FORMAN, ND - Federal health inspectors documented safety deficiencies at Four Seasons Health Care Inc following a complaint-driven investigation in late December 2025, finding the facility failed to maintain an environment free from accident hazards and provide adequate supervision to prevent resident injuries.
Federal Investigation Uncovers Safety Lapses
The Centers for Medicare and Medicaid Services conducted a complaint investigation at the Forman facility on December 29, 2025, resulting in citations under federal regulatory tag F0689. Inspectors determined the nursing home did not meet federal requirements for maintaining a safe environment and preventing accidents through proper supervision.
The violation was classified as scope and severity level D, indicating an isolated incident with no actual harm documented but potential for more than minimal harm to residents. While no residents suffered injuries during the inspection period, the identified hazards posed significant risks to the vulnerable elderly population residing at the facility.
Understanding Accident Prevention in Nursing Homes
Maintaining a hazard-free environment represents a fundamental responsibility of nursing home operators. Federal regulations require facilities to systematically identify potential accident risks, implement preventive measures, and provide adequate supervision based on each resident's needs and cognitive status.
Accident hazards in long-term care settings can include wet floors without warning signs, poor lighting in hallways and resident rooms, obstructed pathways, improperly stored equipment, and inadequate handrails or grab bars. Even seemingly minor environmental hazards can result in catastrophic injuries for elderly residents with mobility limitations, balance issues, or cognitive impairment.
Falls represent the leading cause of fatal and non-fatal injuries among nursing home residents. According to the Centers for Disease Control and Prevention, each year approximately 1,800 nursing home residents die from fall-related injuries, and those who survive often experience decreased mobility and increased fear of falling that diminishes their quality of life.
Supervision Requirements Under Federal Standards
Federal nursing home regulations mandate that facilities provide adequate supervision to prevent accidents based on comprehensive resident assessments. Staff must understand each resident's risk factors, including history of falls, medications that affect balance or cognition, mobility limitations, and conditions like dementia that may impair judgment.
Proper supervision strategies include regular visual checks, assistance with transfers and ambulation, toileting schedules to prevent rushing to bathrooms, accessible call lights, and appropriate use of assistive devices. Facilities must balance resident autonomy and dignity with necessary safety precautions.
When supervision proves inadequate, residents face heightened risks of falls, wandering incidents, injuries from environmental hazards, and preventable accidents. Cognitively impaired residents require particularly vigilant oversight, as they may not recognize dangers or seek help when needed.
Facility Response and Correction Timeline
Four Seasons Health Care Inc submitted a plan of correction following the inspection findings. The facility reported implementing corrective measures by January 28, 2026, approximately one month after inspectors documented the deficiencies.
The complaint-driven nature of this investigation suggests concerns raised by residents, family members, staff, or other parties prompted the federal review. CMS typically conducts complaint investigations when allegations warrant immediate attention beyond routine annual surveys.
Regulatory Oversight and Resident Rights
Federal and state regulators maintain oversight of nursing homes participating in Medicare and Medicaid programs. Facilities must comply with comprehensive quality and safety standards addressing resident care, staffing, environment, and administration.
When deficiencies are identified, facilities must develop and implement correction plans addressing both the specific violations and systemic issues that allowed problems to occur. Regulators conduct follow-up monitoring to verify sustained compliance.
Residents and families can access inspection reports, complaint investigation findings, and facility quality data through Medicare's Nursing Home Compare website. This transparency enables informed decision-making when selecting long-term care facilities and empowers families to advocate for safe, quality care.
The complete inspection report with detailed findings is available through the Centers for Medicare and Medicaid Services for those seeking additional information about the specific deficiencies documented at Four Seasons Health Care Inc.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Four Seasons Health Care Inc from 2025-12-29 including all violations, facility responses, and corrective action plans.
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