Inspection Reports for
Four Seasons Nursing and Rehabilitation Center
1555 Rockaway Parkway, Brooklyn, NY, 11236
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Feb 15, 2024
Visit Reason
The inspection was conducted as part of the Recertification and Abbreviated Survey to evaluate compliance with regulations regarding timely reporting and investigation of alleged abuse incidents.
Findings
The facility failed to ensure that all alleged abuse violations were reported immediately, within 2 hours, to the administrator and State Survey Agency. Additionally, the facility failed to promptly investigate all allegations of abuse, including injuries of unknown origin.
Deficiencies (2)
F 0609: The facility failed to timely report suspected abuse allegations to the administrator and State Survey Agency within 2 hours as required. Four residents were involved in delayed reporting incidents.
F 0610: The facility failed to promptly investigate all allegations of abuse, including injuries of unknown origin, as evidenced by delayed investigations for two residents.
Report Facts
Residents sampled: 38
Residents sampled: 39
Residents involved: 4
Residents involved: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Named in relation to providing mouth care and reporting alleged abuse incident | |
| Registered Nurse #1 | Supervisor who documented and was informed about abuse incident | |
| Director of Nursing | Director of Nursing | Responsible for reporting allegations and supervising abuse investigations |
| Quality Assurance Director | Quality Assurance Director | Responsible for reporting allegations of abuse and other reportable incidents |
| Administrator | Administrator | Made aware of abuse allegations and initiated investigations |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Feb 15, 2024
Visit Reason
The inspection was conducted as a Recertification and Abbreviated Survey to assess compliance with regulatory standards and facility operations.
Findings
The facility was found deficient in timely reporting of abuse allegations, medication administration and notification practices, medication storage security, and food storage safety standards. Several residents were involved in abuse allegations that were not reported within required timeframes. Medications were not administered or held without physician notification. Medications were stored unsecured on the 3rd floor nurses' station. Expired and unlabeled food items were found in the kitchen walk-in refrigerator and the 7th floor pantry.
Deficiencies (4)
F 0609: The facility failed to report alleged abuse incidents within 2 hours to the administrator and State Survey Agency for 4 residents involved in altercations.
F 0658: Licensed Practical Nurses did not notify the physician when Resident #402 refused or had medications held without orders, violating professional standards.
F 0761: The facility failed to store all drugs and biologicals in locked compartments; discontinued medications and stock meds were unsecured on the 3rd floor nurses' station.
F 0812: Food was not stored according to professional standards; expired food items were found in the kitchen walk-in refrigerator and unlabeled, undated food in the 7th floor pantry.
Report Facts
Residents sampled: 38
Residents affected by abuse reporting deficiency: 4
Residents affected by medication administration deficiency: 1
Units with medication storage deficiency: 1
Pantries with food storage deficiency: 1
Total units observed for medication storage: 7
Total pantries observed for food storage: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Reported Resident #57 bleeding and provided mouth care after alleged abuse |
| Registered Nurse #1 | Registered Nurse Supervisor | Supervised and documented incident involving Resident #57 |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Did not notify physician of Resident #402 medication refusal |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Held Resident #402 medications without physician order |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse reporting and medication administration policies |
| Quality Assurance Director | Quality Assurance Director | Responsible for reporting allegations of abuse to Department of Health |
| Dietary Supervisor | Dietary Supervisor | Interviewed about expired food items and food storage policies |
| Director of Food Service | Director of Food Service | Interviewed about food storage and housekeeping responsibilities |
| Director of Housekeeping | Director of Housekeeping | Interviewed about cleaning pantry refrigerators and discarding expired food |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Described medication storage practices on unit without medication room |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: Jan 25, 2022
Visit Reason
Inspection history and complaint-related citations summary for Four Seasons Nursing and Rehabilitation Center
Complaint Details
11 complaints received from November 1, 2021 to October 31, 2025 with 5 complaint-related inspections and 32 complaint-related citations across categories including dietary services, physical environment, quality of care, and resident rights.
Findings
Multiple deficiencies were cited across complaint-related inspections including quality of care, dietary services, physical environment, and resident rights. Standard health and life safety code citations were issued with no actual harm or immediate jeopardy noted. A stipulation and order was issued related to quality of care with a fine.
Deficiencies (9)
Accuracy of assessments — quality of care
Food procurement, store/prepare/serve-sanitary — quality of care
Infection prevention & control — quality of care
Label/store drugs and biologicals — quality of care
Maintains effective pest control program — quality of care
Safe/clean/comfortable/homelike environment — quality of care
Electrical systems - essential electric system — life safety code
Emergency lighting — life safety code
Sprinkler system - maintenance and testing — life safety code
Report Facts
Total inspections: 9
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jan 25, 2022
Visit Reason
The inspection was a Recertification survey conducted from 1/18/2022 to 1/25/2022 to assess compliance with state and federal regulations for nursing home licensure and certification.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, accurate resident assessments, proper medication labeling and storage, food safety and pest control, and infection prevention practices including hand hygiene and oxygen tubing management.
Deficiencies (6)
F 0584: The facility failed to maintain a safe environment with a broken wall, exposed call bell wire, and hanging call bell plate in residents' living areas on the 6th floor.
F 0641: The facility inaccurately documented a resident's assessment by recording insulin injections for a resident who did not have a diabetes diagnosis or insulin orders.
F 0761: Two multi-use insulin vials were not labeled with the open date as required by professional standards and facility policy.
F 0812: Emergency food storage area was contaminated with rodent droppings and a live mouse was observed, indicating inadequate food safety and pest control.
F 0880: The facility failed to ensure infection prevention by not providing hand hygiene to residents before meals and allowing oxygen tubing to touch the floor.
F 0925: The facility did not maintain an effective pest control program, evidenced by multiple rodent sightings and droppings in various areas including emergency food storage.
Report Facts
Residents reviewed for assessment: 35
Residents reviewed for Medication Storage: 6
Residents reviewed for Respiratory Care: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Resident Care Coordinator/Unit Manager | Interviewed regarding resident assessment and medication orders |
| RN #4 | Registered Nurse | Interviewed regarding medication labeling and oxygen tubing |
| CNA #4 | Certified Nursing Assistant | Observed and interviewed regarding hand hygiene practices |
| Director of Maintenance | Interviewed regarding maintenance of broken wall | |
| Director of Environment of Care | Interviewed regarding environmental maintenance and pest control | |
| Director of Nursing | DON | Interviewed regarding hand hygiene and oxygen tubing infection control |
| Food Service Supervisor | FSS | Interviewed regarding pest control and food storage |
| Dietary Aide | Interviewed regarding emergency food storeroom cleaning and pest sightings | |
| Infection Control Coordinator | ICC | Interviewed regarding oxygen tubing infection control education |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jun 3, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with nutritional care standards, specifically monitoring the adequacy of nutrition and hydration for residents receiving tube feeding.
Findings
The facility failed to ensure adequate monitoring and adjustment of tube feeding for a resident with a PEG tube, resulting in continued weight loss despite interventions. There was no timely re-evaluation of the tube feeding formula and rate by the medical, dietary, or nursing staff, contributing to the resident's weight loss.
Deficiencies (1)
F 0692: The facility did not ensure a resident maintained acceptable nutritional status after PEG tube feeding placement. The resident continued to lose weight due to lack of timely re-evaluation and adjustment of the tube feeding formula and rate.
Report Facts
Weight loss percentage: 20
Weight loss percentage: 16
Weight loss percentage: 4.76
BMI: 13.22
BMI: 12.98
Calories: 960
Calories: 1200
Resident weight: 80
Resident weight: 78.2
Resident weight: 77
Resident weight: 75.6
Resident weight: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian | Regional Manager | Interviewed regarding dietary monitoring and tube feeding recommendations |
| Licensed Practical Nurse | LPN | Interviewed regarding weight monitoring and communication with dietary staff |
| Certified Nursing Assistant | CNA | Interviewed regarding weight measurements and reporting |
| Medical Doctor | MD | Interviewed regarding PEG placement and feeding tube orders |
| Nursing Supervisor | Supervisor | Interviewed regarding coordination of feeding tube orders and dietary communication |
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