Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Four Seasons Health Care Inc during CMS and state inspections, most recent first.
Staff failed to assess and utilize the correct sling sizes for two residents during full body mechanical lift transfers, resulting in the use of slings without proper size identification or the use of an incorrect size. Staff relied on a general sizing chart in the supply room rather than individualized assessments, and there was no documentation or education provided regarding appropriate sling selection.
A resident with severe cognitive impairment was subjected to repeated unwanted sexual contact by another resident, also with severe cognitive impairment, despite staff interventions after the initial incident. The inappropriate contact occurred multiple times in a monitored lounge area before one-to-one supervision was implemented, in violation of the facility's abuse prevention policy.
A resident with COPD, pulmonary fibrosis, and CHF experienced a decline in condition, with low oxygen saturation levels and difficulty breathing. The facility failed to document nurse progress notes for several days and did not promptly assess or notify a physician of the resident's condition changes. The resident expressed distress and was eventually transferred to the ER, where he passed away shortly after arrival.
The facility failed to develop an effective QAPI process, resulting in continued noncompliance with federal regulations. Deficiencies were identified in areas such as Bed Hold Policy, Care Plan Timing, Quality of Care, Accident Hazards, Food Sanitation, and Infection Control. Despite having a policy for performance improvement, the facility did not maintain compliance, as evidenced by deficiencies cited during surveys.
The facility failed to ensure a safe, clean, and homelike environment in multiple areas, including the supply room, laundry room, oxygen storage room, and resident rooms. Observations revealed dust on an oxygen concentrator, debris in the laundry room, and damaged walls and furniture in resident rooms. Staff interviews confirmed a lack of processes for identifying areas needing cleaning or repairs.
The facility failed to accurately code the MDS for several residents, including the presence of an indwelling catheter, insulin use, and antiplatelet medication. These inaccuracies were confirmed by an administrative nurse and could affect the development of comprehensive care plans.
The facility failed to provide sufficient nursing staff, resulting in delays in care for three residents. A resident reported waiting 20-30 minutes for toileting assistance at night, while another had to wait for two staff members to assist, leading to prolonged periods in a wet pad and soreness. A third resident experienced 1-2 hour delays in receiving pain cream for knee pain across all shifts. These issues highlight inadequate staffing, particularly during the overnight shift.
The facility failed to adhere to food storage and sanitation standards, with a metal scoop improperly stored in a flour bin, an unlabeled shaker in a cooler, and expired sanitizer test strips affecting concentration results. Additionally, dried substances were found in a resident refrigerator, indicating a lack of cleanliness.
A facility failed to provide a timely written bed hold notice to a resident or their representative during a hospital transfer. The policy requires the notice to be given before transfer or within 24 hours in emergencies. However, the notice was delayed by eight days, as confirmed by an administrative staff member.
A facility failed to complete a PASARR for a resident newly diagnosed with delusions and hallucinations. Despite communication with a physician and an increase in antipsychotic medication, the facility did not update the Level I screen as required, leading to a deficiency in compliance with regulatory procedures.
The facility failed to update care plans for three residents, impacting staff communication and care continuity. A resident's care plan was not revised after a foley catheter removal, while two residents' care plans contained outdated medication information, referencing incorrect anticoagulant treatments.
A nurse failed to administer Voltaren gel according to physician orders, applying an undetermined amount directly from the tube to a resident's arms and shoulders without measuring the correct dosage. The facility's policy requires medications to be administered as ordered and in accordance with professional standards, which was not followed in this instance.
A facility failed to use a gait belt during a resident's transfer, risking falls and injury, despite the resident's history of repeated falls and a care plan requiring assistance. Additionally, a resident with dementia ingested craft paint due to an unlocked supply cabinet, leading to an ER visit. The facility's policy required such materials to be secured.
The facility failed to ensure medications were securely stored and properly dated, with a treatment cart left unlocked and unattended, and expired medications found in the medication room. An administrative staff member expected staff to lock the treatment cart when unattended.
A facility failed to follow its infection control policy during wound care for a resident. The policy requires gowns and gloves for high-contact activities to prevent the spread of multidrug-resistant organisms. A nurse changed a resident's abdominal wound dressing wearing only gloves, without a gown, and the room lacked EBP signage. The facility also did not obtain an order for enhanced barrier precautions for the resident, who required daily dressing changes.
The facility did not post accurate and complete staffing information for three days during a survey. Observations showed that the daily staffing reports were not updated as required by facility policy. An administrative staff member noted that the charge nurse was responsible for posting the daily staffing report.
Failure to Assess and Use Correct Sling Size During Mechanical Lift Transfers
Penalty
Summary
The facility failed to utilize appropriate assistive devices necessary to prevent accidents and/or injury for two residents observed during mechanical lift transfers. Specifically, staff did not assess or use the correct sling sizes for residents requiring full body mechanical lift transfers. For one resident, the sling used during transfer did not have a size noted, and for another, staff could not locate the resident's usual sling and instead used a large-sized sling without confirming its appropriateness. Staff interviews revealed that sling size information was only available on a chart in the supply room, and there was no individualized assessment or documentation of correct sling size for each resident. Further review and interviews confirmed that the facility had not assessed residents who require full body mechanical lifts for the appropriate sling size, nor had they provided staff with adequate information or education regarding proper sling selection. The lack of assessment and failure to ensure the use of correct sling sizes during transfers placed residents at risk for falls and injuries, as observed during the survey.
Failure to Prevent Repeated Sexual Abuse Between Residents with Dementia
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from repeated unwanted sexual contact by another resident, also with severe cognitive impairment. On the day of the incident, a staff member observed one resident with his face in the breast area of another resident in the lounge. When questioned, the resident stated he was just talking to her. The affected resident was removed to a safer location near the nurse's station, and the other resident was redirected to his room and counseled. Despite these interventions, the same resident was observed again shortly after kissing the affected resident on the mouth in the lounge, and later, touching her inappropriately. The affected resident was noted to have wandering behaviors and frequently entered the lounge area, which was monitored by the facility's camera system. The inappropriate sexual contact occurred three times within a short period before the facility implemented one-to-one supervision for the resident exhibiting the sexual behaviors. Both residents had diagnoses of dementia and were identified as having severe cognitive impairment on their Minimum Data Set assessments. The facility's policy stated that all residents have the right to be free from abuse, including sexual abuse, and that residents must not be subjected to abuse by anyone, including other residents. However, the facility did not prevent the repeated incidents of nonconsensual sexual contact before taking more intensive supervisory action.
Failure to Provide Timely Care and Intervention
Penalty
Summary
The facility failed to provide necessary care and services for a resident with chronic obstructive pulmonary disease, pulmonary fibrosis, and congestive heart failure. The resident's medical record lacked documentation of nurse progress notes for three consecutive days, and there was a failure to assess, monitor, and implement interventions in response to the resident's declining condition. On one occasion, the resident's oxygen saturation was recorded at 81% while on three liters of oxygen, yet there was no documented assessment, treatment intervention, or physician notification. Later, the resident's oxygen saturation improved slightly to 89%, but again, no further action was documented. The resident expressed feeling unwell and reported difficulty breathing, stating he was dying and unable to eat. Despite these significant changes in condition, there was a delay in notifying the physician, with a gap of several hours between the resident's report of distress and the facility's contact with the physician's clinic. The resident was eventually transferred to the emergency room, where he passed away shortly after arrival. The lack of timely intervention and communication with the physician contributed to the resident's decline and subsequent death.
Facility's Ineffective QAPI Process Leads to Multiple Deficiencies
Penalty
Summary
The facility failed to develop an effective Quality Assurance and Performance Improvement (QAPI) process to evaluate and identify problems and opportunities to improve services and outcomes. This failure was identified through a review of the facility's QAPI program, policies, survey findings, and staff interviews. The facility's policy, dated 10/02/24, outlined a systematic approach to performance improvement, including data analysis, corrective action, and performance tracking. However, the facility did not maintain compliance with federal requirements, as evidenced by deficiencies cited during the last standard survey and a subsequent Federal Monitoring Survey. The deficiencies included issues related to the Notice of Bed Hold Policy, Care Plan Timing and Revision, Quality of Care, Accident Hazards/Supervision/Devices, Food Procurement and Sanitation, and Infection Prevention and Control. Despite the facility's policy stating that the Quality Assessment and Assurance (QAA) Committee would continue to collect and analyze data to ensure improvements, the facility failed to effectively utilize its Quality Assurance processes. This resulted in continued noncompliance with federal regulations, as indicated by the deficiencies cited under F625, F657, F684, F689, F812, and F880.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in several areas, including the supply room, laundry room, oxygen storage room, and resident rooms. Observations during the survey revealed an oxygen concentrator with dust on the outside and filter, and oxygen tubing and a mask were found on the floor beside the machine. Additionally, a portable liquid oxygen tank and a nebulizer machine were also placed on the floor next to the concentrator. In the laundry room, there was visible dust and debris on a fan grate and blades, which were blowing into the clean laundry area. The oxygen storage room had two ceiling vents with a thick layer of dust, cracked and broken floor tiles, a visible layer of fine dirt along the floor perimeter, and ceiling tiles with water leak marks. In the resident rooms, Unit A had scuff marks, chipped paint, and gouges on the walls. Room B8 had an overbed table with a two-inch strip of missing laminate along the front length, exposing the wood, and a large area of loose laminate on the right top side. The top of the oxygen concentrator in room B8 was also covered in dust. During interviews, a maintenance staff member confirmed the lack of a process for identifying areas needing cleaning or repairs and was unaware of any resident room concerns. An administrative staff member stated that staff were expected to clean and sanitize oxygen and nebulizer equipment before storage and dispose of items like oxygen tubing and masks in the resident's room.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for eight residents, which is crucial for reflecting each resident's current status and needs. Specifically, the facility did not accurately code the presence of an indwelling catheter for one resident, as the MDS indicated its presence despite observations and medical records showing otherwise. Additionally, the facility failed to code insulin use for another resident who had physician orders for insulin glargine to manage diabetes mellitus type 2. Furthermore, the facility did not code the use of antiplatelet medication, specifically aspirin, for six residents on their respective MDS assessments. These omissions were confirmed by an administrative nurse during interviews, highlighting a pattern of inaccurate MDS coding across multiple residents. This inaccuracy in MDS coding could potentially impact the development of comprehensive care plans and the care provided to the residents.
Insufficient Nursing Staff Leads to Delays in Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was available to meet the needs of residents, as evidenced by confidential interviews with three residents. Resident A reported a consistent wait time of 20-30 minutes for toileting clean-up assistance during the night shift, which had been ongoing since their admission several weeks prior. Resident B expressed that the facility was understaffed, requiring two staff members for assistance, resulting in prolonged periods of sitting in a wet pad and developing soreness. This issue was particularly noted after evening care and throughout the night. Resident C experienced delays of 1-2 hours in receiving pain cream for knee pain, with these delays occurring across all shifts. These findings indicate a failure to provide adequate staffing to meet the residents' needs, particularly during the overnight shift.
Deficiencies in Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper food storage and preparation standards in both the kitchen and a resident refrigerator. During a kitchen tour, a metal scoop was found improperly stored inside a flour bin, contrary to the facility's policy that requires scoops to be kept outside storage bins in protective containers. Additionally, an unlabeled and undated shaker containing milk and oatmeal was found in a reach-in cooler, which was identified as belonging to a staff member. This lack of labeling and dating contravenes the facility's policy on food safety, which mandates that all food brought into the facility be labeled and dated. Furthermore, the facility did not ensure the proper concentration of sanitizer solution used for cleaning resident dining room tables. An unidentified dietary staff member tested the sanitizer concentration and found it to be out-of-range, with the test strips used being expired. This could potentially affect the effectiveness of the sanitizer. Additionally, dried liquid substances were observed on two shelves inside a refrigerator located in the main lobby, which is used to store foods brought in by family members. The dietary manager confirmed the expectations for food storage and acknowledged the expired test strips, which may have affected the sanitizer test results.
Failure to Provide Timely Bed Hold Notice
Penalty
Summary
The facility failed to provide a timely written bed hold notice to a resident or their representative during a hospital transfer. According to the facility's policy, a written notice detailing the bed hold policy should be provided before a resident is transferred to the hospital, or within 24 hours in the case of an emergency transfer. However, for one resident who was transferred to the hospital, the facility delayed providing this notice until eight days after the transfer. This delay was confirmed by an administrative staff member during an interview, indicating a lapse in adhering to the facility's policy and regulatory requirements.
Failure to Complete PASARR for Resident with New Mental Health Diagnosis
Penalty
Summary
The facility failed to complete a status change assessment for a resident who was newly diagnosed with mental illness, specifically delusions and hallucinations. According to the North Dakota PASARR Provider Manual, a change in status process must be initiated when a significant change in a resident's mental health status occurs. This includes contacting the contracted agency to update the Level I screen and determine if a Level II evaluation is necessary. The resident's medical record indicated that a PASARR was completed in August 2021, but subsequent progress notes in September 2024 documented communication with a physician regarding the resident's delusions and hallucinations, leading to an increase in antipsychotic medication. However, there was no evidence that the facility staff completed a PASARR related to these new diagnoses. During an interview, a social services staff member confirmed that the facility did not complete a change in status Level I screen for the resident. This oversight could result in the delivery of care and services that do not align with the resident's current needs, as the facility did not follow the required procedures for updating the resident's mental health status. The lack of a completed PASARR assessment following the emergence of new mental health conditions represents a deficiency in the facility's compliance with regulatory requirements.
Failure to Update Care Plans Following Medical Changes
Penalty
Summary
The facility failed to review and revise care plans to reflect the current status of three residents, which limited the staff's ability to communicate needs and ensure continuity of care. For Resident #4, the care plan was not updated to reflect the removal of a foley catheter, as confirmed by an administrative nurse during an interview. Despite the absence of an indwelling catheter observed on 10/28/24, the care plan still indicated its presence. For Resident #10, the care plan inaccurately referenced monitoring for bleeding problems due to Plavix use, despite a physician's order for Eliquis, an anticoagulant medication. Similarly, Resident #23's care plan was not updated after the discontinuation of warfarin on 05/01/24, as it still included instructions for PT/INR checks and Coumadin dose adjustments. These discrepancies highlight the facility's failure to update care plans following significant changes in residents' medical treatments.
Failure to Administer Topical Medication as Ordered
Penalty
Summary
The facility failed to adhere to professional standards of practice in the administration of topical medication for a resident. During a medication pass, a nurse was observed applying Voltaren gel to a resident's arms and shoulders without measuring the correct dosage as specified in the physician's orders. The orders required the application of 2 grams of Voltaren gel to the shoulders and 4 grams to the knees, but the nurse dispensed an undetermined amount directly from the tube into a gloved hand, failing to use the dosing card as per the manufacturer's specifications. The deficiency was confirmed through observation, record review, and staff interviews. The facility's medication administration policy mandates that medications be administered as ordered by the physician and in accordance with professional standards. The administrative staff acknowledged that the nurse did not follow the provider's orders for accurately measuring and applying the medication, which could potentially lead to adverse outcomes for the resident.
Failure to Utilize Gait Belt and Secure Hazardous Materials
Penalty
Summary
The facility failed to properly utilize assistive devices necessary to prevent accidents and/or injury for a resident during a gait belt transfer. A licensed nurse assisted the resident to stand up from a sitting position by placing her arm under the resident's arm, failing to utilize a gait belt during the transfer. The resident's medical record indicated repeated falls, and the care plan required staff assistance with transfer and locomotion. This failure to use a gait belt placed the resident at risk for falls and/or injury. Additionally, the facility failed to ensure the safety of a resident who ingested non-toxic craft paint. The resident, who had diagnoses of dementia, restlessness, agitation, and wandering, was found with craft paint on his arms, mouth, and pants. The nurse was unsure of how much paint the resident might have consumed, and the resident was sent to the ER for evaluation. The facility's incident report noted that the cabinet containing the paint was unlocked, despite staff being aware that it should always be locked to prevent access by residents with altered mental status.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure medications were properly dated, expired medications were discarded, and medications were securely stored in two of three storage areas, specifically the treatment cart and medication room. During an observation, a staff nurse left a treatment cart unlocked and unattended for approximately 20 minutes while entering a resident's room. During this time, residents and staff walked past the unlocked cart, and one resident stood next to it without the nurse present. This lack of security could lead to unauthorized access to medications. Additionally, an observation of the medication room revealed that a locked refrigerator contained expired medications and an undated multi-dose vial. Specifically, three acetaminophen suppositories had expired on 12/31/23, and an opened, undated multi-dose vial of tubersol was found. An administrative staff member stated that she expected staff to lock the treatment cart when it was unattended or out of sight, indicating a failure to adhere to facility policies regarding medication storage and security.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to its infection prevention and control policy during wound care for a resident. The policy, titled Enhanced Barrier Precautions (EBP), requires the use of gowns and gloves during high-contact resident care activities, such as wound care, to prevent the transmission of multidrug-resistant organisms. During the survey, it was observed that a staff nurse entered the resident's room, which lacked EBP signage, and proceeded to change the resident's abdominal wound dressing while only wearing gloves, neglecting to wear a gown as mandated by the facility's policy. Additionally, the facility staff did not obtain an order for enhanced barrier precautions for the resident, who had a wound on the right abdomen requiring daily dressing changes as per the physician's order.
Failure to Post Accurate Daily Staffing Information
Penalty
Summary
The facility failed to ensure the posting of accurate and complete staffing information on three out of four days during the survey period from October 27 to October 29, 2024. This deficiency was identified through observation, review of facility policy, and staff interviews. The facility's policy requires the posting of daily staffing information for each shift, detailing the number of licensed and unlicensed staff responsible for resident care. However, observations revealed that the facility did not update the staffing reports on the clipboard located by the nurse's station during the specified days. An administrative staff member indicated that the charge nurse was expected to complete and post the daily census/staffing report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Forman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Dakota Veterans Home | 21.5 mi | — | 0 | 0 |
| Good Samaritan Society - Oakes | 21.7 mi | — | 11 | 1 |
| Wheatcrest Hills Healthcare Center | 22.4 mi | — | 4 | 0 |
| Parkside Lutheran Home | 23.6 mi | — | 10 | 0 |
| St Gerard's Community Of Care | 35.3 mi | — | 0 | 0 |
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