Four Seasons Health Care Inc
FOUR SEASONS HEALTH CARE INC in FORMAN, ND — inspection on September 24, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident #2's medical record occurred on 08/28/25.
Diagnoses included dementia.
The MDS, dated [DATE], identified severe cognitive impairment.
The initial FRI report, received by the SA on 08/25/25 at 11:28 a.m., identified nonconsensual sexual contact between Resident #1 and #2 occurred on 08/23/25.
After the third occurrence, the facility initiated one to one (1:1) supervision for Resident #1.The facility's final investigation report, dated 08/25/25, stated, . At approximately 1315 [1:15 p.m.] on August 23, 2025, in the resident lounge area, a staff member found [Resident #1] with his face in the breast area of [Resident #2].
When the staff member asked [Resident #1] what he was doing, he stated, 'I was just talking to her.' [Resident #2] was removed from the lounge area and taken to a location closer to the nurse's station for observation. [Resident #1] was redirected to his room and counseled that this behavior was inappropriate. at 1330 [1:30 p.m.], [Resident #1] was again observed by staff kissing this female resident on the mouth in the lounge area.
Noted that [Resident #2] exhibits wander behaviors, and per her normal, routinely strolls into the lounge frequently and back out.
This area has the ability for monitoring over the facility camera system. At 1330 [1:30 p.m.] [Resident #2] again removed from the lounge area and into the nurses station for safety.
While staff were attending to other residents, [Resident #1] sought out [Resident #2] and at 1345 [1:45 p.m.] was observed touching [Resident #2] inappropriately. [Resident #1] was again immediately redirected to his room.
Staff continued monitoring both residents following the series of incidents.
During an interview on the afternoon of 08/28/25, an administrative nurse (#1) reported both residents remain on hourly checks, and no further interactions have occurred.The Facility failed to protect Resident #2 from inappropriate and unwanted sexual contact from Resident #1 and the sexual contact continued two more times before the facility implemented 1:1 supervision.
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