they do their rounds, they have to make sure that the call light is within reach. Per the ADON, all staff are trained to answer the call light. The ADON stated if the resident is in the bed the call light is placed next to the resident; they can clip the call light on the bedsheet or some on the resident's gown, and wrapping around the siderails is practical, so call light will not easily fall. A review of the facility's policy and procedure titled "Communication- Call System," reviewed on January 29, 2020, indicated that the facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities. Call cords will be placed within the resident's reach in the resident's room.

F585 SS=D Grievances CFR(s): 483.10(j)(1)-(4)

F585 03/24/2020 §483.10(j) Grievances. §483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 4 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay. §483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph. §483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident. §483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include: (i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; (ii) Identifying a Grievance Official who is responsible for overseeing the grievance FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 5 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; (iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; (iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law; (v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns (s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued; (vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and (vii) Maintaining evidence demonstrating the result of all grievances for a period of no less FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 6 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE than 3 years from the issuance of the grievance decision. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure prompt attempts were made to resolve grievances regarding lack of permission for going out of the facility, for one of 60 residents (Resident 66), reviewed for the care area of resident rights. This deficient practice violated the resident's right to have his grievance resolved promptly. Findings: A review of Resident 66's Admission Record indicated the resident was readmitted on 6/5/19, with diagnoses including pneumonia (an infection of the air sacs in one or both the lungs) and end-stage renal disease (ESRD-last stage of chronic kidney disease when the kidneys fail leading to the need of long-term dialysis (the purification of blood as a substitute for the normal function of the kidney) or a kidney transplant to maintain life). A review of Resident 66's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 12/3/19, indicated the resident has clear speech, and is able to make self-understood and understands others. A review of Resident 66's Discharge Care Plan initiated on 6/7/19, indicated the resident wants to be discharged home and is able to participate in the discharge planning process. The care plan included interventions to arrange resident/family conference to establish a discharge plan and to review the discharge plan with resident/family and to follow-up as needed with the resident/family to assure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 7 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE understanding of the plan or answer additional questions. During an interview on 2/18/20 at 9:40 a.m., Resident 66 stated he asked the facility staff if he can go out of the facility, and they did not give him permission. The resident stated he has spoken to the Social Services Director and the licensed nurses, but he has not been allowed to go out of the facility. The resident stated he feels that it is not fair that he cannot go out, and he feels like a prisoner. During an interview on 2/21/20 at 7:33 a.m., the Social Services Director (SSD 1) stated when residents have concerns, the concerns are addressed with all the Interdisciplinary Team (IDT- a group of different disciplines meet to address the resident's problem) members before addressing the concerns as a grievance. SSD 1 stated Resident 66 used to have an out on pass (OOP) order. SSD 1 stated the resident's primary physician ordered to have a facility staff to go out of the facility with the resident for a safety measure. SSD 1 confirmed there was no IDT done for an out on pass (OOP-permission to go out of the facility) change to have a facility staff with the resident. During a concurrent interview, and record review, of Resident 66's clinical (medical) record on 2/21/20 at 7:45 a.m., the Licensed Vocational Nurse, (LVN) 7 confirmed the resident only has a physician's order for OOP with a responsible party. LVN 7 confirmed there was no order to be accompanied by a facility staff. LVN 7 stated the physician's order for OOP, was discontinued on 9/4/19. LVN 7 confirmed there was no IDT meeting documented on the resident's clinical record addressing the resident's OOP order or request. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 8 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's policy and procedure titled "Grievances and Complaints" reviewed and approved on 1/29/2020, indicated the facility advises residents and their representatives of their right to file grievances without discrimination or reprisal, and of the process for filing grievances or complaints. The facility ensures that there is no retaliation for filing a grievance or complaint and ensures that there is a prompt review, investigation, and response to and resolution of grievances and complaints. The disposition of all resident grievances and/or complaints is recorded in the facility's Resident Grievance/Complaint log. A review of the facility's policy and procedure titled "Out On Pass" reviewed and approved on 1/29/2020, indicated it is the facility's policy to meet resident's physical and psychosocial needs when going out on pass. The facility will make reasonable efforts to ensure the resident safety and uphold residents' rights. Procedure: II. If the resident experiences a significant change in condition affecting the resident's decision-making capacity, physical abilities, or ability to take medications, the Nursing Staff will notify the Attending Physician and Psychiatrist (if applicable) of the need to review the resident's ability to leave the facility on a pass.

F623 SS=B Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 03/24/2020 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 9 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 10 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 11 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer to the hospital for two of six residents (Resident 155 and Resident 174), reviewed for the care area of transfers. This deficient practice had the potential to deny Resident 155 and 174 protection from being inappropriately discharged and had the potential to result in the residents not being aware of how to contact the State Long Term Care Ombudsman and on how to appeal the transfer if necessary. Findings: a. A review of Resident 155's Face Sheet (Admission Record) indicated that the resident was initially admitted to the facility on 12/26/13 and readmitted on 2/5/20, with a diagnosis that included morbid obesity (well above one's normal weight), difficulty walking, and generalized muscle weakness. A review of the Minimum Data Set (MDS, a resident assessment tool) dated 1/19/20, indicated Resident 155 had the ability to make themselves understood and the ability to understand others. A review of Resident 155's physician's order indicated that on 1/28/20, there was an order for discharge to the hospital via 911 (emergency transport) due to desaturation (low blood oxygen concentration, usual range for an adult's oxygen is 95%-100%) at 83% on room air. During a concurrent interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 12 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review, on 2/24/20 at 8:55 AM of Resident 155's Notice of Transfer/Discharge, Licensed Vocational Nurse 6 (LVN 6), verified that there was no signature documented on the Notice of Transfer/Discharge form. LVN 6 stated this is how the facility shows evidence that the resident received notification and proper preparation for the transfer. During a concurrent interview, and record review, on 2/24/20 at 8:41 AM of Resident 155's Notice of Transfer/Discharge form, Social Services Director 2 (SSD 2), stated that there was no signature from the resident which is a form of documented evidence of a Notice of Transfer/Discharge was provided to the resident. SSD 2 stated, that they need a signature from the resident because he has the capability to sign for himself. During a concurrent interview, and record review, on 2/24/20 at 10:17 AM with the Director of Nursing (DON) of Resident 155's Notice of Transfer/Discharge form, the DON verified that the resident was not aware of his transfer. The DON stated the resident should have signed the Notice of Transfer/Discharge form to provide some sort of documentation that the resident was aware. A review of the policies and procedures titled, "Notice of Transfer/Discharge" dated 1/29/20, indicates, "Before the transfer or discharge occurs, the facility must notify the resident and, if known, the responsible party, and ombudsman of the transfer and reasons for the transfer, and document in the resident's clinical record. If the resident "has capacity" to make his/her own health care decisions, the nurse will send the completed Notice of Proposed Transfer and Discharge form with the resident's other transfer forms." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 13 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE b. A review of Resident 174's Face Sheet indicated that the resident was initially admitted to the facility on 10/29/19 and readmitted on 1/6/20, with a diagnoses that included heart failure (the heart can't pump enough blood to meet the body's needs) and diabetes (high blood sugar). A review of the MDS dated 2/4/20, indicated that Resident 174 has the ability to make selfunderstood and has the ability to understand others. A review of Resident 174's physician's order indicated on 1/2/19, there was an order for discharge to the hospital via 911 due to increased wheezing (whistling sound or rattling sound in the chest) and increased temperature, secondary to diagnosis of pneumonia (a lung inflammation caused by infection). During a concurrent interview, and record review ,on 2/24/20 at 8:55 AM, of Resident 174's Notice of Transfer/Discharge form, Licensed Vocational Nurse 6 (LVN 6), verified that there was no signature documented on the Notice of Transfer/Discharge form. LVN 6 stated this is how the facility shows evidence that the resident received notification and proper preparation for the transfer. During a concurrent interview, and record review, on 2/24/20 at 9:31 AM, of Resident 174's Notice of Transfer/Discharge, Social Services Director 2 (SSD 2), stated that there was no signed documented evidence of a Notice of Transfer/Discharge, which was supposed to be provided to Resident 174 when he was admitted to the hospital. SSD 2 stated, they need a signature from the resident, because he has the capability to sign for himself. SSD 2 stated the signature demonstrates evidence that the resident was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 14 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE notified of his hospital transfer and was properly prepared. During a concurrent interview, and record review, on 2/24/20 at 10:17 AM, of Resident 174's Notice of Transfer/Discharge form the Director of Nursing (DON) verified that the resident was not aware of his transfer. The DON stated the resident should have signed the Notice of Transfer/Discharge form to provide some sort of documentation that the resident was aware. A review of the policies and procedures titled, "Notice of Transfer/Discharge" dated 1/29/20 indicates, "Before the transfer of discharge occurs, the facility must notify the resident and, if known, the responsible party, and ombudsman of the transfer and reasons for the transfer, and document in the resident's clinical record. If the resident "has capacity" to make his/her own health care decisions, the nurse will send the completed Notice of Proposed Transfer and Discharge form with the resident's other transfer forms."

F656 SS=E Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 03/24/2020 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 15 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to develop and implement an individualized plan of care for one (1) out of four (4) residents (Resident 35) investigated under the care area of care planning by failing to ensure that a comprehensive personcentered care plan was developed. This deficient practice resulted in failure to provide an activity program tailored to the needs of the resident. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 16 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 35's Admission Record indicated the resident was originally admitted to the facility on 02/09/18 and readmitted on 03/15/18, with diagnoses of muscle weakness, hydrocephalus (a condition characterized by excess fluid build-up in the fluid-containing cavities of the brain), and lack of coordination. A review of Resident 35's Minimum Data Set (MDS- an assessment and screening tool) dated 11/14/19, indicated that Resident 35's cognitive skills (cognition refers to conscious mental activities, and includes thinking, reasoning, understanding, learning, and remembering) for daily decision making is severely impaired. The MDS also indicates that Resident 35 requires extensive assistance from staff for bed mobility, dressing, and personal hygiene. On 2/18/20 at 10:00 a.m., during a record review and interview with the Activity Director (AD), indicated that Resident 35's Activities Care Plan dated February 2019, included goals for the resident to attend and participate in group activities and participate in 1:1 room visits. The Activities Care Plan, did not provide any approaches and interventions tailored to the specific needs of Resident 35. There were no approaches or interventions marked to indicate which specific interventions are to be provided. The AD stated they should have indicated Resident 35's activity preferences when developing or renewing the care plan. The AD stated by identifying which interventions are applicable, then the Activity Care Plan will serve as a guide in the provision of a specific intervention or approach. A review of the facility's policy and procedures (last reviewed 1/29/20), titled "Comprehensive Person-Centered Care Planning," indicated that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 17 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE it is the policy of this facility to provide personcentered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest, mental, and psychosocial well-being.

F660 SS=D Discharge Planning Process CFR(s): 483.21(c)(1)(i)-(ix)

F660 03/24/2020 §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to postdischarge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 18 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a postacute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 19 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure the Interdisciplinary Team (IDT-a group of healthcare providers from different fields), was involved in developing a discharge plan that reflects the resident's discharge needs, goals, and treatment preferences (Resident 83), for one of 15 residents reviewed for the care area of comprehensive resident centered care plans. This deficient practice had the potential to result in incomplete or ineffective discharge planning and can lead to lack of necessary care for Resident 83's after discharge. Findings: A review of Resident 66's Admission Record indicated the resident was readmitted on 6/5/19, with diagnoses including pneumonia (an infection of the air sacs in one or both the lungs) and end-stage renal disease (ESRD-last stage of chronic kidney disease when the kidneys fail leading to the need of long-term dialysis or a kidney transplant to maintain life). A review of Resident 66's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 12/3/19, indicated the resident has clear speech, is able to make selfunderstood and understood others. A review of Resident 66's Discharge Care Plan initiated date 6/7/19, indicated the resident wants to be discharged home and be able to participate in the discharge planning process. The care plan included interventions to arrange resident/family conference to establish a discharge plan and to review the discharge plan with the resident/family and to follow-up as needed with the resident/family to assure FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 20 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE understanding of the plan or to answer additional questions. During an interview on 2/18/20 at 9:40 a.m., Resident 66 stated he wants to go home, and his primary physician has told him to be here for another six weeks. The resident stated he has been here about 9 months. During an interview, on 2/19/20 at 3:57 p.m., the Licensed Vocational Nurse (LVN 1) stated during discharge planning the licensed nurses will inform the resident/family/responsible party of the date of discharge. The licensed nurse will prepare the resident's medication list with them. If there is home health, the Social Services Director will call the home health agency and inform them the resident is going home, one week from now. LVN 1 stated the Social Services Director will call the home health agency and inform them of any durable medical equipment (medical devices used in the home to assist in the quality of living) the resident may need at home. During an interview on 2/20/20 at 7:41 a.m., the Social Services Director (SSD 1) stated her role includes discussing discharge planning with the resident/responsible party with home health agencies including discharge order. SSD 1 stated the Interdisciplinary Team (IDT- when different disciplines meet to address resident's problem) meeting is done when residents are discharged and she follows-up the next day. SSD 1 stated the discharge planning is done upon admission. During a concurrent interview, and record review, of Resident 66's clinical record on 2/20/20 at 7:43 a.m., SSD 1 stated the goal for Resident 66 is he wants to ambulate before he goes home. SSD 1 confirmed there was no IDT meeting done after resident's readmission on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 21 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 6/5/19. SSD 1 stated the IDT meeting is done based on the MDS calendar and she is responsible for scheduling the IDT meetings. SSD 1 stated there should have been an IDT discharge planning in September (2019) and December (2019) on the resident's clinical (medical) record. A review of the facility's policy and procedure titled "Transfer and Discharge" reviewed and approved on 1/29/2020, indicated the Social Services Staff will conduct a Discharge Planning Assessment, develop a post discharge plan of care, and orient the resident to the impending discharge. Procedure: E. The MDS will be updated to reflect resident's improvement in status quarterly, annually and with significant changes in the resident's condition. H. Social Services Staff will document the discharge planning, preparation, and the resident's post-discharge needs in Discharge Planning Assessment. J. Social Services Staff may coordinate a care conference to discuss discharge needs, plans, and teaching, and will involve other IDT members as appropriate.

F679 SS=D Activities Meet Interest/Needs Each Resident CFR(s): 483.24(c)(1)

F679 03/24/2020 §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 22 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: done Based on interview, and record review, the facility failed to provide an on-going activities based on comprehensive assessment and preferences for one of four residents (Resident 118), reviewed for the care area of Quality of Life, Activities. This deficient practice had the potential to affect the resident's sense of self-worth and psychosocial well-being through a feeling of usefulness, self-respect, and self-satisfaction. Findings: A review of Resident 118's Admission Record indicated the resident was originally admitted to the facility on 05/27/15 and readmitted on 10/2/16, with diagnoses that included Parkinson's disease (a chronic and progressive movement disorder), Huntington's disease (a condition that leads to progressive degeneration of nerve cells in the brain) and dementia (a group of symptoms that affects memory, thinking and interfers with daily life). A review of Resident118's Minimum Data Set (MDS- an assessment and screening tool) dated 1/11/19, indicates that Resident 118's cognitive skills (cognition refers to conscious mental activities, and includes thinking, reasoning, understanding, learning, and remembering) for daily decision making is moderately impaired. The MDS also indicates that Resident 118 requires extensive assistance from staff for bed mobility, transfer, dressing and personal hygiene. A review of Resident 118's Activities Care Plan dated 10/7/19, indicates that Resident 118's activity needs included religious and spiritual activity. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 23 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 2/20/20 at 9:24 a.m., during a record review, and interview, with the Assistant Director of Nursing (ADON) and Activity Director (AD), the Activity Attendance Log for the months of December 2019 and January 2020 of Resident 118, did not indicate that the resident was provided with or attended any religious activity. The ADON stated religious services/meetings are done as a group activity and some residents prefer one to one visits. The ADON confirmed that for Resident 118, there was no documentation in the activity attendance log to indicate the resident was provided with religious visits. The AD confirmed that there were no attempts made by the facility, to reach out to the community specific to Resident 118's religious affiliation. A review of the facility's policy and procedure, titled "Activities Program," last reviewed on 1/29/20, indicated that the facility provided an Activity Program designed to meet the needs, interests, and preferences of residents. The activities are varied and work to address the needs and interests identified through the assessment process. The Activity Program will address areas including, but not limited to, social activities, indoor and outdoor activities, and religious programs.

F684 SS=K Quality of Care CFR(s): 483.25

F684 03/24/2020 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 24 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE centered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to administer 17 doses of Flovent HFA (an inhaled steroid medication used to treat breathing problems) and failed to monitor oxygen saturations levels (a measure of how much oxygen is in the blood) every shift to maintain the oxygen levels at 92% (percent) as required by the physician's order from 2/11/2020 to 2/20/2020 to one of five randomly observed residents (Resident 291). The facility also failed to administer eight doses of Lantus insulin (a medication used to treat high blood sugar) between 2/14/2020 and 2/22/2020 to one of 12 randomly observed residents (Resident 17. These failures had the potential for Residents 17 and 291 to experience significant harm including respiratory arrest (the inability to breathe) or coma (a prolonged period of unconsciousness brought on by illness or injury) likely resulting in hospitalization or death. On 2/20/2020 at 3:30 PM, the Department of Public called an Immediate Jeopardy situation (IJ) a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the administrator (ADM) and director of nursing (DON). On 2/21/2020 at 3:45 PM, the DON and ADM provided an acceptable plan of action (POA) that included the following summarized actions: 1. A licensed nurse notified Resident 291's attending physician (MD 1), and informed her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 25 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE that the resident did not receive the Flovent HFA inhaler for approximately nine days. MD 1 gave orders to administer Flovent HFA as soon as it was available. MD 1 reassessed Resident 291 and found no signs or symptoms of respiratory distress. 2. A licensed nurse called the pharmacy, on 2/20/2020, to request an expedited order of the Flovent HFA for Resident 291. The DON requested that any future requests for medication authorizations be sent to him directly. Upon arrival, on 2/20/2020 at 11:30 AM, a licensed nurse administered Flovent HFA to Resident 291. 3. The licensed nurses will monitor Resident 291's oxygen level and titrate (measure and adjust the balance) the according to the physician's order. The licensed nurses will continue to monitor Resident 291's oxygen saturation level and his overall condition. 4. The DON provided one-on-one training and progressive disciplinary action to the licensed nurses involved in signing the Medication Administration Record (MAR) for doses of Flovent HFA not administered and failed to monitor Resident 291's oxygen saturation levels as required by the physician's order. 5. A licensed nurse conducted a facility-wide inspection of all medication orders and availability for all residents in the facility to ensure that medications were on hand to provide for their needs. The DON stated after completing the facility-wide inspection for all residents there were no additional missing medications. On 2/22/2020 at 7:47 AM, the Department did a facility-wide random check of medication availability, Resident 17's Lantus insulin was missing from Station 2's Medication Cart B. On 2/22/2020 at 10:05 AM, during an interview, the DON stated the facility's staff must have FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 26 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE overlooked Resident 17's missing Lantus insulin during the facility-wide random check of medication. On 2/22/2020 at 4:45 PM, the facility provided an amended POA that included the following additional summarized actions: 1. A licensed nurse assessed Resident 17's condition and there were no signs or symptoms of high or low blood sugar levels. The licensed nurse notified the attending physician (MD 2), that the nurses did not administer Resident 17's Lantus insulin for eight days. MD 2 gave an order to administer the Lantus as soon as it was available. MD 2 also ordered additional lab tests to assess Resident 17's condition. 2. A licensed nurse contacted the pharmacy and requested an expedited delivery of Lantus insulin for Resident 17. 3. The facility's pharmacy consultant provided retraining to licensed nurses on the proper protocols for ordering medications for the residents from the pharmacy. On 2/22/2020 at 5:48 PM, while onsite and after confirming the facility's implementation of the immediate corrective actions, the Department removed the Immediate Jeopardy, in the presence of the administrator and DON. Cross-referenced with F760. Findings: 1. A review of Resident 291's clinical record indicated an admission to the facility on 2/10/2020 with diagnoses that included pneumonia (an infection in the lungs) and asthma (a condition that causes difficulty breathing). A review of Resident 291's physician orders, dated 2/10/2020, prescribed Flovent HFA 110 micrograms ([mcg] a unit of measure) per FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 27 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE inhalation to inhale one puff by mouth into lungs twice daily for shortness of breath. Review of Resident 291's physician's order, dated 2/11/2020, indicated the resident was to receive oxygen at two to five liters ([L] a unit of measure for volume) per minute via nasal cannula (a device worn around the ears used to deliver supplemental oxygen into the nostrils), and to titrate and keep the oxygen saturation level (a measurement of oxygen in the blood) at 92%. Further review of the order indicated that facility staff should monitor oxygen saturation on every shift and adjust the oxygen dose as needed to maintain a saturation level of 92%. The order further indicated to monitor the resident's oxygen saturation level every (Q) shift. On 2/20/2020 at 9:53 AM, during a medication administration for Resident 291, the registered nurse (RN 2) prepared the following medications for Resident 291's morning medication administration: 1. One capsule of dutasteride (a medication used to treat urinary problems) 0.5 milligrams ([mg] a unit of measure). 2. Fluticasone nasal spray (a medication used to treat allergies.) 3. One tablet of levetiracetam (a medication used to treat seizures [uncontrolled electrical activity in the brain]) 500 mg. 4. One capsule of tamsulosin (a medication used to treat urinary problems) 0.4 mg. 5. Thirty milliliters ([ml] a unit of measure for volume) for urinary tract infection to Heal (a supplement.) 6. One tablet of meclizine (a medication used to treat dizziness) 12.5 mg. 7. One tablet of risperidone (a medication used to treat mental illness) 1 mg. 8. One tablet of divalproex sodium (a medication used to treat seizures) 500 mg. 9. One tablet of multivitamins with minerals (a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 28 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE supplement.) 10. Thirty ml of Pro Heal (a supplement.) On 2/20/2020 at 10:15 AM, during an interview, RN 2 stated she has a total of ten medications and supplements to administer to Resident 291. RN 2 stated Resident 291 also needed to have Flovent HFA 110 mcg administered but that she was unable to find the inhaler in the medication cart. RN 2 stated she would have her supervisor check on availability of the Flovent. On 2/20/2020 at 10:16 AM, Resident 291 was observed sleeping in his bed wearing his nasal cannula (a lightweight tube with two prongs at the end inserted into the nostrils to receive a mixture of air and oxygen). On 2/20/2020 at 10:19 AM, RN 2 was observed administering all ten medications listed above to Resident 291. On 2/20/2020 at 10:34 AM, during an interview, the Licensed Vocational Nurse (LVN) 6 stated she was the unit manager for Nursing Station 2 and Resident 291's Flovent inhaler was not anywhere in the facility. LVN 6 stated the initial order was on 2/10/20 and the facility ordered the Flovent from the pharmacy that day. LVN 6 stated she would check with the pharmacy, as it usually does not take that long to deliver the medications. LVN 6 added she informed MD 1, on 2/20/20 that the Flovent was currently unavailable and MD 1's response was to administer the Flovent to Resident 291 as soon as it was available. LVN 6 stated pharmacy is to deliver the medication later today (2/20/2020.) The licensed nurse was unable to produce a pharmacy delivery receipt for 2/10/20 or any other record of delivery for Resident 291's Flovent HFA. A review of Resident 291's MAR for February FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 29 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2020 indicated that between 2/11/2020 and 2/20/2020, the six licensed nurses (RN 2, Assistant director of staff development (ADSD), LVN's 2, 3, 4, and 5) signed they administered 17 doses of Flovent on the following dates and times: 1. RN 2 on 2/11 and 2/13/2020 at 9 AM, 2/14 and 2/15/2020 at 5 PM 2. LVN 2 on 2/12, 2/15, and 2/17/2020 at 9 AM 3. Assistant director of staff development (ADSD) on 2/14/2020 at 9 AM 4. LVN 3 on 2/16/2020 at 9 AM 5. LVN 4 on 2/18/2020 at 9 AM 6. LVN 5 on 2/11, 2/12, 2/13, 2/16, 2/17, 2/18, and 2/19 at 5 PM A review of Resident 291's February 2020 MAR for oxygen administration indicated between 2/12/2020 and 2/20/2020, the licensed nurses documented the oxygen levels a total of six of 25 opportunities on the following shifts and dates: 1. 11 AM-7PM shift on 2/15, 2/16, and 2/17/2020. 2. 7 AM-3 PM shift on 2/12, 2/16, and 2/17/2020. On 2/20/2020 at 11:21 AM, during an interview, LVN 6 stated after speaking with the pharmacist, they never delivered the Flovent, because it required approval from the DON due to the high cost. LVN 6 stated she was unable to explain why the licensed nurses signed as administering 17 doses of Flovent when the medication was never available in the facility. On 2/20/2020 at 11:36 AM, during an interview, the DON stated he could not explain why six licensed nurses signed administering Resident 291's Flovent on the MAR when the medication was not available. The DON agreed it was impossible for Resident 291 to have actually received his Flovent as documented if the pharmacy never delivered the medication. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 30 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE DON stated he would provide a list of the names of each licensed nurse who signed, but did not give the Flovent and provide them with retraining regarding the proper procedures for the documentation of medications. On 2/20/2020 at 12:13 PM, during an interview, RN 2 stated she recognized her initials on Resident 291's MAR as administering the 9 AM Flovent on 2/11/2020 and 2/13/2020. RN 2 stated her initials on those dates and times meant she administered the medication. RN 2 added if, for any reason, she did not give the medication she would initial the dose, circle her initials, and provide a written explanation on the back of the MAR. There was no documentation on the back of the MAR. RN 2 continued she would then follow up with the pharmacy and the physician as required. RN 2 stated she administered Flovent to Resident 291 on the dates and times she signed but was unable to explain how, since the pharmacy did not deliver the medication. RN 2 stated she may have confused the Flovent with another inhaler prescribed to Resident 291, but acknowledged it was unlikely since they were scheduled to be given at different times. RN 2 stated it is possible that she signed Resident 291's MAR indicating she gave him the Flovent without actually giving the medication. On 2/20/2020 at 12:32 PM, during an interview, the ADSD stated sometimes she is responsible for medication administration when other nurses are not available. The ADSD stated she signed Resident 291's MAR for Flovent at 9 AM on 2/14/2020. Her signature meant she gave the medication to the resident. The ADSD continued if she did not give the medication, for any reason, she would circle her initials on the MAR and explain why on the back of the MAR. There was no documentation on the back of the MAR. The ADSD added she felt rushed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 31 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE having to give medications on the morning of 2/14/2020, due to a nurse calling off duty. The ADSD also stated she most likely signed the MAR indicating she gave the Flovent to Resident 291 when in fact she had not. On 2/20/2020 at 12:45 PM, during an interview, MD 1 stated she is Resident 291's attending physician and the resident is currently recovering from pneumonia due to an infection caused by drug-resistant bacteria (is the ability of bacteria to resist the power of an antibiotic). MD 1 stated she prescribed Flovent and other medications on the resident's admission to the facility (2/10/2020) but was not aware he was not receiving the Flovent until today (2/20/20). MD 1 stated concerns for Resident 291 because the resident also has underlying asthma (a condition in which the tubes that carry air in and out of the lungs narrow and swell causing a reversible obstruction), so she prescribed Flovent. MD 1 stated without the Flovent to prevent or treat inflammation (the body's response to harmful stimuli, which may cause swelling) in the airways and lungs, Resident 291 could be at risk for respiratory arrest due to a combination of asthma and diminished lung capacity from pneumonia. MD 1 continued this could cause the resident to need hospitalization or even cause him to die. MD 1 stated she was unaware the licensed nurses signed the resident's MAR as giving the Flovent when in fact they had not. MD 1 expressed concern that Resident 291's MAR did not reflect the care actually provided to him as she relies on accurate information from the nursing staff in order to make the best treatment decisions. MD 1 added if Resident 291's condition deteriorated she may assume the Flovent, at its current dose is ineffective. This would prompt her to order an increased dose or switch to stronger oral steroid (a synthetic drug used to decrease inflammation), FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 32 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE which would put the resident at additional risk for adverse effects associated with higher doses of steroids (such as increased pressure in the eyes, swelling in the lower legs, high blood pressure, mood swings, and weight gain). On 2/20/2020 at 1:49 PM, during a telephone interview, the registered pharmacist (RPH 1) stated they received Resident 291's order for Flovent on 2/10/2020 along with all of the other medications. RPH 1 stated the Flovent needed authorization due to "high cost" based on their agreement with the facility. The pharmacy faxed an authorization request to the DON on the same day (2/10/2020), but did not receive the signed authorization back until 2/20/2020. RPH 1 confirmed they delivered Resident 291's Flovent HFA to the facility on 2/20/2020. A review of the pharmacy's faxed document titled "Notification of Non-Covered Items Price Quote & Billing Authorization" indicated the pharmacy faxed the request for Resident 291's Flovent HFA 110 mcg authorization, to the facility, on 2/10/2020 at 11:42 PM. On 2/20/2020 at 3:30 PM, during an interview, the DON stated he was unaware of ever receiving the pharmacy's request for authorization for the Flovent before today. The DON stated as soon as he received the fax, he signed it and sent it back. The DON stated he spoke with the pharmacy manager and requested to email all future authorizations directly to him. The DON acknowledged the licensed nurse failed to monitor Resident 291's oxygen saturation levels per the physician's order. The DON added as the facility's leader, he takes full responsibility and full ownership of the problems identified with resident care, including the fact that six licensed nurses falsified Resident 291's MAR and did not monitor the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 33 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident's oxygen level. The DON stated he would take appropriate steps to remedy the problem. During a concurrent interview, the ADM added, "We know we have a problem and we will work to fix it." 2. A review of Resident 17's clinical record indicated an admission to the facility on 2/8/19 with diagnoses including diabetes mellitus (a medical condition whereby the body is not able to regulate blood sugar.) A review of Resident 17's physician orders, dated 2/14/2020, indicated to give Lantus insulin by subcutaneous (under the skin) injection every night at bedtime give ten units (a measurement for the dosage of insulin). On 2/22/2020 at 7:47 AM, during a random inspection of Station 2 Medication Cart B, RN 1 verified the availability of Resident 17's medications listed on the MAR. Upon checking, RN 1 was unable to locate Resident 17's Lantus Insulin in the medication cart. During a concurrent interview, RN 1 stated she searched the medication storage room`s refrigerator, where unopened insulin vials or pens are kept, to try to locate Resident 17's Lantus insulin but was still unable to find any Lantus Insulin for Resident 17. On 2/22/2020 at 9:31 AM, during an interview, LVN 6 stated the physician`s medication orders are transmitted via fax to the pharmacy and the transmission will generate a transaction report which is then kept on file. LVN 6 further explained the pharmacy provides receipts of delivery for medications, which the facility also files. LVN 6 stated she was unable to produce any transmission record that the pharmacy received Resident 17's Lantus insulin order or that the pharmacy had delivered it to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 34 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility. LVN 6 stated Lantus insulin is a diabetic medication and if Resident 17`s diabetes is not appropriately managed, she could become hyperglycemic (high blood sugar), which could lead to diabetic ketoacidosis (a potentially lifethreatening complication of diabetes mellitus which may include symptoms such as vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion, and loss of consciousness). A review of Resident 17`s MAR from February 2020 indicated between 2/14/2020 and 2/21/2020, the licensed nurses' signed administering a total of eight doses of Lantus insulin on the following dates: 1. RN 2 on 2/14 and 2/15/2020. 2. LVN 5 on 2/16, 2/17, 2/18, 2/19, and 2/20/2020 3. RN 3 on 2/21/2020. On 2/22/20 at 10:05 AM, during an interview, the DON confirmed that the facility failed to transmit Resident 17's physician order for Lantus insulin to the pharmacy and consequently no delivery receipt of the Lantus insulin would be on file. The DON agreed it would have been impossible for Resident 17 to receive Lantus insulin, since the licensed nurse' had not ordered it, from 2/14 to 2/21/2020. On 2/22/2020 at 10:15 AM, during a telephone interview, RPH 2 confirmed the pharmacy neither received an order for Resident 17's Lantus insulin nor sent any out for delivery prior to 2/22/2020. On 2/22/2020 at 1:30 PM, during an interview, RN 2 explained on 2/14 and 2/15/2020, it was her first time working the 3-11 PM shift and she was responsible for administering Resident 17's Lantus insulin on those dates. RN 2 stated she signed as giving Resident 17's Lantus FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 35 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE insulin on the MAR on 2/14 and 2/15/2020. RN 2 stated she administered the Lantus to Resident 17 on those dates but was unable to explain how when the pharmacy never delivered the medication. RN 2 then stated she needs more training, as she is new to nursing and admitted that it was "her mistake." RN 2 stated she may have confused Lantus with another type of insulin ordered for Resident 17 but agreed that it was unlikely since the other insulin is usually given at different times. RN 2 also stated she feels that Station 2 has a high resident load compared to some of the other nursing stations in the facility and feels like she is sometimes overwhelmed with the amount of medication she has to administer. RN 2 stated she could have signed Resident 17's MAR that she gave Lantus when in fact she did not. On 2/22/20 at 2:40 PM, Resident 17 was observed lying in bed, alert, awake, but unable to verbalize a response. A review of the facility's policy and procedure document titled "Medication - Administration", last revised on 1/1/2012, indicated, "Medication will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner" and "Whenever a medication is held for any reason, the hour it was held must be initialed and circled in the Medication Administration Record (MAR) by the responsible Licensed Nurse. The Licensed Nurse will document on the back on the MAR, noting the time and the reason the medication was held." A review of the facility's policy and procedure document titled "Falsification & Omission", last revised on 1/1/2012, indicated, "Entries in a medical record at the Facility will be factual and will accurately reflect the services provided to the resident, the condition of the resident, and the resident's response to services provided" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 36 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and "Willful material falsifications and omissions are prohibited, a willful material falsification is made with the knowledge that the record falsely reflects the condition of the resident or the care of services provided."

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 03/24/2020 SS=D CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of three residents (Resident 84) investigated under the care area of Quality of Care, pressure ulcer, received the necessary care and services to prevent pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) from developing by failing to ensure a physician's order was in place for application of a silicone, foam, dressing on resident's sacrococcyx (tailbone) area. This deficient practice had the potential to result in the resident developing a pressure ulcer and or a pressure ulcer reopening. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 37 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: A review of Resident 84's Admission Record indicated the resident was readmitted on 12/2/19, with diagnoses including unstageable pressure ulcer (tissue loss with unknown depth) of the sacral region and sepsis (an inflammation throughout the body due to a bloodstream infection). A review of Resident 84's History and Physical dated 12/4/19, indicated the resident has the capacity to understand and make decisions. A review of Resident 84's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 12/9/19, indicated the resident required extensive assistance with bed mobility, transferring, dressing, and personal hygiene and total assistance with toileting with physical assistance from nursing staff. A review of Resident 84's Skin-Short Term Non-Pressure Ulcer Care Plan initiated on 12/3/19, indicated the resident will be free from further skin breakdown. The care plan interventions included administering medication and treatment as ordered. During an observation on 2/20/20 at 11:01 a.m., the Certified Nursing Assistant (CNA 2), provided peri-care (washing the genitals and anal area), for Resident 84. CNA 2 removed a bordered, foam, dressing from the resident's sacral (low back) area. CNA 2 stated she will ask LVN 8, if the resident needs a new dressing after she is done. During an interview, on 2/24/20 at 8:47 a.m., the Licensed Vocational Nurse (LVN 7) confirmed there is no physician's order for the use of the bordered, foam, dressing to Resident 84's sacral area. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 38 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a concurrent interview, and record review, of Resident 84's clinical (medical) record on 2/24/20 at 10:53 a.m., LVN 8 stated for the use of foam dressings there needs to be a physician order. LVN 8 stated he did not clarify the recommendation from the wound specialist for the silicone, foam, dressing. A review of the facility's policy and procedure titled "Physician Orders" reviewed and approved on 1/29/2020, indicated that the facility will ensure that all physician's orders are complete and accurate. A review of the facility's policy and procedure titled "Dressings-Application" reviewed and approved on 1/29/2020, indicated dressings are applied under the direction of an Attending Physician order or to provide for cleanliness, protection, and resident comfort until the Attending Physician can be reached for further orders.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 03/24/2020 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 39 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on observation, interview, and record review the facility staff failed to ensure the resident's safety for one of four residents (Resident 31), reviewed for the care area of Quality of Care, free of accidents, by failing to follow the physician's order and the care plan interventions to provide a "low bed", for Resident 31, to assist in minimizing the risk of injury from falls. This deficient practice had the potential to result in an avoidable injury in the event of a fall for Resident 31. Findings: A review of Resident 31's Face Sheet (Admission Record) indicated that the resident was admitted to the facility on 11/6/19, with a diagnoses of generalized muscle weakness and difficulty walking. A review of Resident 31's Minimum Data Set (MDS, a resident assessment tool), dated 11/13/19, indicated that Resident 31 has the ability to make themselves usually understood by others and has the ability to understand others. A review of Resident 31's physician order dated on 11/6/19, indicated to provide a "Low bed for safety". During an observation on 2/18/20 at 8:30 AM, Licensed Vocational Nurse 6 (LVN 6) verified that Resident 31's bed was not in a low position, but rather raised high, with the head of the bed elevated at a 40-degree angle. During a concurrent interview, and record review, on 2/18/20 at 8:35 AM, of Resident 31's care plan, LVN 6, verified that there was a care plan titled, "Fall Risk Prevention & FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 40 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Management Care Plan", with an intervention to provide a low bed. LVN 6 stated the intervention in the care plan needed to be implemented. LVN 6 verified that there was no written documentation that education was provided to the resident or responsible party of the resident being at risk for falls. LVN 6 stated the resident preferred her bed up high but, verified that there was no written documentation in the care plan of the resident's preference. LVN 6 stated there should have been written documentation of the resident's preference. A review of Resident 31's care plan dated 11/6/19, titled, "Fall risk Prevention and Management Care Plan", indicated the following: - Problem/Need: Resident is at risk for fall and has difficulty walking - Goal: Provide safe environment that minimizes complications associated with falls - Approach/Interventions: Bed in low position. During a concurrent interview, and record review, on 2/24/20 at 10:07 AM, the Director of Nursing (DON) verified and stated, Resident 31's care plan indicated an intervention for low bed and the nurse should have implemented the intervention that was documented in the care plan. A review of the policy and procedures revised date of 1/29/20 titled, "Fall Management Program" indicates, the purpose is, "To provide a safe environment that minimizes complications associated with falls. The Licensed Nurse will evaluate the resident's response to the Plan of Care during weekly Summary evaluation and update the residents' Care Plan as necessary".

F690 Bowel/Bladder Incontinence, Catheter, UTI FORM CMS-2567(02-99) Previous Versions Obsolete

F690 Event ID: G5LP11 03/24/2020 Facility ID: CA920000004 If continuation sheet 41 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=E CFR(s): 483.25(e)(1)-(3) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, record review and interview, the facility failed to provide peri-care (washing the genitals and anal area) in a manner to prevent odors, and infection for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 42 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE three of three residents (Resident 84, 290, and 55), who are at risk or have a history of urinary tract infection (UTI- an infection that affects any part of the urinary tract-kidneys, ureters, urinary bladder and the urethra), investigated under the care area of Quality of Care, bowel and bladder care. These deficient practices placed Resident 84, 290, and 55 at risk for UTI, skin breakdown and exposure to foul order. Findings: a. A review of Resident 84's Admission Record indicated the resident was readmitted on 12/2/19, with diagnoses including sepsis (an inflammation throughout the body due to a bloodstream infection) and UTI. A review of Resident 84's History and Physical dated 12/4/19, indicated the resident has the capacity to understand and make decisions. A review of Resident 84's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 12/9/19, indicated the resident required extensive assistance with bed mobility, transferring, dressing, and personal hygiene and total assistance with toileting with physical assistance from nursing staff. A review of Resident 84's Bowel and Bladder Care Plan initiated on 12/2/19, indicated the resident's goals are to be kept dry, clean, and comfortable. The care plan interventions included observing signs of UTI, but did not include interventions of providing incontinence care after each incontinent episode. During an observation on 2/20/20 at 11:01 a.m., the Certified Nursing Assistant (CNA 2) provided peri-care to Resident 84. CNA 2 filled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 43 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE one basin with water. CNA 2 soaked the washcloth in the basin, and gave the wash cloth to the resident. Resident 84 wiped her face, neck, and hands. CNA 2 raised the bed higher and repositioned the resident in bed. CNA 2 placed the washcloth in a plastic bag and obtained a new wash cloth and soaked the cloth in the basin. CNA 2 removed the fasteners/tape from the resident's briefs. CNA 2 used the wash cloth and cleansed the resident's left groin and used the same side of the wash cloth, to wash the right side of the groin, and resident's genital area. CNA 2, then dipped the washcloth in the basin. CNA 2 used the same washcloth and cleaned the resident's anal area and buttocks. CNA 2 removed the bordered, foam, dressing from the resident's sacral (low back) area. CNA 2 obtained another wash cloth dipped, in the basin and cleaned the anal area a second time and dried the resident with a towel using different sides for each area. CNA 2 was observed to use no soap. During an interview, on 2/21/20 at 1:43 p.m., CNA 2 stated she uses only one wash cloth to clean the back and front of the resident's genital area. CNA 2 confirmed she did contaminate the site cleaning the resident from the left groin to the vaginal area and to the anal area, using same washcloth, dipped in the same water in the basin. CNA 2 stated the contamination has potential for the resident to get a urinary infection. CNA 2 confirmed she did not use soap for providing peri-care. During an interview, on 2/24/20 at 3:29 p.m., the Director of Staff Development (DSD) stated she is in-charge of providing CNAs in-services (training). The DSD stated the procedure for providing peri-care for female residents, the CNAs should have two basins and wipe in a front to back motion using one side of the wash cloth, to different sites to prevent infection and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 44 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to use soapy water, not just plain water. b. A review of Resident 290's Admission Record indicated the resident was readmitted on 2/13/20, with diagnoses including anemia (a condition of having a lower-than-normal number of red blood cells) and urinary tract infection (UTI-infection that affects part of the urinary tract-kidneys, ureters, urinary bladder and the urethra). A review of Resident 290's History and Physical dated 2/14/20, indicated the resident has the capacity to understand and make decisions. A review of Resident 290's Bowel and Bladder Assessment dated 2/13/20, indicated the resident is continent of both bowel and bladder. During an interview, on 2/18/20 at 10:23 a.m., Resident 290 stated she has waited two hours to be changed. The resident stated she had to lie in urine and bowel movement for two hours. The resident stated it takes a while for anyone to answer her call light. The resident stated she has been here since Thursday of last week (2/13/20). During a concurrent interview, and record review, of Resident 290's clinical (medical) record on 02/24/20, at 2:00 p.m., the Licensed Vocational Nurse (LVN 7) confirmed the resident was admitted with diagnosis of UTI and has a history of chronic infection of the abdominal wound. LVN 7 confirmed a review of the physician's order dated 2/20/20, indicated the resident has new, left, groin redness, moisture associated skin damage (MASD), right groin perineum (between the anus and the genital organs), redness, left buttock MASD, and right buttock MASD. LVN 7 confirmed a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 45 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE change of condition was done for the MASD of the left and right buttock, and the right groin perineum redness. LVN 7 confirmed the resident refused a head to toe assessment upon admission, and on the following day. During a concurrent interview, and record review, on 2/24/20 at 2:39 p.m., LVN 7 confirmed there was no bowel and bladder care plan developed. LVN 7 stated the care plan was missed. c. A review of Resident 55's Admission Record indicated the resident was readmitted on 9/22/19, with diagnosis including hemiplegia (total or partial paralysis of one side of the body) affecting left non-dominant side and generalized muscle weakness.) A review of Resident 55's History and Physical dated 9/24/19, indicated the resident has the capacity to understand and make decisions. A review of Resident 55's Bowel and Bladder Assessment dated 11/20/19, indicated the resident has a score of 15. A score of 15 indicates the resident is an unlikely candidate for a bowel and bladder program. The assessment included a comment to provide good peri-care. A review of Resident 55's MDS dated 11/20/19, indicated the resident required total assistance with bed mobility, transferring, dressing, toileting, and personal hygiene with physical assistance from nursing staff. The MDS indicated resident is always incontinent of urine and bowel. A review of Resident 55's UTI Risk Care Plan re-evaluated date 12/22/19, indicated the resident will be assisted by staff in performing ADLs which cannot be met by the resident. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 46 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE care plan included interventions of assisting the resident with toileting as needed and providing peri-care after each incontinent episode. During an interview on 2/18/20 at 11:25 a.m., Resident 55 stated he waited two hours today for anyone to answer his call light, and no one came. Resident 55 stated when the Certified Nursing Assistant (CNA) comes to answer, they turn off the call light, leave, and do not come back. Resident 55 stated this is "not good". Resident 55 stated he urinates and defecates in his briefs, and has to wait that long soiled. Resident 55 stated this is not the first time it happened and not assisting him happens throughout the day. During a concurrent interview, and record review, of Resident 55's Physician's Order on 2/24/20 at 2:43 p.m., the Licensed Vocational Nurse (LVN 7) confirmed on 1/7/20, the resident has sacrococcyx (tailbone) redness and Moisture Associated Skin Damage (MASDinflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine/stool, perspiration, exudate, mucus, and saliva) and was discontinued. During an interview, on 2/24/20 at 3:41 p.m., the Assistant Director of Nursing (ADON), stated the residents' call lights have to be answered as soon as possible, within five minutes. The ADON stated if the facility staff answer the call light, the staff have to find out which resident is calling, and see what they can provide to the resident. The ADON stated if there is something they cannot provide, then the CNA is to come back to the resident at a specific promised time. The ADON stated if the CNA is not able to go back to assist the resident, the CNA is to give a reason why they could not come back right away. The ADON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 47 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated the reason of providing an explanation to the resident, is so the resident is made aware, and is not placed under the impression they are not being helped. A review of the facility's policy and procedure titled "Perineal Care" reviewed and approved on 1/29/2020, indicated perineal care is provided as part of a resident's hygienic program, a minimum of once daily, and per resident need. Procedure: I. Wash hands thoroughly before and after each procedure and put on gloves. II. Explain procedure to resident and provide privacy. III. May place moisture barrier pad under buttocks. IV. Position resident on back with knees flexed. V. Drape resident exposing perineal area. VI. Wash perineal area thoroughly with solution. A review of the facility's policy and procedure titled "Communication-Call System" reviewed and approved on 1/29/2020, indicated the facility will provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities. III. Nursing Staff will answer call bells promptly, in a courteous manner. IV. Upon responding to request, if item is requested is questionable, assistance will be obtained from the Charge Nurse. V. In answering to request, Nursing Staff will return to resident with the item or reply promptly. A. Assistance will be offered before leaving. A review of the facility's policy and procedure titled "Comprehensive Person-Centered Care Planning" reviewed and approved on 1/29/2020, indicated that it is the facility's policy to provide person-centered, comprehensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 48 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and interdisciplinary care that reflects best practice standards for meeting health, safety, psychological, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. V. IDT Care Planning Conference 1. The facility must provide the resident and representative, if applicable, reasonable notice of care planning conferences to enable resident and representative participation. Participation in care planning for both parties, if applicable, can be done via conference call, videoconferencing, etc.

F692 SS=D Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 03/24/2020 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 49 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review, the facility failed to ensure one of one resident (Resident 37) investigated under the hydration (the act of adding fluid into the body) care area was provided with bedside water to maintain proper hydration. This deficient practice has the potential to put the resident at risk for dehydration (not enough fluid). Findings: A review of Resident 37's Admission Record indicated the resident was readmitted on 8/13/19, with diagnoses including dementia (a loss of mental ability severe enough to interfere with normal activities of daily living) and generalized muscle weakness. A review of Resident 37's History and Physical dated 8/15/19, indicated the resident does not have the capacity to understand and make decisions. A review of Resident 37's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 11/17/19, indicated the resident required supervision with eating and bed mobility with setup help from nursing staff. A review of Resident 37's Physician's Orders indicated the resident the following: - Intravenous (IV-through the vein) hydration normal saline (NS-salt solution with sterile water) 60 milliliters (ml)/hour, 1 liter for variable PO (by mouth) intake, ordered 1/1/2020. - IV hydration NS 60 ml/hr, 1 liter, ordered 1/13/2020 A review of Resident 37's Nutrition and Hydration Care Plan re-evaluated date of 11/13/19, indicated the resident has a risk of dehydration. The care plan goals indicate to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 50 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE maintain adequate hydration. The care plan interventions included offering fluids frequently and offer assistance as necessary. During a concurrent observation, and interview, inside Resident 37's room on 2/18/20 at 10:16 a.m., Resident 37's Family Member (FM 1) stated the resident's roommate informed her that last Sunday, Resident 37 asked for water but the CNA who the resident asked, told the resident she does not need water. FM 1 stated she brings the resident water bottles labeled with resident's room number, because sometimes there is no water pitcher and cup at the bedside. There was no water pitcher observed at the bedside. FM 1 stated the resident does not eat, or drink and the staff should have given the water. During an interview on 2/18/20 at 10:31 a.m., the Certified Nursing Assistant (CNA 3) stated for Resident 37 she does not have time, and it is usually the Restorative Nursing Aide who checks for the resident's water pitcher. During an interview on 2/24/20 at 3:33 p.m., the Director of Staff Development (DSD) stated they have a hydration program at 10 am, 2 p.m., and 8 p.m.. The DSD stated the RNAs offer drinks such as water, juice, and are offered drinks during activities. The DSD stated the CNAs are responsible for passing out the residents' water pitcher. The DSD stated the purpose of the Hydration Program is to prevent dehydration for residents, and have the water pitchers readily available to the residents and to change the water pitchers. A review of the facility's policy and procedure titled "Comprehensive Person-Centered Care Planning" reviewed and approved on 1/29/2020, indicated that it is the facility's policy to provide person-centered, comprehensive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 51 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and interdisciplinary care that reflects best practice standards for meeting health, safety, psychological, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. III. Baseline Care Plan Summary f. Each resident and/or resident representative will actively remain engaged in his or her care planning process through the residents' rights to participate in the development of and be informed in advance of changes in the plan of care.

F698 SS=D Dialysis CFR(s): 483.25(l)

F698 03/24/2020 §483.25(l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure that a resident who was receiving dialysis (clinical purification of blood as a substitute for the normal function of the kidney) treatment received services consistent with professional standards of practice for two of three residents (Resident 86 and 33) investigated under the dialysis care area, by: 1. Failing to identify and accurately assess the types of dialysis access site Resident 86 was using. 2. Failing to accurately complete Resident 33's pre- and post- dialysis treatment assessments. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 52 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE These deficient practices had the potential to result in undetected complications of a dialysis access site, such as infection and can lead to a delay in necessary care, and had the potential to result in lack of provision of necessary treatment and services in the event of an emergency, such as bleeding for Resident 86 and 33. Findings: 1. A review of Resident 86's Admission Record indicated the resident was originally admitted on 4/11/19, with diagnoses of end stage renal disease (ESRD-last stage of chronic kidney disease when the kidneys fail leading to the need of long-term dialysis or a kidney transplant to maintain life) and generalized muscle weakness. A review of Resident 86's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 12/9/19, indicates the resident has adequate hearing, impaired vision, clear speech, made self-understood and understood others. A review of Resident 86's Resident Baseline Evaluation dated 11/22/19, indicates the resident has a right AV shunt (a surgical joining of an artery and a vein under the skin to create a hemodialysis (blood purifying treatment) access site, and a left chest permacath (a long, flexible tube that is inserted into a vein most commonly in the neck, internal jugular vein). A review of Resident 86's Physician's Orders indicated the resident was ordered on 1/31/2020, to be admitted to the facility and to provide Post-dialysis Care, including monitoring the AV(arteriovenous) shunt (access site) / AV graft (surgical) site every shift on the right upper extremity (RUE). Monitor the AV shunt FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 53 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE signs and symptoms on the RUE. During a concurrent interview, and record review, on 2/24/20 at 10:12 a.m., the Licensed Vocational Nurse (LVN 7) confirmed Resident 86 has an order for the right arm AV shunt. During a concurrent interview and record review of Resident 86's clinical (medical) record on 2/24/20 at 11:05 a.m., LVN 7 confirmed the Resident Baseline Evaluation dated 11/22/19, indicated the resident has a left chest permacath and a right arm AV shunt. LVN 7 stated she knows resident has three sites. LVN 7 confirmed there is no documented evidence of the left side chest permacath and the left arm AV shunt. During an interview, on 2/24/20 at 3:36 p.m., the Assistant Director of Nursing (ADON) stated if the resident is on dialysis, there should be an order present upon admission. The ADON stated the order should specify what access site and have to specify in the orders if the shunt has failed, or if more than one, the order must indicate which access site cannot be used, or the access site that is okay to use. The ADON stated the potential for not specifying the dialysis access site to use, has the potential of not being monitored, and places the resident at risk for infection, bleeding, and skin breakdown. The ADON stated the physician should be notified right away, to clarify the order, and to reevaluate what needs to be done. A review of the facility's policy and procedure titled "Physician Orders" reviewed and approved on 1/29/2020, indicated that the facility will ensure that all physician's orders are complete and accurate. 2. A review of Resident 33's Face Sheet FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 54 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (Admission Record) indicated the resident was admitted to the facility on 3/14/15 and readmitted on 1/24/20, with diagnoses including, end stage renal disease (ESRDchronic irreversible kidney failure), dependence on renal dialysis, and diabetes type 2 (having high blood sugar). A review of Resident 33's Minimum Data Set (MDS- an assessment and care screening tool) dated 12/3/19, indicated the resident has the ability to usually make self-understood and sometimes understands others. A review of Resident 33's physician's orders indicated to monitor the resident's Perma Cath/Ash Splint Cath (a catheter placed through a vein into or near your right atrium of the heart, used for dialysis in an emergency or until a long-term device is ready to use) for signs and symptoms on the right chest site for presence of (pain, bleeding, or itching) ordered on 11/3/18. During a concurrent interview, and record review, on 2/18/20 at 8:41 AM of Resident 33's Pre and Post Dialysis Assessment Form, Licensed Vocational Nurse 6 (LVN 6) verified the following: - On 12/30/19, the pre dialysis assessment indicated that the access site assessment was not documented. - On 2/8/20, the pre dialysis assessment indicated that the access site assessment was not documented. - On 2/11/20, the pre dialysis assessment indicated that the access site assessment was not documented. The post dialysis assessment indicated that the access site assessment was not documented. - On 2/15/20, the pre dialysis assessment indicated that the access site assessment was not documented. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 55 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During the concurrent interview, and record review, of 2/18/20 at 8:41 AM, LVN 6 stated the purpose of documenting in the pre and post dialysis assessment sheet is to assess the access site, check for bleeding from the site and that it is part of the nursing assessment. LVN 6 verified that the nurses' caring for this resident, did not document a pre and post assessment on 12/30/19, 2/8/20, 2/11/20 and 2/15/20, and should have done so. A review of Resident 33's Care Plan titled, "Dialysis", indicated interventions to monitor the hemodialysis site for signs and symptoms of infection and bleeding. A review of the facility's policy and procedure titled "Dialysis Care" reviewed and approved on 1/29/2020, indicated the facility will arrange for dialysis care as ordered by the Attending Physician. The facility maintains a contract with a dialysis service provider which addresses communications between the facility and provider. Procedure: II. Care Plan A. The IDT will ensure that the resident's Care Plan includes documentation of the resident's renal condition and necessary precautions (e.g. shunt site, weights, dietary and fluid restrictions, no B/P on affected side, or lab draws, IV, injection on arm with shunt, observe for signs and symptoms of infection, etc).

F755 SS=D Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 03/24/2020 §483.45 Pharmacy Services The facility must provide routine and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 56 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to accurately account for one dose of a controlled substance (medications with a high potential for abuse) for one resident (Resident 85) in one of three inspected medication carts (Station 1 Medication Cart.) This deficient practice increased the risk that medications may not be available for Resident 85 when needed and also increased the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 57 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility's risk for the potential loss, diversion (transfer of a medication from a legal to an illegal use), or accidental exposure to controlled substances. Findings: On 2/19/2020 at 1:41 PM, during an observation of Station 1 Medication Cart, the following discrepancy was found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication). A review of Resident 85's Narcotic and Hypnotic Record for morphine sulfate ER (a medication used to treat severe pain) 60 milligrams ([mg] a unit of measure for mass) indicated that there were 26 doses left, however, the medication card only contained 25 doses. On 2/19/2020 at 2:18 PM, during an interview, the licensed vocational nurse (LVN 1) stated she failed to sign the Narcotic and Hypnotic Record for Resident 85's dose of morphine that was given today, but she understands that it is the facility's policy that each dose of a controlled substance must be signed right away to ensure accountability of the medications within the facility. A review of the facility's policy and procedure document titled "Controlled Medications", dated 8/1/2010, indicated that "When a controlled medication is administered, the licensed nurse administering the medications immediately enters the following information on the accountability record. Signature of the nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 58 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE administering the dose, completed after the medication is actually administered."

F760 SS=J Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 03/24/2020 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to administer 17 doses of Flovent HFA (an inhaled steroid medication used to treat breathing problems) between 2/11/2020 and 2/20/2020 to one of five randomly observed residents (Resident 291) and failed to administer eight doses of Lantus insulin (a medication used to treat high blood sugar) between 2/14/2020 and 2/22/2020 to one of 12 randomly observed residents (Resident 17.) This failure had the potential for Residents 17 and 291 to experience significant harm including respiratory arrest (the inability to breathe) or coma (a prolonged period of unconsciousness brought on by illness or injury) likely resulting in hospitalization or death. On 2/20/2020 at 3:30 PM, the Department of Public called an Immediate Jeopardy situation ([IJ a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the administrator (ADM) and director of nursing (DON). On 2/21/2020 at 3:45 PM, the DON and ADM FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 59 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE provided an acceptable plan of action (POA) that included the following summarized actions: 1. A licensed nurse notified Resident 291's attending physician (MD 1), and informed her that the resident did not receive the Flovent HFA inhaler for approximately nine days. MD 1 gave orders to administer Flovent HFA as soon as it was available. MD 1 reassessed Resident 291 and found no signs or symptoms of respiratory distress. 2. A licensed nurse called the pharmacy, on 2/20/2020, to request an expedited order of the Flovent HFA for Resident 291. The DON requested that any future requests for medication authorizations be sent to him directly. Upon arrival, on 2/20/2020 at 11:30 AM, a licensed nurse administered Flovent HFA to Resident 291. 3. The DON provided one-on-one training and progressive disciplinary action to the licensed nurses involved in signing the Medication Administration Record (MAR) for doses of Flovent HFA not administered to Resident 291. 4. A licensed nurse conducted a facility-wide inspection of all medication orders and availability for all residents in the facility to ensure that medications were on hand to provide for their needs. The DON stated after completing the facility-wide inspection for all residents there were no additional missing medications. On 2/22/2020 at 7:47 AM, the Department did a facility-wide random check of medication availability, Resident 17's Lantus insulin was missing from Station 2's Medication Cart B. On 2/22/2020 at 10:05 AM, during an interview, the DON stated the facility's staff must have overlooked Resident 17's missing Lantus insulin during the facility-wide random check of medication. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 60 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 2/22/2020 at 4:45 PM, the facility provided an amended POA that included the following additional summarized actions: 1. A licensed nurse assessed Resident 17's condition and there were no signs or symptoms of high or low blood sugar levels. The licensed nurse notified the attending physician (MD 2), that the nurses did not administer Resident 17's Lantus insulin for eight days. MD 2 gave an order to administer the Lantus as soon as it was available. MD 2 also ordered additional lab tests to assess Resident 17's condition. 2. A licensed nurse contacted the pharmacy and requested an expedited delivery of Lantus insulin for Resident 17. 3. The facility's pharmacy consultant provided retraining to licensed nurses on the proper protocols for ordering medications for the residents from the pharmacy. On 2/22/2020 at 5:48 PM, while onsite and after confirming the facility's implementation of the immediate corrective actions, the Department removed the Immediate Jeopardy, in the presence of the administrator and DON. Cross-referenced with F684 Findings: 1. A review of Resident 291's clinical record indicated an admission to the facility on 2/10/2020 with diagnoses that included pneumonia (an infection in the lungs) and asthma (a condition that causes difficulty breathing.) A review of Resident 291's physician orders, dated 2/10/2020, prescribed Flovent HFA 110 micrograms ([mcg] a unit of measure for mass) per inhalation to inhale one puff by mouth into lungs twice daily for shortness of breath. On 2/20/2020 at 9:53 AM, during a medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 61 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE administration for Resident 291, the registered nurse (RN 2) prepared the following medications for Resident 291's morning medication administration: 1. One capsule of dutasteride (a medication used to treat urinary problems) 0.5 milligrams ([mg] a unit of measure for mass). 2. Fluticasone nasal spray (a medication used to treat allergies.) 3. One tablet of levetiracetam (a medication used to treat seizures [uncontrolled electrical activity in the brain]) 500 mg. 4. One capsule of tamsulosin (a medication used to treat urinary problems) 0.4 mg. 5. Thirty milliliters ([ml] a unit of measure for volume) of UTI Heal (a supplement.) 6. One tablet of meclizine (a medication used to treat dizziness) 12.5 mg. 7. One tablet of risperidone (a medication used to treat mental illness) 1 mg. 8. One tablet of divalproex sodium (a medication used to treat seizures) 500 mg. 9. One tablet of multivitamins with minerals (a supplement.) 10. Thirty ml of Pro Heal (a supplement.) On 2/20/2020 at 10:15 AM, during an interview, RN 2 stated she has a total of ten medications and supplements to administer to Resident 291. RN 2 stated Resident 291 also needed to have Flovent HFA 110 mcg administered but that she was unable to find the inhaler in the medication cart. RN 2 stated she would have her supervisor check on availability of the Flovent. On 2/20/2020 at 10:16 AM, Resident 291 was sleeping in his bed wearing his nasal cannula (a lightweight tube with two prongs at the end inserted into the nostrils to receive a mixture of air and oxygen). On 2/20/2020 at 10:19 AM, RN 2 administered FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 62 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE all ten medications listed above to Resident 291. On 2/20/2020 at 10:34 AM, during an interview, the Licensed Vocational Nurse (LVN) 6 stated she was the unit manager for Nursing Station 2 and Resident 291's Flovent inhaler was not anywhere in the facility. LVN 6 stated the initial order was on 2/10/20 and the facility ordered the Flovent from the pharmacy that day. LVN 6 stated she would check with the pharmacy, as it usually does not take that long to deliver the medications. LVN 6 added she informed MD 1, on 2/20/20 that the Flovent was currently unavailable and MD 1's response was to administer the Flovent to Resident 291 as soon as it was available. The pharmacy is to deliver the medication later today (2/20/2020.) The licensed nurse was unable to produce a pharmacy delivery receipt for 2/10/20 or any other record of delivery for Resident 291's Flovent HFA. A review of Resident 291's MAR for February 2020 indicated that between 2/11/2020 and 2/20/2020, the six licensed nurses (RN 2, Assistant director of staff development (ADSD) LVN's 2, 3, 4, and 5) signed they administered 17 doses of Flovent on the following dates and times: 1. RN 2 on 2/11 and 2/13/2020 at 9 AM, 2/14 and 2/15/2020 at 5 PM 2. LVN 2 on 2/12, 2/15, and 2/17/2020 at 9 AM 3. Assistant director of staff development (ADSD) on 2/14/2020 at 9 AM 4. LVN 3 on 2/16/2020 at 9 AM 5. LVN 4 on 2/18/2020 at 9 AM 6. LVN 5 on 2/11, 2/12, 2/13, 2/16, 2/17, 2/18, and 2/19 at 5 PM On 2/20/2020 at 11:21 AM, during an interview, LVN 6 stated after speaking with the pharmacist, they never delivered the Flovent, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 63 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE because it required approval from the DON due to the high cost. LVN 6 stated she was unable to explain why the licensed nurses signed as administering 17 doses of Flovent when the medication was never available in the facility. On 2/20/2020 at 11:36 AM, during an interview, the DON stated he could not explain why six licensed nurses signed administering Resident 291's Flovent on the MAR when the medication was not available. The DON agreed it was impossible for Resident 291 to have actually received his Flovent as documented if the pharmacy never delivered the medication. The DON stated he would provide a list of the names of each licensed nurse who signed, but did not give the Flovent and provide them with retraining regarding the proper procedures for the documentation of medications. On 2/20/2020 at 12:13 PM, during an interview, RN 2 stated she recognized her initials on Resident 291's MAR as administering the 9 AM Flovent on 2/11/2020 and 2/13/2020. RN 2 stated her initials on those dates and times meant she administered the medication. RN 2 added if, for any reason, she did not give the medication she would initial the dose, circle her initials, and provide a written explanation on the back of the MAR. There was no documentation on the back of the MAR. RN 2 continued she would then follow up with the pharmacy and the physician as required. RN 2 stated she administered Flovent to Resident 291 on the dates and times she signed but was unable to explain how, since the pharmacy did not deliver the medication. RN 2 stated she may have confused the Flovent with another inhaler prescribed to Resident 291, but acknowledged it was unlikely since they were scheduled to be given at different times. RN 2 stated it is possible that she signed Resident 291's MAR indicating she gave him the Flovent without FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 64 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE actually giving the medication. On 2/20/2020 at 12:32 PM, during an interview, the ADSD stated sometimes she is responsible for medication administration when other nurses are not available. The ADSD stated she signed Resident 291's MAR for Flovent at 9 AM on 2/14/2020. Her signature meant she gave the medication to the resident. The ADSD continued if she did not give the medication, for any reason, she would circle her initials on the MAR and explain why on the back of the MAR. There was no documentation on the back of the MAR. The ADSD added she felt rushed having to give medications on the morning of 2/14/2020, due to a nurse calling off duty. The ADSD also stated she most likely signed the MAR indicating she gave the Flovent to Resident 291 when in fact she had not. On 2/20/2020 at 12:45 PM, during an interview, MD 1 stated she is Resident 291's attending physician and the resident is currently recovering from pneumonia due to an infection caused by drug-resistant bacteria (is the ability of bacteria to resist the power of an antibiotic). MD 1 stated she prescribed Flovent and other medications on the resident's admission to the facility (2/10/2020) but was not aware he was not receiving the Flovent until today (2/20/20). MD 1 stated concerns for Resident 291 because the resident also has underlying asthma (a condition in which the tubes that carry air in and out of the lungs narrow and swell causing a reversible obstruction), so she prescribed Flovent. MD 1 stated without the Flovent to prevent or treat inflammation (the body's response to harmful stimuli, which may cause swelling) in the airways and lungs, Resident 291 could be at risk for respiratory arrest due to a combination of asthma and diminished lung capacity from pneumonia. MD 1 continued this could cause the resident to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 65 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE need hospitalized or even cause him to die. MD 1 stated she was unaware the licensed nurses signed the resident's MAR as giving the Flovent when in fact they had not. MD 1 expressed concern that Resident 291's MAR did not reflect the care actually provided to him as she relies on accurate information from the nursing staff in order to make the best treatment decisions. MD 1 added if Resident 291's condition deteriorated she may assume the Flovent, at its current dose is ineffective. This would prompt her to order an increased dose or switch to stronger oral steroid (a synthetic drug used to decrease inflammation), which would put the resident at additional risk for adverse effects associated with higher doses of steroids (such as increased pressure in the eyes, swelling in the lower legs, high blood pressure, mood swings, and weight gain). On 2/20/2020 at 1:49 PM, during a telephone interview, the registered pharmacist (RPH 1) stated they received Resident 291's order for Flovent on 2/10/2020 along with all of the other medications. RPH 1 stated the Flovent needed authorization due to "high cost" based on their agreement with the facility. The pharmacy faxed an authorization request to the DON on the same day (2/10/2020), but did not receive the signed authorization back until 2/20/2020. RPH 1 confirmed they delivered Resident 291's Flovent HFA to the facility on 2/20/2020. A review of the pharmacy's faxed document titled "Notification of Non-Covered Items Price Quote & Billing Authorization" indicated the pharmacy faxed the request for Resident 291's Flovent HFA 110 mcg authorization, to the facility, on 2/10/2020 at 11:42 PM. On 2/20/2020 at 3:30 PM, during an interview, the DON stated he was unaware of ever FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 66 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE receiving the pharmacy's request for authorization for the Flovent before today. The DON stated as soon as he received the fax, he signed it and sent it back. The DON stated he spoke with the pharmacy manager and requested to email all future authorizations directly to him. The DON stated as the facility's leader, he takes full responsibility and full ownership of the problems identified with resident care, including the fact that six licensed nurses falsified Resident 291's MAR and would take appropriate steps to remedy it. During a concurrent interview, the ADM added, "We know we have a problem and we will work to fix it." 2. A review of Resident 17's clinical record indicated an admission to the facility on 2/8/19 with diagnoses including diabetes mellitus (a medical condition whereby the body is not able to regulate blood sugar.) A review of Resident 17's physician orders, dated 2/14/2020, indicated to give Lantus insulin by subcutaneous (under the skin) injection every night at bedtime give ten units (a measurement for the dosage of insulin). On 2/22/2020 at 7:47 AM, during a random inspection of Station 2 Medication Cart B, RN 1 verified the availability of Resident 17's medications listed on the MAR. Upon checking, RN 1 was unable to locate Resident 17's Lantus Insulin in the medication cart. During a concurrent interview, RN 1 stated she searched the medication storage room`s refrigerator, where unopened insulin vials or pens are kept, to try to locate Resident 17's Lantus insulin but was still unable to find any Lantus Insulin for Resident 17. On 2/22/2020 at 9:31 AM, during an interview, LVN 6 stated the physician`s medication orders are transmitted via fax to the pharmacy and the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 67 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE transmission will generate a transaction report which is then kept on file. LVN 6 further explained the pharmacy provides receipts of delivery for medications, which the facility also files. LVN 6 stated she was unable to produce any transmission record that the pharmacy received Resident 17's Lantus insulin order or that the pharmacy had delivered it to the facility. LVN 6 stated Lantus insulin is a diabetic medication and if Resident 17`s diabetes is not appropriately managed, she could become hyperglycemia (high blood sugar), which could lead to diabetic ketoacidosis (a potentially lifethreatening complication of diabetes mellitus which may include symptoms such as vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion, and loss of consciousness). A review of Resident 17`s MAR from February 2020 indicated between 2/14/2020 and 2/21/2020, the licensed nurses' signed administering a total of eight doses of Lantus insulin on the following dates: 1. RN 2 on 2/14 and 2/15/2020. 2. LVN 5 on 2/16, 2/17, 2/18, 2/19, and 2/20/2020 3. RN 3 on 2/21/2020. On 2/22/20 at 10:05 AM, during an interview, the DON confirmed that the facility failed to transmit Resident 17's physician order for Lantus insulin to the pharmacy and consequently no delivery receipt of the Lantus insulin would be on file. The DON agreed it would have been impossible for Resident 17 to receive Lantus insulin, since the licensed nurse' had not ordered it, from 2/14 to 2/21/2020. On 2/22/2020 at 10:15 AM, during a telephone interview, RPH 2 confirmed the pharmacy neither received an order for Resident 17's Lantus insulin nor sent any out for delivery prior FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 68 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to 2/22/2020. On 2/22/2020 at 1:30 PM, during an interview, RN 2 explained on 2/14 and 2/15/2020, it was her first time working the 3-11 PM shift and she was responsible for administering Resident 17's Lantus insulin on those dates. RN 2 stated she signed as giving Resident 17's Lantus insulin on the MAR on 2/14 and 2/15/2020. RN 2 stated she administered the Lantus to Resident 17 on those dates but was unable to explain how when the pharmacy never delivered the medication. RN 2 then stated she needs more training, as she is new to nursing and admitted that it was "her mistake." RN 2 stated she may have confused Lantus with another type of insulin ordered for Resident 17 but agreed that it was unlikely since the other insulin is usually given at different times. RN 2 also stated she feels that Station 2 has a high resident load compared to some of the other nursing stations in the facility and feels like she is sometimes overwhelmed with the amount of medication she has to administer. RN 2 stated she could have signed Resident 17's MAR that she gave Lantus when in fact she did not. On 2/22/20 at 2:40 PM, Resident 17 was lying in bed, alert, awake, but unable to verbalize a response. A review of the facility's policy and procedure document titled "Medication - Administration", last revised on 1/1/2012, indicated, "Medication will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner" and "Whenever a medication is held for any reason, the hour it was held must be initialed and circled in the Medication Administration Record (MAR) by the responsible Licensed Nurse. The Licensed Nurse will document on the back on the MAR, noting the time and the reason the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 69 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication was held." A review of the facility's policy and procedure document titled "Falsification & Omission", last revised on 1/1/2012, indicated, "Entries in a medical record at the Facility will be factual and will accurately reflect the services provided to the resident, the condition of the resident, and the resident's response to services provided" and "Willful material falsifications and omissions are prohibited, a willful material falsification is made with the knowledge that the record falsely reflects the condition of the resident or the care of services provided."

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 03/24/2020 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 70 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to store all drugs and biologicals under proper temperature controls in two of three medication carts (Station 1 and Station 3) reviewed for drug storage by failing to: 1. Label one opened Levemir insulin pen (a medication used to treat high blood sugar) for Resident 84 and one opened lispro insulin pen (a medication used to treat high blood sugar) for Resident 86 with an open date in one of three inspected medication carts (Station 1 Medication Cart.) 2. Store one unopened Lantus insulin pen (a medication used to treat high blood sugar), for Resident 79 and one unopened vial of Novolin R insulin (a medication used to treat high blood sugar) for Resident 94 in the refrigerator in one of three inspected medication carts (Station 3 Medication Cart.) These deficient practices increased the risk that Residents 79, 84, 86, and 94 could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death. Findings: On 2/19/2020 at 1:41 PM, during an observation of Station 1 Medication Cart, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 71 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE labeled with an open date as required by their respective manufacturer's specifications: 1. One opened Levemir insulin pen for Resident 84 not labeled with an open date. A review of the manufacturer's product labeling, Levemir insulin pens should be used or discarded with 42 days of opening or once they've been stored at room temperature. 2. One opened lispro insulin pen for Resident 86 not labeled with an open date. A review of the manufacturer's product labeling, lispro insulin pens should be used or discarded within 28 days after opening. On 2/19/2020 at 2:18 PM, during an interview, the licensed vocational nurse (LVN 1) confirmed that the insulin pens for Resident 84 and 86 were opened but not labeled with an open date. LVN 1 stated that she will discard these two pens as she cannot be sure how long they've been stored at room temperature and reorder from the pharmacy if necessary. LVN 1 stated that using ineffective insulin or insulin that has not been stored properly increases the risk that it may not work when given to a resident. LVN 1 stated that if insulin does not work, the resident may suffer complications of high blood sugar that could result in hospitalization or death. On 2/19/2020 at 2:24 PM, during an observation of Station 3 Medication Cart, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One unopened Lantus insulin pen for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 72 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 79 stored at room temperature and not labeled with a date on which room temperature storage had begun. A review of the manufacturer's product labeling, Lantus insulin pens should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and used or discarded within 28 days of opening or once they've been stored at room temperature. 2. One unopened vial of Novolin R insulin for Resident 94 stored at room temperature and not labeled with a date on which room temperature storage had begun. A review of the manufacturer's product labeling, unopened vials of Novolin R should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and used or discarded within 40 days of opening or once they've been stored at room temperature. On 2/19/2020 at 2:48 PM, during an interview, LVN 9 confirmed that the Lantus for Resident 79 and the Novolin R for Resident 94 were unopened, stored at room temperature, and there was no way to determine how long they had been stored at room temperature. LVN 9 stated that she will discard the insulin that was stored improperly as she cannot be sure that it is safe to administer to residents. LVN 9 stated that insulin that has not been stored properly may not work and may cause the residents to have health complications as a result. A review of the facility's policy and procedure document titled "Storage of Medications", dated 8/1/2010, indicated that "Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. Medications requiring 'refrigeration' or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 73 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 'temperatures between between 2 degrees Celsius (C) (36 degrees Fahrenheit) and 8 degrees Celsius (C) (46 degrees Fahrenheit) are kept in a refrigerator with a thermometer to allow temperature monitoring." A review of the facility's policy and procedure document titled "Vials and Ampules of Injectable Medications", dated 8/1/2010, indicated that "The date opened and the initials of the first person to use the vial are recorded on multi-dose vials on the vial label or an accessory label affixed for that purpose." A review of the facility's policy and procedure document titled "Specific Procedures for All Medications", dated 8/1/2010, indicated "Check expiration date on package/container. When opened a multi-dose container, place the date opened on the container."

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 03/24/2020 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 74 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 182 residents who receive food from the kitchen of 191 facility residents by failing to: 1. Ensure Reach-in refrigerator #2 did not have rusted shelves (4). 2. Ensure Reach-in freezer #6 did not have an ice accumulation (ice build-up) inside on the right side, top part. 3. Ensure Reach-in freezer #4 did not have ice accumulation inside on the bottom right side. 4. Ensure the door handle of the walk-in refrigerator was not broken. 5. Ensure one Dietary Aide (DA) washed his hands upon re-entering the kitchen. These deficient practices had the potential to compromise the integrity of the food and placed residents at risk for foodborne illnesses (illness caused by the ingestion of contaminated food or beverages). Findings: a. During the Kitchen Initial Tour Observation, on 2/18/20, at 7:12 A.M., with the Dietary Supervisor (DS), the following were observed: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 75 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. There were 4 rusted shelves inside the #2 Reach-in refrigerator. 2. The inside, right side, top part of the #6 Reach-in freezer had ice accumulation (ice build-up). 3. The inside, right side, bottom, part of the #4 Reach-in freezer had ice accumulation. 4. The door handle of the walk-in refrigerator was broken. During an interview, on 2/18/20, at 7:15 A.M., the Dietary Supervisor (DS) stated that the four white shelves inside the #2 Reach-in refrigerator should be free from the rust and chipping paint. The DS stated the rust is a potential for food contamination. The DS confirmed that #6 reach-in freezer should not have ice accumulation at the top where the motor was, and the #4 reach-in freezer should have no ice accumulation at the bottom. The DS stated an ice accumulation has a potential to degrade the quality of the foods being served to the residents. During an interview, on 2/18/20, at 7:30 A.M., the DS stated that the Administrator was aware of the ice accumulation and that the corporate is in the process of replacing the 2 reach-in freezers. The DS confirmed that the handle on the door of the walk-in refrigerator broke and the broken part to lock the latch was missing. The DS stated the broken handle is why the door would not close. The DS verified that maintenance was aware of the issue a week ago, and stated that maintenance will be ordering the missing/broken part. b. During a breakfast tray line observation, on 2/20/20, at 6:50 A.M., a Dietary Aide (DA) was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 76 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE observed re-entering the kitchen without washing his hands. The DA went straight to take and distribute the pre-poured juices and milk cups on each breakfast tray cart. During a concurrent interview, the DA stated he should have washed his hands but, forgot and missed it. During an interview, on 2/20/20, at 8 A.M., the DS stated that all dietary staff should wash their hands when entering the kitchen, because not washing hands is a potential for food contamination. A review of the facility's Policy and Procedures, with a review date of 1/29/2020, titled "Dietary Department-General," indicated the dietary department is responsible for establishing a program that meets the nutritional needs of the residents and accounts for cultural, religious, physical, psychological, and social needs. The P&P indicated the primary objective of the dietary department include: maintenance of standards for sanitation and safety. The Dietary Manager is also responsible for the day-to-day education of dietary staff with regards to topics such as sanitation, food preparation, etc. A review of the facility's Policy and Procedures, with a review date of 1/29/20, titled "Infection Control for Dietary Employees," indicated proper handwashing by personnel will be done upon entering the kitchen, and immediately before engaging in food preparation, including working with non-prepackaged food, clean equipment and utensils, and unwrapped singleuse food containers and utensils.

F813 SS=D Personal Food Policy CFR(s): 483.60(i)(3)

F813 03/24/2020 §483.60(i)(3) Have a policy regarding use and storage of foods brought to residents by family FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 77 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure safe and sanitary storage of food for one of three residents (Resident 22), reviewed for the care area of personal food by: 1. Failing to date and label of one glass container of food belonging to Resident 22, that was stored inside the resident's personal refrigerator. 2. Failing to ensure Resident 22's personal refrigerator was at a temperature of 41 degrees Fahrenheit (F) or below. These deficient practices had the potential to result in food-borne illnesses (food poisoningcan cause symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea and fever and can lead to other serious medical complications and hospitalization, for Resident 22. Findings: During an observation on 2/19/20, at 7:59 A.M., Resident 22's personal refrigerator inside his room contained a big glass container, half-filled with Jalapenos. The use-by date indicated 2019. The thermometer reading was a temperature of 48 degrees F. During a concurrent interview, Licensed Vocational Nurse 2 (LVN 2), stated that the Jalapenos were not safe for Resident 22's consumption, as they were beyond the use-by date. LVN 2 confirmed that the temperature reading of the thermometer was 48 degrees F. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 78 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the Resident 22's Face Sheet (Admission Record), indicated that the resident was admitted to the facility on 11/27/06, with diagnosis including unspecified injury of the head. A review of the Resident 22's History and Physical (H&P), dated 10/20/2019, indicated the resident had the capacity to understand and make decisions. A review of the Resident 22's Minimum Data Set (MDS- a resident care-screening tool), dated 11/13/19, indicated that the resident is cognitively (process of acquiring knowledge and understanding) intact. The MDS indicated the resident required extensive assistance from staff with bed mobility, transfer, dressing, and toilet use, limited assistance with personal hygiene, and supervision with eating. A review of the facility's Policy and Procedures, review date of 1/29/20, titled "Food Brought in by Visitors," indicated the nurse assigned to the resident will also account for the resident's intake of food from sources outside the facility. When food is brought into a nursing home prepare by others, the nursing home is responsible for ensuring that the food container is clearly labeled with the resident's name and date received and stored in a refrigerator designated for this purpose. The P&P indicated ensuring a safe food handling once the food is brought to the facility, including safe reheating and hot/cold holding, and handling of leftovers. A review of the facility's Policy and Procedures, review date of 1/29/20, titled "Refrigerator/Freezer Temperature Records," indicated a daily temperature record is to be kept for refrigerated and frozen storage areas. The P&P indicated the refrigerator temperature must be 41 F or below. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 79 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F842 Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/24/2020 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 80 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain an accurate record of the current physician's orders by adding an erroneous order for gabapentin (a medication used to treat nerve pain) on the February 2020, Physician Orders Recap for one of five randomly observed residents (Resident 138.) reviewed for the care area of pharmacy services. The deficient practice of including gabapentin on Resident 138's Physician Orders Recap FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 81 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE when the physician never prescribed the medication increased the risk that Resident 138 could have been given gabapentin which may have caused adverse effects (undesired, harmful effects of a medication) including drowsiness and dizziness and can lead to preventable falls/injury. Findings: A review of Resident 138's clinical (medical) record indicated that he was admitted to the facility on 1/8/18, with diagnoses including muscle weakness and difficulty walking. A review of Resident 138's Physician Orders Recap for February 2020, indicated that Resident 138 had a physician's order, dated 12/28/2019, for gabapentin 300 milligrams ([mg] a unit of measure for mass) three times daily by mouth. On 2/20/2020 at 9:33 AM, during an observation of the morning medication for Resident 138, Registered Nurse (RN) 2 was observed preparing the following medications for administration: 1. One tablet of Acetaminophen with codeine 300/30 mg (a medication used to treat moderate to severe pain.) 2. One tablet of multivitamins with minerals (a supplement.) 3. One tablet of Vitamin C 500 mg (a supplement.) 4. Thirty milliliters ([ml] a unit of measure for volume) of Pro Heal (a supplement.) 5. One tablet of baclofen 10 mg (a muscle relaxer.) On 2/20/2020 at 9:44 AM, during an interview, RN 2 stated that she had a total of five total medications and supplements to administer to Resident 138. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 82 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 2/20/2020 at 9:46 AM, Resident 138 was observed taking all five medications listed above with water. A review of Resident 138's Medication Administration Record (MAR, a record of medications given to a resident by a licensed nurse) from December 2019 to February 2020, indicated that the physician's order for gabapentin 300 mg was never transcribed to the MAR. A review of Resident 138's clinical record indicated that there was no original physician's order for gabapentin and contained no other record that he ever received gabapentin. On 2/21/2020 at 8:29 AM, during an interview, the licensed vocational nurse (LVN 6) confirmed that she could not find the initial physician's order for gabapentin within Resident 138's clinical record. LVN 6 stated that the order for gabapentin was not transcribed onto the MAR for the December 2019 or the January 2020, Physician's Order Recap. LVN 6 stated that she would contact Resident 138's pain specialist nurse practitioner (NP) to clarify with him whether or not he ordered the gabapentin. On 2/21/2020 at 8:41 AM, during an interview, LVN 6 stated that, according to the NP, Resident 138 was never prescribed gabapentin and that the order is on the February 2020, Physician Orders Recap is an error from the medical records department. LVN 6 stated that it is the responsibility of the medical records staff to transcribe the orders accurately into the monthly recap. On 2/21/2020 at 11:48 AM, during an interview, the medical records director (MRD) stated that she is responsible typing the order recaps for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 83 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the residents on Nursing Station 2. The MRD stated that she typed the February 2020, Physician Orders Recap for Resident 138, and erroneously included the order for gabapentin. The MRD stated that she would discontinue the order immediately, so that there would be no chance of him actually receiving the medication. The MRD stated that having incorrect orders listed on the Physician Orders Recap increases the risk that the resident may receive medication that was not prescribed for them or possibly that another resident may not receive medication that was prescribed for them. The MRD stated that the facility staff are currently checking every resident's orders on Nursing Station 2 to ensure that every resident's most recent Physician Orders Recap is accurate. A review of the facility's policy and procedure document titled "Falsification & Omission", last revised 1/1/12, indicated that "Entries in a medical record at the Facility will be factual and will accurately reflect the services provided to the resident, the condition of the resident, and the resident's response to the services provided. A deficiency is any omitted entry or incorrect entry that is not knowingly omitted or documented incorrectly."

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 03/24/2020 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 84 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 85 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program for one of two residents (Resident 98), reviewed for the care area of infection prevention and control, by: 1. Failing to ensure hand hygiene was performed after resident care and before going to care for another resident (Resident 98). These deficient practices had the potential to result in cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) among residents. Findings: a. A review of Resident 98's Face Sheet (Admission Record) indicates the resident was admitted to the facility on 7/1/11, and was readmitted on 5/15/19, with diagnosis of dysphagia (difficulty or discomfort with swallowing). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 86 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 98's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 12/17/19, indicates the resident has the ability to make themselves sometimes understood and had the ability to sometimes understand others. A review of Resident 98's physician's order included the following: - Flush (rinse with water) gastrostomy tube (GT - a surgical procedure for inserting a tube through the stomach for feeding or drainage) with 5 milliliters (mL) in between medication administration. - Flush GT with 300 mL of water every four hours. - Check/monitor GT placement (location) every shift - Check/monitor GT patency (function) every shift - Check tube feeding residual (what remains after most of the formula absorbed) every shift, if the residual is greater than 100 mL hold for 2 hours then recheck, resume if residual is less then 100 mL, call the doctor if the residual remaining is more than 100 mL. During a concurrent observation, and interview, on 2/24/20 at 12:41 PM, Licensed Vocational Nurse 4 (LVN 4) checked the resident's GT placement (location), patency (function), and flushed the GT for Resident 98. LVN 4 finished the resident's care, took off her gloves, proceeded to walk out of the room and went to the medication cart. LVN 4 touched a stethoscope without performing any hand hygiene. LVN 4 did not perform hand hygiene after giving care to Resident 98, and before going to care for another resident. LVN 4 stated that hand hygiene should have been done after Resident 98's care, to prevent cross contamination. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 87 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of the facility's policy and procedures titled, "Hand hygiene" dated 1/29/20, indicated, "Alcohol based hand hygiene products can and should be used to decontaminate hands, immediately upon exiting a resident occupied area (e.g., before exiting into a common area such as a corridor) regardless of glove use; After removing personal protective equipment PPE and before moving to another resident in the same room or exiting the room. Hand hygiene is always the final step after removing and disposing of personal protective equipment."

F912 SS=B Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to meet the required room size of 80 square feet for 30 out of 77 resident rooms in multiple resident bedrooms. This deficient practice had the potential to result in inadequate space to provide necessary and safe nursing care and privacy for the residents. Findings: During the general observation of the facility from February 18, 2020, to February 21, 2020, the facility had rooms that measured less than 80 square feet per resident in multiple residents' bedroom. A review of the Client Accommodations FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 88 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Analysis indicated the following: Room No: Room Sq. Footage: Resident Capacity: Square Ft. Per Resident 1 231 3 77 2 231 3 77 3 231 3 77 4 231 3 77 5 231 3 77 6 231 3 77 7 231 3 77 8 231 3 77 9 231 3 77 10 231 3 77 11 231 3 77 15 231 3 77 18 231 3 77 19 231 3 77 22 231 3 77 23 231 3 77 24 231 3 77 25 231 3 77 26 231 3 77 27 231 3 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 89 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 77 28 231 3 231 3 231 3 231 3 231 3 231 3 231 3 231 3 231 3 231 3 77 29 77 30 77 31 77 32 77 33 77 34 77 35 77 36 77 37 77 A review of the facility's request for Room Size Waiver dated February 18, 2020, indicated a request for room waiver for Rooms 1, 2,3,4,5,6,7, 8, 9,10,11,15, 18, 19, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, and 37. The facility's waiver letter dated February 18, 2020, indicated the rooms are in accordance with the special needs of residents and will not have an adverse effect on the residents' health and safety or impeded the ability of any resident in the room to attain his/her highest practicable well-being. During the observation from February 18, 2020 to February 21, 2020, there was ample space to provide care to the residents in the rooms, and ample space to move freely inside the rooms. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 90 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On February 18, 2020 at 2:30 p.m., during the group interview with residents, there were no concerns regarding the size of the aforementioned rooms.

F920 SS=D Requirements for Dining and Activity Rooms CFR(s): 483.90(h)(1)-(4)

F920 03/24/2020 §483.90(h) Dining and Resident Activities The facility must provide one or more rooms designated for resident dining and activities. These rooms must-§483.90(h)(1) Be well lighted; §483.90(h)(2) Be well ventilated; §483.90(h)(3) Be adequately furnished; and §483.90(h)(4) Have sufficient space to accommodate all activities. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to accommodate four of 32 residents (Resident 30, 39, 120, and 148) reviewed for Dining and Activities, by lack of sufficient space for the residents' to eat at the same time, when food was served, as indicated in the facility policy, and lack of accessible space for staff to provide assistance with meals for each resident when food was served. This deficient practice had the potential to result in decreased appetite among the residents and had the potential to decrease the residents' quality of life. Findings: During the Dining Observation Task, on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 91 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/18/20, at 12:25 P.M., Resident 120 was observed sitting on her geri-chair (Geriatric chair- designed to allow residents to get out of the confines of their bed, and be able to sit comfortably in a variety of positions), facing the opposite direction of Table 8, while Resident 30, 39, and 148, were being assisted with their lunch by 3 Certified Nursing Aides (CNAs) at Table 8 of the Station 3 Dining Room. During the Dining Observation Task, on 12/18/20, at 12:28 P.M., Certified Nursing Aide 1 (CNA 1) moved Resident 120 in her gerichair closer to Table 8, and then moved Resident 39 away from Table 8. CNA 1 then sat on her chair to assist Resident 120 with her lunch. a. A review of Resident 148's Face Sheet (Admission Record), indicated that the resident was initially admitted to the facility on 7/11/11 and readmitted on 5/25/17, with diagnosis including hypertension (abnormally high blood pressure). A review of Resident 148's History and Physical (H&P) dated 3/22/2019, indicated the resident did not have the capacity to understand and make decisions. A review of the Resident 148's Minimum Data Set (MDS- a resident care-screening tool), dated 11/13/19, indicated that the resident had severe impairment in cognition (process of acquiring knowledge and understanding). The MDS indicated the resident was totally dependent on staff with bed mobility, transfer, dressing, toilet use, personal hygiene, and with eating. b. A review of Resident 30's Face Sheet indicated that the resident was initially admitted on 11/2/13 and readmitted on 8/8/19, with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 92 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE diagnosis including congestive heart failure (CHF- a chronic condition in which the heart doesn't pump blood as well as it should). A review of Resident 30's H&P dated 8/10/19, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 30's MDS dated 11/12/19, indicated that the resident had severe impairment in cognition. The MDS indicated the resident was totally dependent on staff with bed mobility, transfer, dressing, toilet use, personal hygiene, and eating. c. A review of Resident 120's Face Sheet indicated that the resident was initially admitted on 1/3/13 and readmitted on 4/17/16, with diagnosis including Urinary Tract Infection (UTI- an infection in any part of the urinary system). A review of Resident 120's H&P dated 1/16/18, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 120's MDS dated 1/3/20, indicated that the resident had severe impairment in cognition. The MDS indicated the resident was totally dependent on staff with bed mobility, transfer, toilet use, personal hygiene, and eating. d. A review of Resident 39's Face Sheet indicated that the resident was initially admitted on 12/1/15 and readmitted on 4/9/18, with diagnosis including dysphagia (difficulty in swallowing). A review of the Resident 39's H&P dated 5/10/19, indicated the resident did not have the capacity to understand and make decisions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 93 of 94 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055932 (X3) DATE SURVEY COMPLETED 02/24/2020 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 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE A review of Resident 39's MDS dated 11/21/19, indicated that the resident had severe impairment in cognition. The MDS indicated the resident was totally dependent on staff with bed mobility, transfer, dressing, toilet use, personal hygiene, and eating. During an interview, in the Station Three Dining Room, on 12/18/20, at 12:43 P.M., the Minimum Data Set Coordinator (MDS) agreed that Table 8's arrangement was crowded for all four residents and the CNAs needed to sit and assist the residents all together. During an interview in the Station Three Dining Room on 12/18/20, at 12:45 P.M., the Director of Nursing (DON) confirmed that all four residents should have ample space at Table 8 and the residents should be eating at the same time. During an interview, on 2/24/20, at 2:09 P.M., CNA 1 stated she had to finish helping Resident 39, eat lunch first, before helping Resident 120, as she could not help them both at the same time. A review of the facility's Station 3 Dining Room Seating Arrangement dated 2/17/20, indicated that there are eight tables and each table caters to four residents, with a total of 32 residents; and the residents seated at Table 6, 7, and 8, need assistance to eat. A review of the facility's Policy and Procedures (P&P), titled Dining Program, with a review date of 1/29/20, indicated that residents will be monitored by RNAs/CNAs throughout their meal to ensure assistance is provided. The P&P indicated residents at a given table will be served at the same time. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G5LP11 Facility ID: CA920000004 If continuation sheet 94 of 94