Inspection Reports for Caton Park Rehabilitation and Nursing Center, LLC
1312 Caton Avenue, Brooklyn, NY, 11226
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 10, 2025, identified a deficiency for failing to timely report a serious injury involving a resident. Earlier inspections showed a pattern of deficiencies related to care plan updates, resident assessments, infection control, and accident hazard prevention, with many issues corrected after follow-up. Inspectors frequently cited delays in reporting injuries or alleged abuse, care plan and assessment documentation problems, and infection control concerns. Complaint investigations were mostly unsubstantiated except for a substantiated pest control issue in 2023 and some substantiated delays in reporting injuries. The facility’s record shows ongoing challenges with timely reporting and care documentation, with some improvements noted in correcting prior deficiencies.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
7.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Nov 10, 2025
Visit Reason
The abbreviated survey was conducted to evaluate the facility's compliance with reporting requirements related to alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property.
Findings
The facility failed to report a serious injury involving Resident #1 within the required two-hour timeframe to the State Survey Agency. Resident #1 fell from bed during care on 07/28/2025, sustaining multiple fractures and a laceration, but the incident was not reported until 07/31/2025. The Director of Nursing acknowledged the delay was due to gathering more details before reporting.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities within two hours as required.
Report Facts
Days delayed in reporting: 3
Number of residents reviewed for accidents: 1
Number of falls since admission or prior assessment: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for reporting incident to Department of Health and conducting incident investigation; acknowledged delay in reporting | |
| Certified Nursing Assistant #1 | Provided care during which Resident #1 fell from bed | |
| Nurse Supervisor | Notified Director of Nursing immediately after Resident #1's fall | |
| Administrator | First made aware of the incident on 07/28/2025 at 10:00 AM |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Aug 16, 2024
Visit Reason
Inspection revealed multiple standard health and life safety code citations related to care plan timing, resident assessments, accident hazards, infection control, fire drills, and vertical openings. All deficiencies were corrected by late September 2024.
Findings
Inspection revealed multiple standard health and life safety code citations related to care plan timing, resident assessments, accident hazards, infection control, fire drills, and vertical openings. All deficiencies were corrected by late September 2024.
Deficiencies (6)
Care plan timing and revision
Encoding/transmitting resident assessments
Free of accident hazards/supervision/devices
Infection prevention & control
Fire drills
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Aug 16, 2024
Visit Reason
The inspection was conducted as a Recertification survey from 08/12/2024 to 08/16/2024 to assess compliance with regulatory requirements for the nursing home facility.
Findings
The facility was found deficient in timely submission of resident assessments, updating comprehensive care plans especially related to fall prevention, ensuring assistive devices like floor mats were in place for fall risk residents, and maintaining proper infection control practices during medication administration for residents with gastrostomy tubes.
Deficiencies (4)
Late submission of Minimum Data Set assessments for 4 residents to CMS system beyond the required 14 days.
Failure to review and revise the comprehensive fall prevention care plan for Resident #15 after recent assessments and falls.
Failure to provide floor mats as ordered for Resident #75, a fall risk, increasing risk of injury.
Failure to maintain Enhanced Barrier Precautions during gastrostomy tube medication administration for Resident #87.
Report Facts
Number of Minimum Data Set assessments late: 4
Number of residents reviewed for falls: 7
Number of residents sampled: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Unit Manager | Named in fall care plan deficiency and interview regarding Resident #15 |
| Director of Nursing | Interviewed regarding care plan updates and infection control | |
| Certified Nursing Assistant #2 | Interviewed regarding failure to place floor mats for Resident #75 | |
| Licensed Practical Nurse #4 | Interviewed regarding fall risk and floor mat responsibility for Resident #75 | |
| Licensed Practical Nurse #2 | Observed and interviewed regarding failure to don PPE during gastrostomy tube medication administration for Resident #87 | |
| Registered Nurse #2 | Interviewed regarding staff training on Enhanced Barrier Precautions | |
| Infection Control Preventionist | Interviewed regarding infection control training and monitoring | |
| Controller | Interviewed regarding late submission of Minimum Data Set assessments | |
| Director of Minimum Data Set | Interviewed regarding assessment submission process and oversight | |
| Physician | Interviewed regarding fall risk and floor mat order for Resident #75 | |
| Director of Nursing Services | Interviewed regarding floor mat order and fall risk for Resident #75 |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Mar 12, 2024
Visit Reason
Complaint survey found deficiencies in pain management and professional standards of services provided, both corrected by May 2024.
Findings
Complaint survey found deficiencies in pain management and professional standards of services provided, both corrected by May 2024.
Deficiencies (2)
Pain management
Services provided meet professional standards
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Mar 12, 2024
Visit Reason
The abbreviated survey was conducted to evaluate compliance with professional standards of care, focusing on treatment, pain management, and documentation practices for residents.
Findings
The facility failed to ensure timely and appropriate assessment, treatment, and pain management for Resident #1, who sustained a hip fracture that was not promptly identified or managed. Documentation and communication deficiencies were noted among nursing staff and providers.
Deficiencies (2)
Failure to ensure Resident #1 received treatment and care in accordance with professional standards, including timely assessment and notification of physician regarding right leg injury.
Failure to provide appropriate pain management consistent with professional standards, including lack of pain assessment before and after medication administration.
Report Facts
Medication doses administered: 5
Dates of key events: Resident #1 observed with pain on 08/27/23; x-rays on 08/28/23 and 08/30/23; hospital transfer on 08/30/23; surgery on 08/31/23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Observed Resident #1's swollen right leg and administered Tylenol; involved in pain management and notification | |
| Registered Nurse Supervisor #1 | Assessed Resident #1 on 08/27/23, called Nurse Practitioner, but did not document observations | |
| Registered Nurse Supervisor #3 | Assessed Resident #1 on 08/28/23, notified Nurse Practitioner, obtained x-ray order | |
| Nurse Practitioner #1 | Ordered x-rays and pain medication; assessed Resident #1 on 08/29/23 and 08/30/23; ordered hospital transfer | |
| Director of Nursing | Provided statements on expected nursing assessments and pain management policies |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Aug 11, 2023
Visit Reason
Inspection cited deficiency in maintaining an effective pest control program, corrected by September 2023.
Findings
Inspection cited deficiency in maintaining an effective pest control program, corrected by September 2023.
Deficiencies (1)
Maintains effective pest control program
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Jul 26, 2023
Visit Reason
The abbreviated survey was initiated on 07/26/2023 in response to Complaint # NY 00320109 to assess the facility's pest control program and ensure the facility was free of pests.
Complaint Details
Complaint # NY 00320109 triggered the abbreviated survey. The complaint was substantiated by observations of roaches in resident rooms and common areas.
Findings
The survey found evidence of roaches in resident rooms on two of five floors, indicating the facility did not maintain an effective pest control program despite weekly pest control services and documented treatments.
Deficiencies (1)
Failure to maintain an effective pest control program resulting in presence of live and dead roaches in resident rooms and common areas.
Report Facts
Residents Affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Reported that roach sightings were noted in the Vendor's Pest Control Inspection & Service Report book | |
| CNA | Reported seeing roaches two months prior and ants mostly in summer | |
| Housekeeping Staff | Reported seeing about 3 roaches in a resident room and notifying housekeeping supervisor | |
| Director of Maintenance and Housekeeping | Reported contracting pest control vendor and weekly exterminator visits |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 9
Date: Aug 10, 2022
Visit Reason
Multiple standard health and life safety code citations including care plan development, resident assessments, quality of care, reporting alleged violations, dental services, building construction, electrical systems, and exit signage. All corrected by late 2022.
Findings
Multiple standard health and life safety code citations including care plan development, resident assessments, quality of care, reporting alleged violations, dental services, building construction, electrical systems, and exit signage. All corrected by late 2022.
Deficiencies (9)
Develop/implement comprehensive care plan
Encoding/transmitting resident assessments
Quality of care
Reporting of alleged violations
Routine/emergency dental services in nursing facility
Services provided meet professional standards
Building construction type and height
Electrical systems - essential electric system
Exit signage
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 10, 2022
Visit Reason
The inspection was conducted as a recertification and complaint investigation survey from 08/03/2022 to 08/10/2022, focusing on allegations of abuse, resident assessment transmissions, care plan development, quality of care, and dental services.
Complaint Details
The complaint investigation focused on allegations of abuse including injury of unknown origin, specifically regarding Resident #40's right shoulder dislocation not reported timely to NYSDOH.
Findings
The facility failed to timely report an injury of unknown origin to the NYSDOH, did not transmit Minimum Data Set assessments timely, failed to develop comprehensive care plans for certain residents, did not follow physician orders for IV line removal and blood sugar testing, and did not assist a resident in obtaining necessary dental surgery appointments.
Deficiencies (5)
Failure to timely report allegations of abuse including injury of unknown origin to the New York State Department of Health within 2 hours.
Minimum Data Set assessments were not electronically transmitted within required timeframes.
Did not develop or implement comprehensive person-centered care plans for residents with specific medical needs.
Services provided did not meet professional standards of quality, including failure to remove IV line timely and failure to perform ordered blood sugar testing.
Did not obtain or assist resident with obtaining necessary dental services and appointments.
Report Facts
Residents investigated for abuse: 3
Residents reviewed for Resident Assessment task: 14
Residents with untimely MDS transmission: 5
Sampled residents for care plan deficiencies: 34
Residents affected by care plan deficiencies: 2
Days midline IV remained after discontinuation order: 23
Days FSBS testing ordered but not performed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Manager #1 | Registered Nurse Manager | Interviewed regarding Resident #102's IV line removal and FSBS testing for Resident #50 |
| Director of Nursing | Director of Nursing | Interviewed regarding reporting requirements and facility policies |
| Nurse Practitioner | Nurse Practitioner | Provided medical orders and interviewed regarding Resident #40 and Resident #79 dental follow-up |
| Unit Clerk | Unit Clerk | Responsible for making outside consultant appointments; stated no dental appointment was made for Resident #79 |
| Registered Nurse Unit Manager #1 | Registered Nurse Unit Manager | Interviewed about dental appointment issues for Resident #79 |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding renewal orders and implementation |
| Physician's Assistant | Physician's Assistant | Interviewed regarding Resident #40's injury diagnosis |
Inspection Report
Capacity: 60
Deficiencies: 1
Date: May 30, 2022
Visit Reason
Covid-19 survey cited deficiency in reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 survey cited deficiency in reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 26, 2022
Visit Reason
Complaint survey cited a level 3 deficiency for free of accident hazards/supervision/devices causing actual harm, corrected by June 2022.
Findings
Complaint survey cited a level 3 deficiency for free of accident hazards/supervision/devices causing actual harm, corrected by June 2022.
Deficiencies (1)
Free of accident hazards/supervision/devices
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Mar 29, 2022
Visit Reason
Complaint survey cited deficiencies in accident hazards and resident records identifiable information, both corrected by May 2022.
Findings
Complaint survey cited deficiencies in accident hazards and resident records identifiable information, both corrected by May 2022.
Deficiencies (2)
Free of accident hazards/supervision/devices
Resident records - identifiable information
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Mar 21, 2022
Visit Reason
Covid-19 survey cited deficiency in reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 survey cited deficiency in reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Feb 28, 2022
Visit Reason
Covid-19 survey cited deficiency in reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 survey cited deficiency in reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Jan 31, 2022
Visit Reason
Covid-19 survey cited deficiency in reporting to the national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 survey cited deficiency in reporting to the national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 6, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with care standards, specifically focusing on the provision of appropriate care to maintain or improve residents' range of motion.
Findings
The facility failed to ensure that a resident (Resident #67) received services and treatment to prevent further decrease in range of motion, as the resident was observed multiple times without the prescribed hand roll device. Interviews with staff revealed lapses in device application and communication.
Deficiencies (1)
Failure to provide appropriate care to maintain and/or improve range of motion by not ensuring a resident wore the prescribed hand roll device as ordered by the physician.
Report Facts
Residents reviewed for Limited Range of Motion: 2
Residents affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Interviewed regarding the missing hand roll device and its application | |
| Licensed Practical Nurse (LPN) | Interviewed regarding rounds and observation of the resident's use of the hand roll device |
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