Inspection Reports for
Capstone Center for Rehabilitation and Nursing
302 Swart Hill Road, Amsterdam, NY, 12010
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
17 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
233% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Annual Inspection
Census: 118
Deficiencies: 7
Date: Dec 10, 2024
Visit Reason
The inspection was a recertification survey and abbreviated survey to assess compliance with regulatory requirements for nursing home operations, including housekeeping, staffing, medication administration, and resident care.
Findings
The facility was found deficient in housekeeping and maintenance, staffing shortages and competency issues, medication administration and documentation errors, improper medication storage and labeling, and failure to promptly notify physicians of critical lab results.
Deficiencies (7)
F 0584: The facility failed to provide effective housekeeping and maintenance services on 1 of 3 resident units and the building exterior, with soiled walls beneath hand sanitizer dispensers and building facade stained with mold-like substance.
F 0676: The facility did not ensure a dependent resident received adequate and consistent interpreter services in accordance with professional standards of care.
F 0725: The facility did not provide sufficient nursing staff to meet resident needs from 12/02/2024 through 12/10/2024, with multiple shifts short of Licensed Practical Nurses and Certified Nurse Assistants.
F 0726: The facility nursing staff did not document unit narcotics were counted by two licensed staff members and signed appropriately on narcotic record sheets.
F 0760: The facility did not ensure residents were free from significant medication errors, with multiple instances of undocumented administration of Oxycodone for 4 residents.
F 0761: The facility did not ensure drugs and biologicals were labeled and stored properly, including unlabeled eye drops, unlocked narcotic boxes, medication refrigerator temperature above therapeutic range, and non-medication items stored in narcotic cabinet.
F 0773: The facility did not promptly notify the ordering physician of laboratory results outside clinical reference ranges for a resident's high blood sugar readings on multiple dates.
Report Facts
Residents present: 118
Staffing shortages: 1
Medication errors: 4
Medication administration omissions: 30
Medication refrigerator temperature: 50
Blood sugar readings: 600
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | Named in medication administration documentation discrepancy for Resident #22 | |
| Registered Nurse #1 | Named in medication administration documentation discrepancy and narcotic count oversight | |
| Director of Nursing #1 | Director of Nursing | Discussed narcotic count policies and staffing issues |
| Nurse Educator #1 | Nurse Educator | Discussed staff training and narcotic count procedures |
| Administrator #1 | Administrator | Discussed staffing incentives and narcotic count oversight |
| Licensed Practical Nurse #1 | Observed medication cart and narcotic box issues | |
| Licensed Practical Nurse #14 | Observed unlabeled eye drops and refrigerator temperature | |
| Licensed Practical Nurse #15 | Observed medication cart and narcotic box issues |
Inspection Report
Routine
Deficiencies: 13
Date: Dec 10, 2024
Visit Reason
Routine recertification survey and complaint investigations to assess compliance with state and federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and respect, reasonable accommodation, notification of significant resident condition changes, housekeeping and maintenance, care plan updates, communication services, activity provision, feeding tube care, respiratory care, pain management, staffing levels, nursing competencies, medication administration, and medication storage and labeling.
Deficiencies (13)
F 0550: The facility did not ensure residents were treated with dignity and respect; plastic flatware was provided to residents not care planned for it, and staff spoke in an undignified manner to some residents.
F 0558: The facility did not reasonably accommodate the needs of Resident #86 by ensuring their call device was accessible at all times.
F 0580: The facility failed to immediately notify the physician of a significant change in Resident #115's condition, resulting in actual harm.
F 0584: The facility did not provide effective housekeeping and maintenance; walls beneath hand sanitizer dispensers were stained and the building exterior was soiled with mold-like substance.
F 0657: Care plans for Residents #16 and #79 were not updated to reflect multiple falls and corresponding interventions.
F 0676: Resident #367 did not receive adequate and consistent interpreter services; staff used gestures and limited Spanish, and activities were not provided in Spanish.
F 0693: Residents #114 and #172 had feeding tubes; multiuse feeding sets and formula bottles were not labeled with date/time opened or discarded within required timeframes.
F 0695: Resident #86's oxygen tubing was not changed weekly as ordered; documentation showed tubing last changed 11/24/2024 with no change on 12/01/2024 as ordered.
F 0697: Residents #22, #25, and #317 did not receive pain management consistent with professional standards; pain assessments before and after medication were not documented and medication administration documentation was incomplete.
F 0725: Facility staffing minimums were not met from 12/02/2024 through 12/10/2024; multiple shifts on all units were short Licensed Practical Nurses and Certified Nurse Assistants.
F 0726: Facility nursing staff did not document narcotic counts by two licensed staff as required; narcotic count sheets were unsigned or signed incorrectly and narcotic count procedures were not consistently followed.
F 0761: Drugs and biologicals were not labeled or stored properly; opened medications lacked open/expiration dates, eye drops were not labeled with resident names, medication refrigerator was above recommended temperature, narcotic box was unsecured, and non-medication items and open food cups were stored in medication carts.
F 0835: Facility failed to administer medications in a manner that ensured resident safety and effective use of resources; electronic medication administration records lacked time stamps for medication administration, preventing verification of medication timing and compliance.
Report Facts
Residents reviewed: 35
Residents reviewed: 30
Residents reviewed: 9
Staffing shortages: 1
Staffing shortages: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Named in medication administration and pain management findings |
| Director of Nursing #1 | Director of Nursing | Named in multiple interviews regarding medication administration, staffing, and policy compliance |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Named in medication administration and narcotic count findings |
| Nurse Educator #1 | Nurse Educator | Named in narcotic count and staff competency findings |
| Administrator #1 | Administrator | Named in staffing and medication administration findings |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 19
Date: Dec 10, 2024
Visit Reason
Inspection identified 16 health and 3 life safety deficiencies mostly Level 2, many corrected by January 29, 2025.
Findings
Inspection identified 16 health and 3 life safety deficiencies mostly Level 2, many corrected by January 29, 2025.
Deficiencies (19)
Activities daily living (adls)/mntn abilities
Activities meet interest/needs each resident
Administration
Care plan timing and revision
Competent nursing staff
Lab srvcs physician order/notify of results
Label/store drugs and biologicals
Notify of changes (injury/decline/room, etc. )
Pain management
Reasonable accommodations needs/preferences
Resident rights/exercise of rights
Residents are free of significant med errors
Respiratory/tracheostomy care and suctioning
Safe/clean/comfortable/homelike environment
Sufficient nursing staff
Tube feeding mgmt/restore eating skills
Discharge from exits
Doors with self-closing devices
Gas equipment - precautions for handling oxyg
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: May 28, 2024
Visit Reason
The abbreviated survey was conducted to evaluate compliance with regulations regarding timely reporting of suspected abuse, neglect, or injuries of unknown origin, and to assess staffing adequacy and resident transfer/discharge procedures.
Findings
The facility failed to report two incidents involving injuries of unknown origin to the New York State Department of Health within the required timeframe. Additionally, the facility did not ensure sufficient nursing staff to meet resident needs and improperly denied readmission to a resident due to behavioral issues.
Deficiencies (2)
F 0609: The facility did not timely report suspected abuse, neglect, or injuries of unknown origin for two residents as required by state regulations.
F 0725: The facility failed to provide sufficient nursing staff to meet resident needs and did not allow a resident to return to their previous bed after hospital discharge due to behavioral concerns.
Report Facts
Residents Affected: 2
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing #1 | Director of Nursing | Named in relation to injury reporting investigation and statements about reporting requirements |
| Nursing Home Administrator #1 | Nursing Home Administrator | Named in relation to resident readmission and behavioral management issues |
| Registered Nurse #4 | Registered Nurse | Interviewed regarding injury reporting procedures |
| Registered Nurse #5 | Registered Nurse | Interviewed regarding injury reporting procedures |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: May 28, 2024
Visit Reason
Complaint survey with 3 health deficiencies, all Level 2, including permitting residents to return, reporting alleged violations, and sufficient nursing staff; some corrected by August 2024.
Findings
Complaint survey with 3 health deficiencies, all Level 2, including permitting residents to return, reporting alleged violations, and sufficient nursing staff; some corrected by August 2024.
Deficiencies (3)
Permitting residents to return to facility
Reporting of alleged violations
Sufficient nursing staff
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 1, 2024
Visit Reason
The abbreviated survey was conducted to evaluate the facility's compliance with professional standards of care, specifically regarding the timely collection and processing of an ordered urinalysis with culture and sensitivity for Resident #1.
Findings
The facility failed to obtain a timely urine specimen for Resident #1, delaying the diagnosis and treatment of a urinary tract infection. Nursing staff did not document attempts to collect the specimen promptly, nor did they notify the physician of the delay as required by policy.
Deficiencies (1)
F 0684: The facility did not provide appropriate treatment and care according to orders and resident preferences. Resident #1's urinalysis with culture and sensitivity ordered on 5/02/2022 was not obtained until 5/10/2022, and the provider was not notified of unsuccessful specimen collection attempts.
Report Facts
Residents reviewed: 7
Residents affected: 1
Date survey completed: Mar 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing #1 | Director of Nursing | Interviewed regarding expectations and findings related to urine specimen collection |
| Doctorate Nurse Practitioner #1 | Doctorate Nurse Practitioner | Provided medical progress notes and interview statements regarding Resident #1's care |
| Medical Doctor #1 | Attending Facility Physician | Interviewed regarding notification and treatment related to urine culture results |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Mar 1, 2024
Visit Reason
Complaint survey with 1 health deficiency related to quality of care, Level 2, corrected by March 18, 2024.
Findings
Complaint survey with 1 health deficiency related to quality of care, Level 2, corrected by March 18, 2024.
Deficiencies (1)
Quality of care
Inspection Report
Capacity: 60
Deficiencies: 1
Date: Dec 7, 2023
Visit Reason
Covid-19 survey with 1 life safety deficiency related to subdivision of building spaces - smoke barrier, Level 2, corrected by January 25, 2024.
Findings
Covid-19 survey with 1 life safety deficiency related to subdivision of building spaces - smoke barrier, Level 2, corrected by January 25, 2024.
Deficiencies (1)
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jan 21, 2022
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to respond timely to resident call lights, inadequate housekeeping and maintenance, failure to resolve a grievance regarding missing dentures, insufficient nail care for a resident, lack of individualized dementia care plans, improper management of psychotropic medication PRN orders, food service safety violations, and inadequate infection prevention practices related to hand hygiene before meals.
Deficiencies (8)
F 0550: The facility did not ensure staff responded to Resident #55's call light for 45 minutes, with multiple staff observed walking past without responding.
F 0584: The facility did not provide effective housekeeping and maintenance services; walls and floors on 3 resident units were soiled or in disrepair.
F 0585: The facility failed to promptly resolve a grievance for Resident #84 regarding lost dentures and did not keep the resident or representative informed of investigation progress.
F 0677: The facility did not ensure Resident #84's fingernails were cleaned and trimmed according to preference and care plan, despite the resident's requests.
F 0744: The facility did not develop person-centered dementia care plans with individualized interventions for Resident #19.
F 0758: The facility did not limit PRN orders for psychotropic medication lorazepam to 14 days or document clinical justification and duration for extensions for Resident #71.
F 0812: The facility failed to maintain food service safety; dishwashing machine sanitizer was ineffective, manual sanitizer concentration was inadequate, and kitchenettes were dirty and in disrepair.
F 0880: The facility did not ensure staff assisted residents with hand hygiene before meals on the 3rd floor.
Report Facts
Duration of PRN lorazepam order: 34
Duration of PRN lorazepam order: 45
Sanitizer concentration in dishwashing machine: 0
Sanitizer concentration in 3-compartment sink: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding call light response and nail care deficiencies |
| RN #2 | Registered Nurse | Documented family report of missing dentures and involved in investigation |
| Director of Nursing | Director of Nursing | Interviewed regarding call light protocol, missing dentures investigation, PRN medication orders, and hand hygiene |
| Graduate Nurse Manager | Graduate Nurse Manager | Observed walking past call light and interviewed about call light protocol |
| Food Service Director | Food Service Director | Interviewed regarding missing dentures notification and food service sanitation |
| Administrator | Administrator | Interviewed regarding missing dentures investigation, dental services, and PRN medication orders |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 10
Date: Jan 21, 2022
Visit Reason
Complaint survey with multiple health and life safety deficiencies mostly Level 2, including ADL care, food procurement, psychotropic meds, grievances, infection control, resident rights, safe environment, dementia care, and electrical equipment; many corrected by March 2022.
Findings
Complaint survey with multiple health and life safety deficiencies mostly Level 2, including ADL care, food procurement, psychotropic meds, grievances, infection control, resident rights, safe environment, dementia care, and electrical equipment; many corrected by March 2022.
Deficiencies (10)
ADL care provided for dependent residents
Food procurement,store/prepare/serve-sanitary
Free from unnec psychotropic meds/prn use
Grievances
Infection prevention & control
Resident rights/exercise of rights
Safe/clean/comfortable/homelike environment
Treatment/service for dementia
Electrical equipment - testing and maintenanc
Maintenance, inspection & testing - doors
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Oct 22, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for the nursing home.
Findings
The facility was found deficient in developing and providing baseline care plan summaries to residents and their representatives, ensuring ongoing activity programs that meet residents' needs, and maintaining proper communication with dialysis services for residents requiring dialysis.
Deficiencies (3)
F 0655: The facility did not develop or provide baseline care plan summaries to residents and their representatives for 8 of 12 residents reviewed, including failure to develop a baseline care plan for one resident.
F 0679: The facility did not ensure an ongoing program to support residents in their choice of activities for 3 residents reviewed, with residents often unengaged and activity documentation inconsistent or inaccurate.
F 0698: The facility did not ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 resident, with missing post dialysis communication for 7 of 19 treatments.
Report Facts
Residents reviewed for baseline care plan: 12
Residents with baseline care plan deficiencies: 8
Residents reviewed for activities: 3
Residents with activity deficiencies: 3
Dialysis treatments missing communication: 7
Dialysis treatments reviewed: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADRN #2 | Admissions/Discharge Registered Nurse | Stated baseline care plan summaries were not provided to residents or representatives |
| Registered Nurse Manager #1 | Registered Nurse Manager | Interviewed regarding baseline care plan completion and dialysis policy awareness |
| Director of Nursing | Director of Nursing | Interviewed regarding baseline care plan procedures and dialysis communication policy |
| Social Worker | Social Worker temporarily in charge of activities | Interviewed regarding resident activity participation and documentation |
| Activities Aide | Activities Aide | Provided observations on resident activity participation |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Commented on lack of activities in the building |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Commented on resident activity participation and staff involvement |
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