Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Four Seasons Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A ventilator‑dependent resident with chronic respiratory failure and moderately impaired cognition, known for frequently disconnecting from the respiratory circuit, was found with a hand mitten on the right hand tied to the bed frame. The facility’s policy promotes a restraint‑free environment, and a prior order for mittens had been discontinued after the IDT chose non‑restraint interventions such as closer room placement, frequent monitoring, and redirection. Despite this, a respiratory therapist, without a current MD order or adherence to the facility’s restraint protocol, applied the mitten and secured it to the bed frame after repeated self‑disconnections from the vent. Nursing and the MD later assessed the resident and found no visible injury or reported pain, but the use of the mitten in this manner constituted an unauthorized physical restraint imposed for staff convenience or perceived safety rather than under an approved restraint plan.
The facility failed to provide enough nursing staff and a licensed nurse in charge on each shift. PBJ reports and the actual weekend schedule showed repeated shortages of LPNs/LVNs and CNAs across multiple units, especially on weekends, with some shifts missing several staff members at once. Staff interviews confirmed chronic call-outs, frequent short staffing on the 2nd, 3rd, 4th, 5th, 6th, and 7th floors, and that residents sometimes remained in bed or care tasks were delayed when units were short.
Failure to provide fingernail care for two residents who needed ADL assistance. One resident with stroke-related weakness and severely impaired cognition, and another resident with Alzheimer’s disease and moderately impaired cognition, were repeatedly observed with fingernails about a half inch beyond their fingertips. Both stated staff had not cut their nails for weeks, while staff interviews showed CNAs were responsible for checking and cutting long nails but did not consistently do so.
Opened latanoprost eye drops for two residents were found in medication storage without open dates. An LPN stated eye drops were not labeled when opened and staff used the printed bottle expiration date, while another LPN did not know when the drops had been opened. In contrast, an RN, the Director of Pharmacy, and the DON stated the nurse opening the drops is responsible for labeling them with the open date because the medication must be discarded after 6 weeks.
Failure to Follow Contact Precautions: A resident on contact isolation for Candida Auris was observed when a CNA entered the room without first donning required PPE, handed the resident a wipe, and exited without hand hygiene. The CNA then entered another resident’s room after donning a gown but still without hand hygiene. The unit RN and ICP confirmed the expected process was to wear gown, gloves, and mask before entry and perform hand hygiene after removing PPE.
Unauthorized Use of Hand Mitten as Physical Restraint on Ventilator-Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from physical restraints imposed for discipline or staff convenience and not required to treat a medical symptom. During an abbreviated survey, a RN observed a resident’s right hand in a mitten with the mitten strap tied to the bed frame. The resident told the RN that someone had tied them. The facility’s restraint policy states that the facility promotes and encourages a restraint‑free environment and that residents have the right to be free from physical restraints used for discipline or convenience. The resident involved had chronic respiratory failure, was ventilator‑dependent, and had moderately impaired cognition per the MDS. The record showed a history of the resident frequently disconnecting the respiratory circuit, with a behavior care plan directing staff to educate the resident on the risks of disconnecting the respiratory circuit and to redirect the resident with television or music. A prior physician order had authorized hand mittens to prevent accidental decannulation with scheduled releases, but that order was discontinued the next day, and there was no active order for mittens at the time of the incident. According to the facility’s investigation and staff interviews, a respiratory therapist placed a mitten on the resident’s right hand and looped the mitten string around the metal bed frame after the resident repeatedly disconnected from the ventilator during the shift. The respiratory therapist stated they did this after finishing rounds and asked another respiratory therapist to keep an eye on the resident while they were gone, stating they did not want the resident to hurt themself. The respiratory therapy director confirmed there was no current order for a hand mitten and that the resident’s behavior of trying to disconnect from the ventilator had been reported on many occasions. The administrator and medical doctor acknowledged that the facility is restraint‑free and that the interdisciplinary team had previously decided against using mittens, opting instead for closer room placement, frequent monitoring, redirection, and psychosocial interventions, yet the mitten was still applied and tied to the bed frame without an active order or adherence to the facility’s restraint protocol. The resident was assessed by nursing and the physician after the mitten was discovered, with no redness, discoloration, trauma, or other visible injury noted, and the resident denied pain or discomfort. Nonetheless, the act of placing the mitten and tying it to the bed frame constituted the use of a physical restraint without following required procedures, including having a current physician order, documented assessment, consent, and defined parameters for use and release. This sequence of events led to the cited deficiency for failure to protect the resident’s right to be free from physical restraints not required to treat a medical symptom.
Repeated Weekend Nursing Staffing Shortages
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and to maintain a licensed nurse in charge on each shift. Review of the facility’s Payroll Based Journal Staffing Data Reports for Quarter 4 2025 and Quarter 1 2026 showed excessively low weekend staffing. The facility policy stated staffing levels are to be based on resident assessments, care plans, facility assessment, and resident acuity, and the facility assessment identified unit-specific par levels for LPNs/LVNs and CNAs across the 2nd through 7th floors. Review of the actual weekend staffing schedule from July through September 2025 showed repeated shortages across multiple units and shifts. On numerous Saturdays and Sundays, the 2nd, 4th, and 5th floors were short of licensed nurses, and the 3rd, 5th, 6th, and 7th floors were frequently short of CNAs. Some shifts had multiple shortages on the same unit, including instances where the 4th floor was short two licensed nurses, the 5th floor was short two licensed nurses, and the 7th floor was short two CNAs. The staffing deficits occurred on day, evening, and night shifts and were documented repeatedly over many weekends. Interviews confirmed that weekend staffing shortages were ongoing and affected resident care. An RN supervisor stated the 2nd, 3rd, and 5th floors were priority units and needed five CNAs on day shift, but staff reported working with fewer staff on weekends because of chronic call-outs and late call-outs. CNAs and LPNs stated staffing was especially poor on weekends, that missing even one CNA on the trach/vent unit made a difference, and that when the unit was short, staff had to work together to complete care, with some residents left in bed or showers postponed. The Administrator, DON, and Staffing Coordinator acknowledged the facility had a history of low weekend staffing, frequent call-outs, and reliance on overtime and agencies, and that staffing during the July through September period was less than optimal.
Failure to Provide Fingernail Care for Residents Needing ADL Assistance
Penalty
Summary
The facility did not ensure that residents unable to perform activities of daily living received the necessary assistance to maintain grooming and personal hygiene, specifically fingernail care, for two residents reviewed. The deficiency was identified during a recertification survey based on observations, interviews, and record review for Resident #86 and Resident #253, both of whom required staff assistance with personal hygiene and were observed with fingernails approximately a half inch beyond their fingertips. Resident #86 had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side and muscle weakness. The admission MDS documented severely impaired cognition, no rejection of care, and partial/moderate assistance needed for personal hygiene, while the care plan documented total assistance for all ADL tasks related to weakness and debility. During multiple observations over several days, Resident #86’s fingernails remained uncut. The resident stated they could not cut their own fingernails, needed assistance, and had not received nail care since admission. A CNA stated they had asked once about three weeks earlier and the resident refused, but had not asked again, while an LPN stated CNAs were responsible for cutting residents’ fingernails and observed the long nails with the surveyor. Resident #253 had a diagnosis of Alzheimer’s disease, and the admission MDS documented moderately impaired cognition, no rejection of care, and partial/moderate assistance for personal hygiene. The resident was observed multiple times with fingernails approximately a half inch beyond the fingertips and stated staff had not cut them for a few weeks, though the resident wanted them cut. The care plan identified self-care limitations related to metabolic encephalopathy and Alzheimer’s disease and the need for partial/moderate assistance with personal hygiene. A CNA stated they checked fingernails during care and could cut them, but did not ask or offer nail care because they were busy. Other staff, including an LPN, RN, and the DON, stated CNAs were responsible for checking and cutting long fingernails, and that nails were considered long when they extended beyond the fingertips.
Unlabeled Opened Prescription Eye Drops
Penalty
Summary
Drugs and biologicals were not labeled in accordance with currently accepted professional principles because two opened prescription latanoprost eye drop bottles were found without open dates. During the medication storage observation, one opened bottle on Unit 6 for Resident #220 and one opened bottle on Unit 3 for Resident #102 were both in use but not dated when opened. The package insert for Xalatan latanoprost ophthalmic solution stated that once opened, the bottle may be stored at room temperature for 6 weeks, and the Director of Pharmacy stated these eye drops require an open date so they can be discarded after six weeks of opening. Staff interviews showed inconsistent understanding of the labeling requirement. An LPN on Unit 6 stated eye drops are not labeled when opened and that staff use the printed expiration date on the bottle to determine disposal. An LPN on Unit 3 stated the facility does not label eye drops with open dates and did not know when the latanoprost had been opened. In contrast, an RN stated the nurse who opens the eye drops is responsible for labeling them with the open date, and the DON stated the eye drops should be labeled so staff know when to dispose of them. The facility policy reviewed addressed medication storage generally but did not include policies related to prescription eye drops.
Failure to Follow Contact Precautions
Penalty
Summary
The facility did not ensure that infection control protocols were followed for a resident on contact precautions. Resident #8 was admitted with diagnoses including Candida Auris and Multidrug-Resistant Organism, and a physician’s order dated 01/05/2026 documented contact isolation precautions for Candida Auris. On 02/26/2026 at 09:00 AM, a contact isolation sign was observed on the resident’s room door indicating that gloves and gowns were required before entry, and a holder on the door contained blue gowns, gloves, and masks. At the same time, CNA #6 was observed entering the resident’s room while holding wipes without first donning PPE, then handing the resident a wipe and exiting the room without performing hand hygiene. CNA #6 was then observed donning a blue gown and entering another resident’s room without performing hand hygiene. During interview, CNA #6 stated they saw the contact isolation sign and knew they should have put on PPE before entering the room. RN #1 stated staff are to knock, don PPE including gown, gloves, and mask before entering a contact precaution room, and remove PPE and wash hands before leaving. The Infection Control Preventionist stated staff are supposed to wear a gown when entering residents’ rooms on contact precautions to prevent spreading infection from one resident to another resident.
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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 Brooklyn
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atrium Center For Rehabilitation And Nursing | 0.5 mi | ★★★★★ | 0 | 0 |
| Spring Creek Rehabilitation & Nursing Care Center | 0.8 mi | ★★★★★ | 1 | 0 |
| Schulman And Schachne Inst For Nursing & Rehab | 1.1 mi | ★★★★★ | 0 | 0 |
| Linden Center For Nursing And Rehabilitation | 1.7 mi | ★★★★★ | 0 | 0 |
| Rutland Nursing Home, Inc | 2.1 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.