Four Seasons Health Care Inc

In the surveyor’s words

From the most serious findings on record at Four Seasons Health Care Inc, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 24, 2025

  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 placed this resident and all residents at risk for psychosocial harm and mental and emotional distress.During the on-site FRI investigation survey, the survey team consulted the State Survey Agency (SSA) and determined noncompliance with regulatory requirements existed on 08/23/25. On 09/15/25, the SSA consulted with Centers for Medicare and Medicaid (CMS) Regional Office and determined an Immediate Jeopardy (IJ) situation existed on 08/23/25. […]

• Actual harm, isolatedF684Oct 30, 2024

  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. […]

• Actual harm, isolatedF689Aug 30, 2023

  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. […]

• Actual harm, isolatedF689Mar 27, 2023

  Based on record review, review of facility policy, review of facility's fall investigation report, and staff interview, the facility failed to provide appropriate and sufficient supervision to prevent accidents for 1 of 1 sampled resident (Resident #4) who fell out of a mechanical lift. Failure to communicate nursing assessments which identified the resident required more assistance with transfers and failure to re-evaluate transfer methods resulted in Resident #4's fall, which caused pain, bruising, and a fracture. Findings include: Review of the facility policy titled POLICY AND PROCEDURE ON USING PAL LIFT occurred on 03/27/23. This policy, dated 10/01/22, stated, POLICY: It is the policy . […]

• Actual harm, isolatedF689Sep 14, 2022

  1. Based on observation, policy review, review of the Volaro Operator's Manual, record review, and staff interview, the facility failed to provide adequate assistance for 3 of 5 sampled residents (Resident #1, #4, and #6) observed during a sit-to-stand mechanical lift transfer. Failure to ensure proper use of the stand lift, and use the leg strap caused the residents unnecessary pain/discomfort and placed them at risk of possible injury. Findings include: Review of the facility policy titled POLICY AND PROCEDURE ON USING PAL [mechanical] LIFT occurred on 09/14/22. This policy, reviewed October 2021, stated, . POLICY . ensure that each resident is safely transferred using the pal lift. 1. All straps will be buckled unless resident specifically requests no straps. […]