Caton Park Rehabilitation and Nursing Center, LLC

Inspectors wroteBased on record review and interview, the facility failed to ensure that a comprehensive person-centered care plans for each resident was developed and implemented, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. This was evident for one (1) resident (Resident #22) of five (5) residents reviewed for Accidents, one (1) resident (Resident #9) of two (2) residents reviewed for Respiratory Care, one (1) resident (Resident #101) of five (5) residents reviewed for Unnecessary Medications, and one (1) resident (Resident #6) of one (1) resident reviewed for Dental Care, and out of 27 total sampled residents. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure sufficient nursing staff was provided to meet the residents' needs in a manner that promotes each resident's rights, physical, mental, and psychosocial well-being, as determined by resident assessments and individual plans of care. Specifically, 1). Review of the actual staffing schedules dated from 10/01/25 to 12/31/25 revealed that staffing assignments were consistently less than the projected staffing needs specified in the Facility Assessment for Certified Nursing Assistants and Licensed Nursing Staff, and 2.) the facility Payroll Based Journal (Quarter 1 2026 (October 1 - December 31) also triggered for excessively low weekend staffing.

Inspectors wroteNumber of residents sampled:Number of residents cited:Based on observation and interviews, the facility failed to ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident in two (2) medication rooms (Unit 2 and Unit 3) of three (3) medication rooms observed during the Medication Storage and Labeling task and the Central Supply room. Specifically, the medication rooms on Unit 2 and Unit 3, and the Central Supply room in the basement were observed to contain expired foley insertion trays.

Inspectors wroteBased on observation, record review and interviews, the facility to ensure that the resident was free from chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. This was evident for one (1) resident (Resident #105) of five (5) residents reviewed for Unnecessary Medications, out of 27 total sampled residents. Specifically, there was no adequate clinical indication documented in the clinical record to support the ongoing use of Aripiprazole 15 MG daily, no documentation of monitoring of behavioral symptoms, and no documented evidence that a gradual dose reduction had been attempted for Resident #105 since 09/20/2024.

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 1 Based on record reviews and staff interviews, the facility failed to ensure assessments accurately reflect the resident's status. This was evident for one (1) resident (Resident #22) out of five (5) residents reviewed for Accidents out of 27 sampled residents. Specifically, the Minimum Data Set assessment for Resident #22 did not capture the use of a wander/elopement alarm.

Inspectors wroteNumber of residents sampled: 1Number of residents cited: 1Based on record review and staff interviews, the facility failed to ensure that the baseline care plan was completed within 48 hours of a resident's admission. This was evident for one (1) resident (Resident #119) of one (1) resident reviewed for Discharge out of 27 sampled residents. Specifically, the baseline care plan for Resident #119 was not completed within 48 hours of admission.

Inspectors wroteNumber of residents sampled:2Number of residents cited:1 Based on record review and interview, the facility failed to ensure that a resident's comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This was evident for one (1) resident (Resident #70) of two (2) residents reviewed for Activities of Daily Living out of 27 sampled residents. Specifically, the comprehensive care plan related to Activities of Daily Living for Resident #70 was not reviewed and revised after each assessment.

Inspectors wroteNumber of residents sampled: 27Number of residents cited: 1Based on observation, record review, and interviews, the facility failed to ensure that an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident was provided. This was evident for one (1) resident (Resident #63) of three (3) residents reviewed for Activities out of 27 total sampled residents. Specifically, Resident #63 was not provided with activities in their preferred language.

Inspectors wroteNumber of residents sampled: 2Number of residents cited: 1Based on observation, record review, and interviews, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice. This was evident for one (1) resident (Resident #9) of two (2) residents reviewed for Respiratory Care out of 27 sampled residents. Specifically, Resident #9 was observed using oxygen via a nasal cannula at a rate of 4 liters per minute when the Physician's order was written for oxygen to be received at a rate of 2 liters per minute.

Inspectors wroteBased on interviews and record review conducted during an abbreviated survey (2578058) on 11/10/2025, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours to State Survey Agency after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. This was evident for one (1) out of one (1) resident (Resident # 1) reviewed for Accidents. [...]

Inspectors wroteBased on record review and staff interviews conducted during the Recertification survey from 08/12/2024 to 08/16/2024, the facility did not ensure that resident's Comprehensive Care Plans were reviewed and revised for 1 (Resident #15) of 7 residents reviewed for Accident out of 26 sampled residents. Specifically, Resident #15 had a multiple history of falls, and the fall care plan was not reviewed and revised after the most recent Minimum Data Set assessment. The finding is: The facility policy and procedure titled Comprehensive Care Plan dated 1/26/23 states that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs are developed for each resident. [...]

Inspectors wroteBased on staff interview and record review conducted during the Recertification Survey from 08/12/2024 to 08/16/2024, the facility did not ensure a resident received assistance devices consistent with a resident's needs, goals, and care plan to prevent accidents. This was evident for 1 (Resident #75) 7 residents reviewed for Accidents out of 26 total sampled residents. Specifically, floor mats were not in place for Resident #75 as per Physician Order.

Inspectors wroteBased on observation, record review, and interviews conducted during the Recertification survey from 08/12/2024 to 08/16/2024, the facility did not ensure that infection control prevention practices and procedures were maintained. This was evident for 1 resident (Resident #87) observed during the Medication Administration task. Specifically, Enhanced Barrier Precautions were not maintained for gastrostomy tube medication administrations for Resident #87.

Inspectors wroteBased on Record reviews and interviews during the Recertification survey from 08/12/2024 to 08/16/2024, the facility did not ensure that all completed resident assessments were submitted and transmitted into the Quality Improvement Evaluation Assessment Submission and Processing in a timely manner. Specifically, 4 (Resident #66, Resident # 9, Resident #6, and Resident #95) of 6 Minimum Data Set submissions reviewed for Resident Assessment were not submitted to Center for Medicaid and Medicare Services system within 14 days of completion.

Inspectors wroteBased on observation, record review, and interviews conducted during an Abbreviated survey (NY00323120), the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. This was evident in 1 out of 3 residents (Resident #1) sampled. Specifically, Resident #1 was observed with facial grimacing and pointed to their right leg while being cared for by Certified Nursing Assistant #1 on 08/27/23 at approximately 06:00pm. Licensed Practical Nurse #1 and Nurse Supervisor #1 both stated that they observed Resident #1 with facial grimacing, right leg swollen and warm to touch on 08/27/23. There was no documented evidence to support that Resident #1 was assessed and the medical doctor was notified on 08/27/23. A nursing note dated 08/28/23 at 10:41pm documented that an x-ray of Resident #1's right knee was done. [...]

Inspectors wroteBased on observation, interview and record review conducted during an Abbreviated Survey (NY00323120), the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practices, the comprehensive person-centered care plan, and the resident's goals and preferences. This was evident for 1 out of 3 residents (Resident #1) sampled. Specifically, Resident #1, who had severely impaired cognition, was on pain management for diagnoses of pain in other joints. An initial pain assessment was not done on 08/27/23. A medical record review also revealed that Resident #1 continued to complain of pain from 08/28/23 to 08/30/23, but there were no changes in pain management. [...]

Inspectors wroteBased on record review and interviews conducted during the recertification survey, the facility did not ensure Minimum Data Set 3.0 (MDS) assessments were electronically transmitted in a timely manner. This was evident for 5 of 14 residents reviewed for the Resident Assessment task (Resident #4, 13, 8, 17, 9). Specifically, a quarterly assessment was not transmitted within 14 days after the completion date.

Inspectors wroteBased on interviews and record review conducted during a recertification and complaint (NY00283611) survey from 08/03/22 to 8/10/2022, the facility did not ensure that allegations of abuse, including injury of unknown origin, were reported to the New York State Department of Health (NYSDOH) within 2 hours. This was evident for 1 (Resident #40) of 3 residents investigated for abuse. Specifically, Resident #40 complained of right shoulder pain and subsequent right shoulder dislocation was not reported to the NYSDOH within 2 hours.

Inspectors wroteBased on observation, record review and interviews conducted during the recertification survey, the facility did not ensure comprehensive person-centered care plans (CCP) were developed and implemented to meet each resident's needs. This was evident for 2 of 34 sampled residents (Resident #81 and #102). Specifically,1.) Resident #81 had did not have a CCP to address bleeding and anemia, and 2.) Resident #102 did not have a CCP developed to address their Intravenous (IV) hydration and antibiotic treatment.

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure that services provided or met professional standards of quality and acceptable current evidenced-based practices. This was evident in 2 of 34 sampled residents (Resident #102 and #50). Specifically, 1.) a Physician Order (PO) to remove an intravenous (IV) line from Resident #102 was not followed; and 2.) a PO to obtain Fingerstick Blood Sugar (FSBS) testing three times a day for five days on Resident #50 was not followed.

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure that services provided or met professional standards of quality and acceptable current evidenced-based practices. This was evident in 2 of 34 sampled residents (Resident #102 and #50). Specifically, 1.) a Physician Order (PO) to remove an intravenous (IV) line from Resident #102 was not followed; and 2.) a PO to obtain Fingerstick Blood Sugar (FSBS) testing three times a day for five days on Resident #50 was not followed.

Inspectors wroteBased on observation, record review and staff interviews during the recertification survey, the facility did not obtain from an outside resource, routine dental services to meet the needs of each resident or assist the resident with making an outside appointment. This was evident for 1 (Resident #79) of 1 resident reviewed for Dental services. Specifically, the facility did not assist Resident #79 with obtaining an appointment for oral surgery as recommended by the dental consultant. The finding is: The facility Policy and Procedure titled Consultants dated 02/04/2022 documented: Residents will be evaluated by a consultant as ordered by the Primary Medical Doctor (PMD) and in accordance with facility policy. The PMD will review the Consultant's recommendations and follow up accordingly. The PMD will order needed consults for residents. [...]