Four Seasons Health Care Inc
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
(MDS), dated [DATE REDACTED], identified severe cognitive impairment. Review of Resident #2's medical record occurred on 08/28/25. Diagnoses included dementia. The MDS, dated [DATE REDACTED], 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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FOUR SEASONS HEALTH CARE INC in FORMAN, ND inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in FORMAN, ND, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FOUR SEASONS HEALTH CARE INC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.