Four Seasons Health Care Inc
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Based on observation, review of facility policy, record review, and staff interviews, the facility failed to utilize appropriate assistive devices necessary to prevent accidents and/or injury for 2 of 2 sampled residents (Resident #1 and #2) observed during mechanical lift transfers. Failure to assess for and utilize the correct sling sizes for residents during full body mechanical lift transfers placed the residents at risk for falls and/or injuries. Findings include:Review of the policy titled Policy and Procedure on Using the Hoyer Lift occurred
on 12/29/25. This policy, dated December 2023, stated, . It is the policy of Four Seasons Healthcare Center to ensure that each resident is safely transferred using the Hoyer Lift. 1. Identify correct lift and sling for the resident .- Review of Resident #1's medical record occurred on 12/29/25. The current care plan stated, . I need the two person hoyer (full body mechanical) lift and two assist with transfer.Observation on 12/29/25 at 4:15 p.m. showed two certified nurse aides (CNAs) (#1 and #2) assisted Resident #1 from the recliner to
the bed using a full body mechanical lift. The tag on the sling stated, Proactive with no size noted.- Review of Resident #2's medical record occurred on 12/29/25. The current care plan stated, . I use the hoyer lift and two assist with transfer.Observation on 12/29/25 at 3:45 p.m. showed two CNAs (#1 and #2) assisted Resident #2 from the bed to the wheelchair using a full body mechanical lift. Prior to the transfer, CNA (#2) stated he needed to go get a sling since there was not one in the resident's room. When the CNA returned,
he stated, I could not find the one (sling) she normally uses. The tag on the sling brought into the room identified, Invacare and size large. During an interview on 12/29/25 at 4:48 p.m., when asked how staff know what size hoyer sling to use for each resident, the CNA (#1) stated, There is a list posted in the supply room. Review of the list posted in the supply room stated, Hoyer Sling Sizing Chart Medium: 99 to 210 pounds Large: 198 to 350 pounds X - Large: 270 to 600 pounds Weight capacity is between 450 to 600 poundsDuring an interview on 12/29/25 at 5:27 p.m., a CNA (#2) confirmed they did not use the correct sling when they transferred Resident #2 with the mechanical lift. During an interview on 12/29/25 at 5:15 p.m., an administrative nurse (#3) confirmed the facility had not assessed residents who require the full body mechanical lift for appropriate sling size. The facility failed to assess Residents #1 and #2 for the appropriate sling size and provide staff with information and education regarding appropriate sling size when utilizing the mechanical full body lift.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
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.