Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 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.
Missing Comprehensive Care Plans for Multiple Residents: The facility failed to develop and implement comprehensive, person-centered care plans for several residents with identified needs. A resident with dementia and elopement risk had a wander guard in use but no care plan for wandering or the alarm; another resident receiving oxygen had no oxygen care plan; a resident with depression had no care plan tied to antidepressant use; and an edentulous resident had no dental care plan. Staff confirmed the plans were absent in the record.
The facility failed to provide enough nursing staff to meet resident needs, with staffing schedules showing repeated CNA and LPN shortages compared with the Facility Assessment’s required staffing levels. PBJ data also triggered for excessively low weekend staffing. Interviews with residents and staff described delayed call bell response, units sometimes operating with only 1 to 2 CNAs, and staff having to stop other work to help cover care needs.
Expired Foley insertion trays were found in medication rooms on two units and in Central Supply. Staff gave conflicting accounts about who checked supply expiration dates, and several staff members stated they did not routinely verify whether medical supplies were expired before use or delivery. An RN reported that residents with recent Foley catheter insertions had not yet had catheter changes at the facility, and the DON and Infection Preventionist both identified expired supplies as a concern.
A resident with dementia, TBI, anxiety, and schizophrenia remained on Aripiprazole and Clonazepam without adequate documented clinical indication for the ongoing antipsychotic use or evidence of behavioral monitoring. Staff described the resident as confused, mostly nonverbal, dependent for care, and only occasionally screaming, while the chart lacked behavioral documentation and showed no documented GDR attempt despite psychiatry notes continuing the medication and stating GDR was not recommended.
A resident with dementia and other diagnoses had an MDS that documented moderate cognitive impairment but failed to code the use of a wander/elopement alarm. Records and staff interviews showed the resident was at risk for elopement, had physician orders for a wander guard on the right wrist, and the device was observed in use, yet it was omitted from the assessment as an oversight.
A resident admitted with wound infection, PVD, and arthritis did not have a complete baseline care plan within the required 48 hours. The BCP had one section for Dietary, Therapy, and Social Services that was completed but not signed off, and the MDS Coordinator stated they had been told there were 72 hours to finish the BCP and could not explain why the incomplete section was not identified during daily review. The DON stated they did not recall the required timeframe and confirmed the BCP was not complete until all sections were signed off.
A resident with Alzheimer’s dementia, heart disease, and PVD had quarterly MDS assessments showing intact cognition and a need for supervision with all ADLs, but the ADL care plan was not reviewed or revised after those assessments. The care plan for bathing/showering lacked specific details about the assistance needed or the number of staff required, and staff reported issues related to an EMR transition and learning how to update care plans.
A resident with stroke, seizure, and depression, whose MDS listed Cantonese as the preferred language and noted a need for an interpreter, was not provided activities in a language they understood. The resident and representative stated staff did not ask about activity preferences, the resident did not understand English, and the facility had no activities in the resident’s preferred language. Observations and staff interviews showed the resident spent time in the room and dining area without meaningful recreational activities, while the facility’s TV channels were only in English and Spanish.
A resident with dementia, CHF, and SOB had an order for continuous O2 at 2 L/min via NC, but the concentrator was observed delivering 4 L/min over several days. Staff interviews showed the CNA did not check the flow rate, the LPN had no explanation for the incorrect setting, and the RN and DON stated the ordered oxygen rate should be verified at least once per shift.
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.
Missing Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to ensure that comprehensive person-centered care plans were developed and implemented with measurable objectives and timeframes for multiple residents with identified needs. The deficiency involved Resident #22, who had diagnoses including non-Alzheimer's dementia, coronary artery disease, and cerebrovascular accident, and was assessed as having moderate cognitive impairment and being at risk for elopement. Although the resident was observed with a wander guard on the right wrist and had physician orders for wander guard placement and functioning checks, there was no documented comprehensive care plan addressing wandering or the use of the wander/elopement alarm. The facility also did not develop comprehensive care plans for Resident #9, Resident #101, or Resident #6. Resident #9 had unspecified dementia, chronic systolic heart failure, and shortness of breath, was assessed as severely cognitively impaired, and had a physician order for oxygen at 2 liters per minute via nasal cannula; however, no care plan related to oxygen therapy was documented, and the concentrator was observed delivering oxygen at 4 liters per minute. Resident #101 had major depressive disorder, dementia, and generalized anxiety disorder, was assessed as severely cognitively impaired, and had an order for Mirtazapine for depression, but no care plan related to depression was found. Resident #6 had peripheral vascular disease, diabetes mellitus, malnutrition, and anxiety, was assessed as having intact cognition, required substantial to maximal assistance with oral care, and was edentulous, yet no comprehensive dental care plan was documented. Interviews with nursing staff and the DON confirmed that care plans were expected to be created for these conditions and that the records reviewed did not contain the needed plans. Staff also stated the facility had recently changed electronic medical records and that some care plans did not migrate over.
Insufficient Nursing Staffing and Low Weekend Coverage
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs as identified in its Facility Assessment and staffing schedules. The Facility Assessment dated 02/20/2026 documented a bed capacity of 119 residents, an average daily census of 116, and a daily staffing need of 8 RNs/LPNs and 27 CNAs. Review of actual staffing schedules from 10/01/2025 through 12/31/2025 showed staffing assignments were consistently below the projected staffing needs for CNAs and licensed nursing staff, with low CNA staffing noted especially on weekends. Specific examples included multiple shifts where fewer CNAs worked than scheduled, such as 3 CNAs instead of 4 on the 7:00 AM to 3:00 PM shift on Unit 3, 1 CNA instead of 2 on overnight shifts, and 2 CNAs instead of 3 on evening shifts. On some shifts, licensed staff were scheduled but did not work on the unit, including an LPN scheduled on Unit 3 and Unit 1 who did not work those shifts. The Payroll Based Journal Staffing Data Report for Quarter 1 2026 also triggered for excessively low weekend staffing. Resident and staff interviews described delays and short staffing on the units. One resident reported call bells sometimes took 15 to 30 minutes to be answered, and another resident stated there were times when only 1 to 2 CNAs were working on the unit in the evenings. CNAs and an LPN stated that when staffing was short, they had to manage with fewer staff and sometimes stop their own work to help with resident care. The Staff Coordinator, DON, and Administrator acknowledged that staff call outs occurred and that replacements were not always available, while the Regional Staff Coordinator stated the PBJ submission process would not identify low staffing.
Expired Foley insertion trays found in medication rooms and Central Supply
Penalty
Summary
The facility failed to maintain infection control practices and procedures in the medication rooms on Unit 2 and Unit 3 and in the Central Supply room. During observation, expired Foley insertion trays were found stored in the Unit 2 medication room, the Unit 3 medication room, and the Central Supply room in the basement. The facility’s Infection Control Program policy stated the program was designed to prevent, identify, report, investigate, and control the spread of infections and communicable disease and to provide a safe, sanitary, and comfortable environment. The Maintain Central Supply policy stated that expiration dates were to be checked and expired medical stock, equipment, or supplies were to be discarded. In the Unit 2 medication room, two of seven Foley insertion trays were observed with an expired date. An LPN stated they did not check medical supplies in the medication room and suggested the expired supplies might have been delivered that morning, but a Medical Record staff member stated no supplies had yet been delivered to the units that morning. An RN stated they did not check expiration dates before using medical supplies and reported that three residents had Foley catheters inserted at the hospital in the prior month and had not yet had catheter changes at the facility. In the Unit 3 medication room, nine Foley insertion trays were observed, including two with one expired date and one with another expired date. An RN stated nurses should check medical supplies at least once every shift but could not explain why the expired trays remained in the room. The DON stated they checked medication rooms during rounds and that the medication nurse on every shift was responsible for checking supplies for expiration, while the Assistant DON, who served as the Infection Preventionist, stated unit supervisors were responsible for checking supplies once every shift and discarding expired items. In the Central Supply room, two cases containing 20 Foley insertion trays were observed, and one case contained trays all with an expired date. Medical Record staff stated they delivered supplies to the units every Monday and Friday and as needed, but also stated it was hard to maintain and check whether supplies were expired and that expired supplies should not be delivered to the units.
Unnecessary Psychotropic Medication Use Without Adequate Documentation
Penalty
Summary
The facility failed to ensure that one resident was free from chemical restraints imposed for discipline or convenience and failed to document adequate clinical indication for the ongoing use of Aripiprazole 15 mg daily. The resident had diagnoses including dementia, traumatic brain injury, anxiety disorder, and schizophrenia, and the annual MDS documented severely impaired cognition and dependence on staff for ADLs. The resident was observed in bed on two occasions, alert but confused, unable to make appropriate conversation, with no eye contact and no meaningful communication. Review of the medical record showed Aripiprazole 15 mg daily for schizophrenia, started on 09/20/2024 and renewed on 05/01/2026, and Clonazepam 1 mg daily for anxiety, started on 12/30/2024 and renewed on 05/01/2026. Psychiatry notes stated the resident was alert in bed, anxious, screamed and yelled on and off, and was paranoid, delusional, responded to hallucinations, and was disoriented with poor judgment; the notes directed continuation of Aripiprazole and stated gradual dose reduction was not recommended. However, no additional psychiatric notes for 2024 or 2025 were provided, and there was no documented evidence in the resident’s record of behavioral symptoms supporting the ongoing antipsychotic dose. Interviews with staff indicated the resident was confused, rarely talked, screamed at times, and was totally dependent for care, transferred with a Hoyer lift, and used a Geri chair. The CNA stated the resident did not have behavioral problems other than occasional screaming. The RN stated behavioral notes were not documented unless a behavior was reported or witnessed, and could not find behavioral concerns documented anywhere. The ADON stated residents on psychotropics received gradual dose reduction based on psychiatrist recommendation, while the psychiatrist stated they did not do gradual dose reductions with residents who have a psychiatry history. The Medical Director stated the psychiatrist’s recommendations were followed and that, because the resident was stable and had no side effects, there was no need for gradual dose reduction.
MDS Did Not Accurately Reflect Wander Guard Use
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident’s status when the Quarterly MDS for Resident #22 did not document the use of a wander/elopement alarm. Resident #22 had diagnoses including Non-Alzheimer's Dementia, coronary artery disease, and cerebrovascular accident, and the assessment documented moderate cognitive impairment but omitted the wander guard device that was in use. Record review showed that Resident #22 had Elopement Risk Assessments dated 02/10/2026 and 04/30/2026 indicating a score of 3 and that the resident was at risk for elopement. Physician orders dated 06/14/2024, last revised on 04/16/2026, directed that the wander guard be checked for placement every shift on the right wrist and checked for functioning daily during the night shift. The MARs from 04/01/2026 to 05/06/2026 documented observation of the wander guard device every night shift. During an observation on 05/03/2026, Resident #22 was seen in bed, alert and awake, appearing confused, and wearing a wander guard on the right wrist. The MDS Coordinator stated the wander guard was not coded on the assessment and identified it as an oversight.
Baseline Care Plan Not Completed Within Required Timeframe
Penalty
Summary
The facility failed to ensure that the baseline care plan was completed within 48 hours of admission for one resident. Resident #119 was admitted with diagnoses including wound infection, peripheral vascular disease, and arthritis. The admission MDS documented that the resident was cognitively intact and that both the resident and the representative participated in the assessment. The facility policy stated that a baseline care plan is to be developed and implemented within 48 hours of admission. The Baseline Care Plan -V2 for Resident #119 was created on 02/10/2026, and Sections 1, 2, 3, and 5 were signed on that date, but Section 4, which included Dietary, Therapy, and Social Services, was not signed off. There was no lock date for the baseline care plan. The MDS Coordinator stated they were responsible for overseeing completion of baseline care plans, checked the EMR daily, and notified department heads if sections were incomplete, but also stated they had been told by the corporation that there were 72 hours to complete the baseline care plan. The MDS Coordinator reviewed the incomplete section and stated it was completed but not signed off, could not identify which discipline completed it late, and had no explanation for why it was late or why it was not identified during daily monitoring. The DON stated they did not recall the timeframe for completion and stated the baseline care plan was not considered complete until all sections were signed off.
Failure to Review and Revise ADL Care Plan After Assessments
Penalty
Summary
The facility failed to ensure that Resident #70’s comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including the comprehensive and quarterly review assessments. Resident #70 had diagnoses including Alzheimer’s Dementia, Heart Disease, and Peripheral Vascular Disease. Quarterly MDS assessments dated 12/02/2025 and 2/26/2026 documented intact cognition and a need for supervision with all activities of daily living. The CNA Task List Report dated 05/01/2026 documented that the resident received showers twice a week as scheduled and at times four times weekly. The Activities of Daily Living care plan, created 05/18/2025 and last reviewed 10/07/2025, included bathing/showering interventions but did not specify the days of showers, the exact assistance needed, or the number of staff required to assist with showers. There was no documented evidence that the ADL care plan had been reviewed or revised after the 12/02/2025 and 02/26/2026 MDS assessments. During interview, an RN stated all nurses are responsible for initiating and updating care plans, and the DON stated staff were still learning the new electronic medical record system and how to update care plans.
Activities Not Provided in Resident’s Preferred Language
Penalty
Summary
The facility failed to ensure an ongoing program of activities that supported a resident’s choice of meaningful activities and met the resident’s interests and psychosocial needs. The deficiency involved Resident #63, who had diagnoses including stroke, seizure, and depression. The resident’s annual MDS documented a preferred language of Cantonese, a need for an interpreter to communicate with health care staff, moderately impaired cognition, and that books/newspapers/magazines, music, and favorite activities were very important to the resident. Resident #63 stated they spoke Fuzhounese and Mandarin and liked activities offered in those languages. The resident also stated staff had not asked about activity preferences, that the facility did not have activities in their preferred language, and that they could only use their smartphone to pass idle time. The resident representative stated the resident had lived at the facility for five years, no staff had asked about activity preferences, the resident did not understand English, and at home liked watching television, listening to music, and keeping up with news in their preferred language. Observations from 05/03/2026 through 05/08/2026 showed Resident #63 sitting in a wheelchair in their room and main dining room without recreational activities provided in their preferred language. The care plan included assisting with independent leisure activities, providing leisure/community resources, and using a Mandarin translator, and the quarterly activity assessment listed Mandarin as the spoken language and television and movies as favorite activities. Staff interviews indicated the activity assessment was completed by calling the representative, that the resident was not actually asked about preferred activities, and that the facility’s television channels were in English and Spanish only. The Director of Therapeutic Recreation stated the resident did not receive a smart television and did not explain how the facility was providing activities in the resident’s preferred language.
Incorrect Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that a resident who required respiratory care received oxygen at the ordered rate. Resident #9, who had diagnoses including unspecified dementia, chronic systolic heart failure, and shortness of breath, had an order for continuous oxygen via nasal cannula at 2 liters per minute. The resident’s annual MDS documented severely impaired cognition and that oxygen therapy was being received while residing in the facility. From 05/03/2026 through 05/06/2026, Resident #9 was observed lying in bed and receiving oxygen via nasal cannula, but the concentrator beside the bed was set to and delivering oxygen at 4 liters per minute instead of the ordered 2 liters per minute. A CNA stated the resident was confused and always on oxygen but did not check the concentrator flow rate. An LPN stated the oxygen order was 2 liters per minute and had no explanation for why the flow was observed at 4 liters per minute. An RN stated the medication nurse was responsible for ensuring the oxygen was running at the ordered rate at the start of the shift, and the DON stated the oxygen rate should be verified at least once per shift and that the unit nurse supervisor was responsible for checking it at least one time every shift.
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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What surveyors actually found near you
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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.
Illustrative
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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 Rehabilitation And Nursing | 0.8 mi | ★★★★★ | 0 | 0 |
| Ditmas Park Care Center | 0.9 mi | ★★★★★ | 3 | 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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