Four Seasons Nursing and Rehabilitation Center

Inspectors wroteBased on observation, record review, and staff interviews conducted during the abbreviated survey (812190), the facility failed to ensure the resident's right to be treated with respect and dignity which included the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. This was evident in 1 out of 4 residents (Resident #1) sampled for Restraint. Specifically, on 01/30/2024 at 3:18 PM Registered Nurse #1 observed Resident #1's right hand in a mitten and mitten strap tied to the bed frame. Resident #1 was assessed by Registered Nurse Supervisor #1 and Medical Doctor #1 with no redness, discoloration or visible injuries.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, review of the weekend staffing and the Payroll Based Journal Staffing Data Report revealed low weekend staffing. The facility Payroll Based Journal Staffing Data Report for the Quarter 4 2025 dated July 1 - September 30 documented that excessively low weekend staffing triggered on the report. The facility Payroll Based Journal Staffing Data Report for the Quarter 1 2026 dated October 1 - December 30 also documented that excessively low weekend staffing triggered on the report. [...]

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 2 Based on observation, interviews, and record review conducted during the Recertification survey conducted, the facility did not ensure residents unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. This was evident for two (2) of 5 (five) residents (Resident #86 and Resident #253) reviewed for Activities of Daily Living out of 38 total sampled residents. Specifically, Resident #86 and Resident #253 were unable to cut their own fingernails and did not receive staff assistance to do so.

Inspectors wroteBased on observation, record review, and staff interview conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled in accordance with currently accepted professional principles. This was evident for one (1) prescription eye drop bottle on Unit 6 and one (1) prescription eye drop bottle on Unit 3 observed during the Medication Storage task. Specifically, two (2) opened (Latanoprost) prescription eye drops currently being used were not dated when opened.

Inspectors wroteBased on observation, record review and interviews conducted during the Recertification survey, the facility did not ensure that infection control protocols were followed. This was evident for one (1) of one (1) resident (Resident #8) reviewed for Respiratory Care out of 38 sampled residents. Specifically, Resident #8 was being maintained on contact precautions and Certified Nursing Assistant #6 did not don appropriate Personal Protective Equipment (PPE), including gown and gloves, when entering their room and also failed to perform hand hygiene prior to exiting the room.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated Survey (NY00325860, NY00304996) from 02/08/2023 - 02/15/2023, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation of abuse was made, to the administrator of the facility and to the State Survey Agency. This was evident in 4 residents (#57, #133, #150 and #165) of 38 total sampled residents. Specifically, 1.) On 10/05/2023, Resident #57 alleged they were hit by another resident. The facility reported the allegation to the New York State Department of Health on 10/11/2023. Additionally, The Administrator was made aware of the allegation on 10/10/2023. 2.) On 11/04/2022 at 11:05 PM, Resident #165 alleged Resident #133 hit them on their left eye. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification survey from 2/8/2024 to 2/15/2024, the facility did not ensure food was stored in accordance with professional standards for food service safety. This was evident during kitchen observation and in 1 (7th floor) of 6 pantries. Specifically, 1) the kitchen walk-in refrigerator contained expired food items, and 2) the 7th floor pantry contained expired milk and undated, unlabeled food.

Inspectors wroteBased on record review and interviews conducted during the Recertification Survey, the facility failed to ensure that services provided met professional standards of quality. This was evident for 1 (Resident #402) of 38 total sampled residents. Specifically, Licensed Practical Nurse #4 did not notify the physician when Resident #402 refused to take Carvedilol 25 milligrams and Hydralazine 50 milligrams on multiple occasions. In addition, Licensed Practical Nurse #5 held Carvedilol 25 milligrams and Hydralazine 50mg without a physician's order.

Inspectors wroteBased on observation, interview, and record review conducted during the recertification survey, the facility failed to ensure that all drugs and biologicals were stored in locked compartments consistent with state or federal requirements and professional standards of practice. This was evident for 1 (3rd Floor) of 7 units. Specifically, a large bag containing discontinued medications was observed under a desk on 3rd floor nurses' station. Additionally, stock medications were stored on the 3rd floor nurses' station cabinet and were not locked.

Inspectors wroteBased on record review and interviews conducted during the Recertification and Abbreviated Survey (NY00325860) from 02/08/2024 - 02/15/2024, the facility failed to ensure that all allegations of abuse, including injuries of unknown origin, were promptly investigated. This was evident for 2 (Resident #57 and Resident #150) of 39 total sampled residents. Specifically, on 10/05/2023, Resident #57 alleged they were hit by another resident. The facility initiated the investigation on 10/07/2023.

Inspectors wroteBased on observations, record review, and staff interviews conducted during the Recertification survey (TQIS11), the facility did not ensure that food was stored in safe and sanitary manner to prevent food contamination. Specifically, the emergency food storage area was observed with rodent droppings on the elevated plastic stands, the food boxes, and on the plastic covering wrapped around the boxes. In addition, a mouse was observed coming out of an open cereal box. This was evident during the Kitchen Observation facility task.

Inspectors wroteBased on observation, record review and staff interview conducted during the recertification survey (TQIS11), the facility did not maintain an effective pest control program so that the facility is free of pests and rodents. Specifically, a mouse was observed in the emergency food storage area. In addition, mouse droppings were observed on food boxes and the plastic stands. This was evident for the Kitchen Observation facility task. The finding is: The facility policy titled Pest Control Program and Exterminating Policy and Procedure effective 9/1/2016 documented the facility will maintain a robust and comprehensive pest control and maintenance program to control pests, insects and rodents in the facility and its environments. Despite good housekeeping and constant vigilance, pest still may enter the facility. They may be carried in packages or in sacks of food; [...]

Inspectors wroteBased on observation, record review and interview conducted during the recertification survey, the facility did not ensure an infection prevention and control program designed to provide a safe, sanitary and comfortable environment was maintained. Specifically, (1) residents' hands were not cleaned before consuming meals, and (2) oxygen tubing was observed on the floor. This was evident for 1 of 6 units observed for Dining (Unit 2) and 2 of 4 residents reviewed for Respiratory Care (Resident #113 and Resident #174).

Inspectors wroteBased on observations, record reviews and interviews conducted during the Recertification survey conducted 1/18/2022 to 1/25/20221, the facility did not ensure that necessary environmental maintenance services were provided to maintain a safe, clean, comfortable, and homelike environment. Specifically, a broken wall, an exposed inner wire of the call bell, and a hanging call bell wall plate were observed in residents' living areas. This was evident for 1 of how many resident floors (6th floor).

Inspectors wroteBased on record review and interviews conducted during the Recertification survey from 1/18/2022 to 1/25/2022, the facility did not ensure that a resident's assessment was accurate. Specifically, the Minimum Data Set (MDS) 3.0 assessment inaccurately documented that a resident received insulin injections. This was evident for 1 out of 2 residents reviewed for Resident Assessment out of an investigative sample of 35 residents (Resident #115).

Inspectors wroteBased on observation, record review, and staff interview conducted during the Recertification survey (TQIS11), the facility did not ensure that medication and biologicals were labeled properly with the open date based on professional standards of practice. Specifically, two multi-use insulin vials were not labeled with the open date. This was evident for 1 on 6 units reviewed for Medication Storage (Unit 2).