Four Seasons Health Care INC

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Staffing

No payroll-based (PBJ) staffing hours are on file for this home — and the record suggests that is because it did not report them. CMS rates its staffing 1 of 5, which is the rating CMS assigns when a home does not report. Every Medicare-certified nursing home is required to submit its actual payroll data quarterly, and that submission is what makes staffing numbers auditable rather than a claim. A home that does not file is not the same as a home with no data yet: ask this home directly what its nurse-to-resident ratios and weekend RN coverage are, why its payroll data is not filed, and weigh the independent health-inspection score heavily in the meantime.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

29 citations, most serious first. The 12 most serious are shown; the remaining 17 are one tap away and print in full.

• Actual harm · Gcited before2024-10-30 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, review of facility policy, and staff interview, the facility failed to provide necessary care and services for 1 of 1 closed record resident (Resident #28) reviewed. Failure to assess, monitor and implement interventions in response to Resident #28's decline in condition may have contributed to the resident's death. Findings include: Review of the facility policy titled Vital Signs occurred on 10/30/24. This policy, dated 12/12/23, stated, . 'Vital signs' are indicators of health status, including temperature, pulse, blood pressure, respiratory rate, oxygen saturation, and pain. Vital signs shall be obtained at least in the following circumstances: . When the resident's general condition changes. When a resident reports nonspecific symptoms of physical distress (e.g., [example] feeling 'funny' or 'different'). Acceptable ranges for adults: . Oxygen saturation: > [greater than] 90% [percent]. Review of Resident #28's medical record occurred on 10/30/24. Diagnoses included chronic obstructive pulmonary disease (COPD), pulmonary fibrosis (damaged lung tissue),…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2023-08-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, review of the facility reported investigation, review of facility policies, review of personnel records, and staff interview, the facility failed to provide appropriate and sufficient supervision to prevent accidents for 1 of 1 sampled resident (Resident #1) who fell out of a mechanical lift. Failure to follow the nursing care plan resulted in Resident #1's fall, which caused pain, bruising and fractures. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: Review of the facility policy titled Safe Resident Handling/Transfers occurred on 08/30/23. This policy, revised 04/10/23, stated, .residents are handled and transferred safely to prevent or minimize risks for injury. Compliance Guidelines:. 10. Two staff members must be utilized when transferring residents with a mechanical lift (Hoyer). Review of Resident #1's medical record occurred on 08/30/23 and include the diagnoses of chronic pain, disorders of bone density, and adjustment disorder…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · D2026-05-19 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, review of professional reference, and staff interview, the facility failed to notify the physician of a change in condition for 2 of 3 sampled residents (Resident #2 and #3) with a decline in skin integrity. Failure to promptly notify the physician or provider of the change in skin condition limited their ability to make informed decisions regarding the residents' medical care.Findings includeKozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, Carrying Out a Physician's Orders . The nurse is considered responsible for notifying the primary care provider of any significant changes in the client's condition.-Review of Resident #2's medical record occurred on 05/19/26. Diagnoses included left sided hemiplegia and hemiparesis (severe or complete loss of motor function and muscle weakness). The current care plan stated, I get sore areas on my legs and feet due to decrease circulation. I many times refuse to let staff remove my shoes and brace even at night. Staff places…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-05-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, policy review, and staff interview, the facility failed to provide adequate supervision for 1 of 1 sampled resident (Resident #3) who sustained an injury during a sit-to-stand mechanical lift transfer. Failure to ensure supervision while transporting through a doorway with a stand lift resulted in a skin tear and placed the resident at risk of experiencing pain/discomfort and a more serious injury.Findings include:Review of the facility policy titled Policy and Procedure on Using the Sit to Stand Lifts occurred on 05/19/26. This undated policy stated, It is the policy of Four Seasons Healthcare Center to ensure that each resident is safely transferred using the Sit to Stand Lift.Review of Resident #3's medical record occurred on 05/19/26. The current care plan stated, I am at risk for impaired skin integrity r/t [related to] diabetes and immobility. I need assistance with my ADL's [activities of daily living] . I require assist of 1 staff and PAL Lift [type of sit-to-stand mechanical lift] . to move between surfaces.Nurses' notes stated the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-02-19 · tag F0640 — widespread
  Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, review of the Minimum Data Set (MDS) validation reports in Centers for Medicare and Medicaid Services (CMS) Internet Quality Improvement and Evaluation System (iQies), and staff interview, the facility failed to ensure timely electronic data submission of required assessments for 8 of 13 sampled residents (Resident #3, #4, #8, #9, #15, #18, #19, and #22) with late assessments. Failure to follow the MDS data submission specifications does not meet the intended regulatory requirements. Findings include: The Long-Term Care Facility RAI 3.0 User's Manual (Version 1.20.1), page 2-34, stated, . The MDS must be transmitted (submitted and accepted .) electronically no later than 14 calendar days after the MDS completion date . Page 5-1 stated, . All Medicare and/or Medicaid-certified nursing homes . must transmit required MDS data records to CMS' Assessment Submission and Processing (ASAP) system. Review of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-19 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 1 of 5 sampled resident (Resident #18) reviewed for Preadmission Screening and Resident Review (PASRR). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include:The Long-Term Care Facility RAI User's Manual, revised October 2025, pages A-30 through A-32, stated, . A1500: Preadmission Screening and Resident Review (PASRR) . Coding Instructions: . Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness . - Review of Resident #18's medical record occurred all days of survey. Diagnoses included anxiety, depression, and psychotic disorder. A Notice of PASRR…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-19 · tag F0657 — failed to keep the care plan current — isolated
  Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, and resident and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 3 of 13 sampled residents (Resident #3, #5, and #22). Failure to update care plans limited the staff's ability to communicate needs and ensure continuity of care. Findings include: - Review of Resident #3's medical record occurred on all days of survey and identified a diagnosis of Parkinson's Disease. A physician's order, dated 10/18/23 and discontinued on 11/15/24, stated, Resting hand splint to L [left] hand daily. On in AM [morning] and off at HS [hour of sleep-bedtime] as nursing measure for left hand contracture. The current care plan stated, I need assistance with my ADL [activities of daily living] . Brace to my left hand and arm, On in am, off at hs. The facility failed to update Resident #3's care plan with discontinuation of the left hand and arm splint. During an interview on 02/19/26 at 12:30 p.m., an administrative nurse (#1) confirmed the facility failed to update Resident #3's care plan. - Review of…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-02-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, record review, review of facility policy, review of manufacturer's instructions for use, and staff interview, the facility failed to ensure staff followed standards of care for 1 of 1 resident (Resident #3) observed for insulin administration. Failure to administer rapid acting insulin within the time specified by the manufacturer may result in a hypoglycemic (low blood sugar) reaction. Findings include:Review of the facility policy titled Timely Administration of Insulin occurred on 02/19/26. This undated policy stated, . Insulin administration will be coordinated with mealtimes . unless otherwise specified in the physician order . Administer insulin at appropriate times.Prescribing information for Insulin Aspart, found at https://www.novo-pi.com/insulinaspart, stated, . This product is NovoLog(R) (insulin aspart) . Insulin Aspart is rapid acting human insulin analog indicated to improve glycemic control in adults . Preparation and Administration Instructions . Inject Insulin Aspart subcutaneously within 5-10 minutes before a meal .Review of Resident #3's…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-02-19 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
  Develop and implement policies and procedures for flu and pneumonia vaccinations.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, review of the Centers for Disease Control and Prevention (CDC) guidelines and recommendations, and staff interview, the facility failed to offer the pneumococcal vaccine to 2 of 5 residents (Resident #4 and #22) reviewed for immunization status. Failure to offer the recommended pneumococcal conjugate vaccines (PCV) and pneumococcal polysaccharide vaccine (PPSV) to all residents, provide education to residents and their legal representatives, and document the administration or refusal has the potential for non-immunized residents to contract pneumonia and spread the infection to other residents, visitors, and staff. Findings include:Review of the facility policy titled Infection Prevention and Control Program occurred on 02/19/26. This policy, dated 01/02/25, stated, . Influenza and Pneumococcal Immunization: . b. Residents will be offered the pneumococcal vaccines recommended by the CDC upon admission, unless contraindicated or received the vaccines elsewhere.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-12-29 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-09-24 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a FRI, record review, review of facility policy, and staff interview, the facility failed to ensure residents remained free from abuse for 1 of 1 sampled resident (Resident #2) who experienced unwanted sexual contact from another resident (Resident #1). Failure to protect Resident #2 from sexual abuse may result in psychosocial harm and mental and emotional distress.Findings include:Review of the facility policy titled Abuse and Neglect occurred on 08/28/25. This policy, dated 05/13/19, stated, All residents have the right to be free from verbal, sexual, physical, and mental abuse . Residents must not be subjected to abuse by anyone, including . other residents . Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault .Review of Resident #1's medical record occurred on 08/28/25. Diagnoses included dementia. The Minimum Data Set (MDS), dated [DATE], identified severe cognitive impairment. Review of Resident #2's medical record occurred on 08/28/25.…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2024-10-30 · tag F0865 — failed to run a quality-improvement (QAPI) program — widespread
  Have a plan that describes the process for conducting QAPI and QAA activities.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on review of the State Agency (SA) facility files, review of the facility Quality Assurance and Performance Improvement (QAPI) program, review of facility policy, survey findings, and staff interview, the facility failed to develop a QAPI process to evaluate and identify problems and opportunities to improve services/outcomes, decrease or prevent likelihood of problems or occurrence of adverse events, and ensure compliance with federal requirements. Findings include: Review of the facility policy titled QAPI Change Process occurred on 10/30/24. This policy, dated 10/02/24, stated, . The QAA [Quality Assessment and Assurance] Committee utilizes a systematic approach to performance improvement, including analysis of data, corrective action, and performance tracking. As corrective actions are taken, the committee continues to collect and analyze data to determine the effectiveness of any changes. Once actions are implemented, the facility continues to track performance to ensure that improvements are realized and sustained. Performance on the measures are discussed in QAA…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$115,484 in federal fines across 3 penalties.

• $78,309 — penalty dated 2024-10-30
• $29,437 — penalty dated 2023-11-08
• $7,738 — penalty dated 2023-08-30

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

What families pay in ND