Four Seasons Health Care: Immediate Jeopardy - ND
The incidents occurred on August 23, 2025, at Four Seasons Health Care Inc, where both residents have severe cognitive impairment and dementia diagnoses. Federal inspectors found the facility failed to protect the female victim from "inappropriate and unwanted sexual contact" that escalated rapidly despite staff interventions.
At 1:15 p.m., a staff member discovered the male resident with "his face in the breast area" of the female patient in the resident lounge. When confronted, he claimed he was "just talking to her." Staff removed the woman to an area near the nurses' station and counseled the man that his behavior was inappropriate.
Fifteen minutes later, at 1:30 p.m., the same male resident was "again observed by staff kissing this female resident on the mouth in the lounge area." The woman was again removed for safety while the man was redirected to his room.
The female victim routinely wandered throughout the facility as part of her condition, frequently strolling in and out of the lounge area. The facility had camera monitoring capability for this location.
Despite two previous incidents within 15 minutes, staff continued attending to other residents rather than implementing continuous supervision. At 1:45 p.m., just 15 minutes after the second assault, the male resident "sought out" the female victim and "was observed touching [her] inappropriately."
Only after this third sexual assault did Four Seasons implement one-to-one supervision for the male perpetrator.
The facility's investigation report, completed two days later on August 25, documented the timeline of failures. An initial incident report reached state authorities at 11:28 a.m. that same morning.
During interviews with federal inspectors on August 28, an administrative nurse confirmed both residents remained on hourly monitoring and reported no further interactions had occurred since the supervision was implemented.
The inspection classified the violation as "immediate jeopardy to resident health or safety," the most serious category of nursing home deficiency. This designation indicates the facility's failures created a situation where residents faced serious injury, harm, impairment, or death.
Both victims had severe cognitive impairment documented in their medical records and assessments. The male resident's behavior demonstrated a pattern of seeking out the female victim even after staff interventions and counseling.
The 30-minute window between the first and third assault highlighted systematic failures in the facility's protective protocols. Despite having camera monitoring systems and removing the victim twice for safety, staff failed to recognize the escalating danger or implement adequate supervision.
Federal regulations require nursing homes to ensure each resident receives care free from abuse, neglect, and exploitation. Facilities must investigate allegations immediately and implement protective measures to prevent further incidents.
The facility's delayed response violated these fundamental protections. Rather than preventing further assaults after the first incident, Four Seasons allowed the pattern to continue and escalate over the course of half an hour.
The case demonstrates how cognitive impairment creates vulnerability in institutional settings. The female victim's wandering behaviors, typical of dementia patients, made her particularly susceptible to repeated targeting by the male resident.
The inspection report does not indicate whether law enforcement was contacted about the sexual assaults or what disciplinary actions, if any, were taken against staff who failed to protect the victim.
The immediate jeopardy finding affects few residents but represents serious systemic failures in resident protection at Four Seasons Health Care. The facility must demonstrate substantial compliance with federal safety requirements before the designation can be lifted.
For the female victim, the trauma of three sexual assaults in 30 minutes occurred while she was under the facility's care and protection. Her severe cognitive impairment made her unable to consent to or defend herself from the unwanted contact that staff allowed to continue.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Four Seasons Health Care Inc from 2025-09-24 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
FOUR SEASONS HEALTH CARE INC in FORMAN, ND was cited for immediate jeopardy violations during a health inspection on September 24, 2025.
The incidents occurred on August 23, 2025, at Four Seasons Health Care Inc, where both residents have severe cognitive impairment and dementia diagnoses.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.