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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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.