Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Caton Park Rehabilitation And Nursing Center, Llc during CMS and state inspections, most recent first.
A resident with a history of osteoarthritis and prior fractures fell from bed during care, sustaining a head laceration and fractures to the hand and finger. The incident, which resulted in serious bodily injury, was not reported to the State Survey Agency within the required two-hour timeframe, as facility staff delayed reporting while gathering additional details.
A resident with a history of falls and diagnoses of Depression, Parkinson's Disease, and Dementia experienced multiple falls without updates to their fall prevention care plan. Despite a recent Minimum Data Set assessment, the care plan was not revised since March, leading to a deficiency finding. Staff interviews revealed that the Unit Manager missed the update, and the DON confirmed the responsibility for care plan updates.
A resident with a history of stroke and falls did not have floor mats placed as ordered, despite being at high risk for falls. Observations confirmed the absence of mats, and staff interviews revealed a lack of awareness and oversight regarding the order. The resident's care plan specified the need for floor mats to prevent falls, but this was not consistently implemented.
A facility failed to maintain infection control practices during medication administration for a resident with a gastrostomy tube. An LPN did not wear a gown as required by Enhanced Barrier Precautions, despite signage indicating the need. Staff interviews revealed inconsistencies in understanding the policy, with the Infection Control Preventionist confirming in-service training, but the new DON was unaware of the policy.
The facility failed to submit completed resident assessments to CMS within the required timeframe, affecting four residents. The Director of MDS and the Controller acknowledged the oversight, citing a lapse in their submission process.
A resident with a history of cerebrovascular accident and diabetes was observed with facial grimacing and a swollen right leg. Despite multiple observations by staff, there was no timely assessment or notification to the medical doctor. The resident continued to show signs of pain and swelling over several days, leading to a delayed diagnosis of an acute hip fracture. Interviews revealed a lack of thorough physical assessments and timely documentation by the nursing staff.
A facility failed to provide appropriate pain management for a resident with severely impaired cognition and joint pain. Initial pain assessments were not conducted, and there was no documentation of pain levels before and after administering medication. Despite the resident's continued complaints of pain, no changes were made to the pain management plan.
Failure to Timely Report Serious Injury Incident to State Agency
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours, to the State Survey Agency after the allegation was made, as required by facility policy and state regulations. On 07/28/2025, a resident with a history of osteoarthritis of the hip and previous fractures fell from the bed to the floor during care provided by a Certified Nursing Assistant. The resident sustained a laceration to the head and fractures to the right hand and left middle finger, and was subsequently transferred to the hospital for evaluation and treatment. Despite the incident resulting in serious bodily injury, the facility did not report the event to the New York State Department of Health until 07/31/2025, approximately three days after the incident occurred and the Administrator was made aware. The Director of Nursing, who was responsible for reporting such incidents, stated that they delayed reporting in order to gather more details, inadvertently missing the required two-hour reporting window. Facility policy clearly required immediate reporting of such incidents, but this protocol was not followed in this case.
Failure to Update Fall Prevention Care Plan
Penalty
Summary
The facility failed to ensure that a resident's Comprehensive Care Plan was reviewed and revised in a timely manner, specifically for fall prevention. Resident #15, who has a history of falls and was diagnosed with Depression, Parkinson's Disease, and Non-Alzheimer's Dementia, experienced multiple falls without subsequent updates to their care plan. The resident's care plan, created in December 2023, included interventions such as ensuring the call bell and assistive devices were within reach, a rehab referral, and proper footwear. However, there was no documented evidence that the care plan was reviewed or revised after March 2024, despite the resident's continued falls and a recent Minimum Data Set assessment. Interviews with facility staff revealed that the Unit Manager, Registered Nurse #1, acknowledged the oversight in updating the care plan, despite the resident's improvement in ambulation. The Director of Nursing confirmed that Unit Nurse Managers are responsible for updating care plans and that the Minimum Data Set staff handle admission and readmission care plans. The failure to update the care plan after the resident's falls and the recent assessment was identified as a deficiency during the recertification survey.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident received assistance devices as per their care plan to prevent accidents. Specifically, floor mats were not placed on either side of the bed for Resident #75, despite a physician's order and care plan indicating their necessity due to the resident's high fall risk. Observations on multiple occasions confirmed the absence of floor mats, and staff interviews revealed a lack of awareness and oversight regarding the order for floor mats. Certified Nursing Assistant #2 admitted to overlooking the order, while Licensed Practical Nurse #4 acknowledged the resident's fall risk and the need for floor mats, noting that the resident's roommate sometimes moved the mats. Resident #75, who has a history of stroke, falls, and acute left hemiplegia, was identified as having severely impaired cognition and was dependent on staff for all activities of daily living. The resident's care plan highlighted the risk of falls and specified interventions, including the use of floor mats, to mitigate this risk. Despite these documented needs, the facility's staff failed to consistently implement the necessary safety measures, as confirmed by the Director of Nursing Services, who expressed uncertainty about how the oversight occurred.
Infection Control Deficiency in Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control prevention practices during a medication administration task for a resident with a gastrostomy tube. The facility's policy on Enhanced Barrier Precautions requires the use of gowns and gloves during high-contact resident care activities, especially for residents with indwelling medical devices like feeding tubes. However, during an observation, a Licensed Practical Nurse (LPN) administered medication to a resident via a gastrostomy tube without donning a gown, despite signage indicating the need for Enhanced Barrier Precautions. Interviews with staff revealed inconsistencies in understanding and implementing the Enhanced Barrier Precautions policy. The LPN admitted to forgetting to wear the required personal protective equipment (PPE). A Registered Nurse (RN) indicated that staff were instructed to wear gloves but not specifically gowns during medication administration via gastrostomy tubes. The Infection Control Preventionist confirmed that staff were in-serviced on the precautions, but the Director of Nursing, who was new to the facility, was not knowledgeable about the policy. This lack of adherence to infection control protocols was identified as a deficiency during the recertification survey.
Late Submission of Resident Assessments
Penalty
Summary
The facility failed to ensure timely submission of completed resident assessments to the Quality Improvement Evaluation Assessment Submission and Processing system. During the recertification survey conducted from August 12 to August 16, 2024, it was found that four out of six Minimum Data Set (MDS) submissions reviewed were not submitted to the Centers for Medicare and Medicaid Services (CMS) system within the required 14 days of completion. The specific residents affected were Resident #66, Resident #6, Resident #95, and Resident #9, whose assessments were completed between June 1 and June 4, 2024, but were only submitted on August 14, 2024. Interviews with facility staff revealed that the Director of Minimum Data Set and the Controller were responsible for the oversight. The Director stated that they follow the Resident Assessment Instrument manual for assessment completion and submission, and the Controller receives daily reports from Sigma Care listing MDS assessments needing submission. Both acknowledged the late submissions as an oversight, with the Controller unaware of the delay until the survey. This deficiency was documented under 10 NYCRR 415.11.
Failure to Provide Timely and Appropriate Medical Assessment
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Resident #1, who had a history of cerebrovascular accident with right hemiparesis and type 2 diabetes mellitus, was observed with facial grimacing and pointing to their right leg. Despite multiple observations by staff, including a CNA, LPN, and Nurse Supervisor, there was no documented evidence that Resident #1 was assessed and that the medical doctor was notified on the initial day of the complaint. The resident continued to show signs of pain and swelling in the right leg over several days without appropriate and timely medical intervention. On 08/27/23, Resident #1 was first observed with facial grimacing and a swollen right leg. The LPN and Nurse Supervisor noted these symptoms but only administered Tylenol for pain relief without further assessment or documentation. The following days saw continued documentation of pain and swelling by various nursing staff, but it wasn't until 08/30/23 that a significant assessment was made, revealing external rotation and shortening of the right leg. This led to the resident being transferred to the hospital, where an acute comminuted and distracted intertrochanteric fracture of the right hip was diagnosed. Interviews with the staff revealed a lack of thorough physical assessments and timely documentation. The Director of Nursing confirmed that the Registered Nurse Supervisors should have conducted a thorough physical assessment to rule out a fracture and reported their findings to the doctor. The failure to perform these assessments and document the findings led to a delay in appropriate medical intervention for Resident #1, resulting in prolonged pain and suffering for the resident.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident with severely impaired cognition and a diagnosis of joint pain. An initial pain assessment was not conducted on the resident's admission date, and despite the resident's continued complaints of pain over several days, there were no changes made to the pain management plan. Additionally, there was no documented evidence that the resident's pain levels were monitored before and after administering pain medication to determine its effectiveness. The resident was admitted with diagnoses including cerebrovascular accident with right hemiparesis and type 2 diabetes mellitus. The comprehensive care plan for pain management included ongoing assessment of pain, but this was not followed. The resident was given Tylenol as needed, but the administration times were not consistently documented, and there was no evidence of pain assessments using a pain scale before and after medication administration. Multiple staff members, including LPNs and RNs, were involved but failed to document pain assessments and the effectiveness of the pain medication. Interviews with the nursing staff and the nurse practitioner revealed inconsistencies in the documentation and communication regarding the resident's pain management. The Director of Nursing confirmed that pain medication administration should include pre and post pain scale assessments, which were not documented in this case. The lack of proper pain assessment and documentation led to inadequate pain management for the 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) |
|---|---|---|---|---|
| Palm Gardens Center For Nursing And Rehabilitation | 0.6 mi | ★★★★★ | 12 | 0 |
| The Monarch At Brooklyn Rehab And Nursing Center | 0.8 mi | ★★★★★ | 8 | 0 |
| Ditmas Park Care Center | 0.9 mi | ★★★★★ | 0 | 0 |
| Dr Susan Smith Mckinney Nursing And Rehabilitation | 1.6 mi | ★★★★★ | 0 | 0 |
| Boro Park Center For Rehabilitation And Healthcare | 1.8 mi | ★★★★★ | 0 | 0 |
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