Four Seasons Living Center: Care Plan Failures - MO
That detail came from LPN B, a nurse at the facility who told inspectors during a May 26 interview that the behavior was a known pattern. The resident had done it again on May 21. They had been doing it since admission.
Nobody had updated the care plan.
That is the core of what inspectors found during a complaint inspection at Four Seasons Living Center, a nursing facility at 2800 Highway TT in Sedalia. The visit took place May 26, 2026, and the report was printed August 8.
LPN B told inspectors the resident's fire alarm pulling should have been addressed in the care plan. She said she did not know if it had been. She said new interventions should be added when a resident keeps showing the same behavior and the old approach isn't working.
The resident themselves told inspectors they did not know what interventions, if any, were in place for their behavior.
That is a significant gap. A care plan is the document that tells every nurse, every aide, every staff member who walks into that room what this person needs, what their risks are, and what to do when something goes wrong or keeps going wrong. Without it, each staff member is essentially starting from scratch.
The corporate nurse, interviewed the same afternoon, said she would expect to see interventions in the care plan after any change in behavior, and new interventions if the original ones stopped working. She noted that nurses have the ability to update care plans themselves. She did not explain why it hadn't happened.
The administrator, interviewed on June 9, two weeks after the inspection, said staff had only recently reported the fire alarm behavior to her. She said she expected the care plan to have included new interventions after the first time the alarm was pulled. She said nurses were able to make those updates. She said the facility was now re-educating nurses to update care plans when a resident showed a new behavior, and to notify the care plan coordinator when that happened.
Re-education. That is the word facilities use when a system has failed and they are not sure how to explain why.
What the record shows is this: a resident with a documented, recurring behavior, a behavior that triggered a fire alarm, a behavior staff connected directly to a specific want, was living at this facility without a care plan that reflected any of that. The nurses knew. The LPN knew. The corporate nurse knew what should have happened. The administrator knew what she expected. None of that knowledge made it into the document that was supposed to capture it.
Inspectors cited the deficiency at a level of minimal harm or potential for actual harm, affecting a few residents. That is one of the lower rungs on the federal harm scale. But the classification describes the outcome, not the failure. The failure here was a facility's inability to translate what its own staff observed and understood into the written plan of care that governs how that resident is treated every day.
Pulling a fire alarm disrupts an entire building. It moves staff. It can cause falls among residents who react to alarms. It creates confusion. It is not a trivial behavior to leave unaddressed in any formal way, and the facility's own nurses said so when asked directly.
The resident, for their part, kept doing what had worked, or what they believed might work. They wanted cigarettes. They pulled the alarm. Staff recognized the pattern. The care plan remained unchanged.
That is where the report ends, with a facility promising to train its nurses to do what its nurses already knew they were supposed to do.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Four Seasons Living Center from 2026-05-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 13, 2026 · Our methodology
FOUR SEASONS LIVING CENTER in SEDALIA, MO was cited for violations during a health inspection on May 26, 2026.
That detail came from LPN B, a nurse at the facility who told inspectors during a May 26 interview that the behavior was a known pattern.
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.