Capstone Center for Rehabilitation and Nursing

Inspectors wroteBased on observation, record review, and interviews conducted during a survey, the facility failed to ensure care and services were provided in a manner that promoted dignity and respect for one (1) (Resident #1) of 4 residents reviewed and for one (1) of three (3) nursing units observed. Specifically, (a.) During an interview on 5/28/2026, Resident #1's family member reported that the resident's clothes were soaked with urine and were malodorous during several visits. There was evidence that the resident refused their clothes changed several times in June, July, and August 2025 and there was no documented evidence that the nurse was notified and (b.) during observation of the fourth-floor unit on 5/29/2026, a staff member was observed entering three (3) resident rooms without knocking on the door.

Inspectors wroteBased on record review and interviews conducted during a survey, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for one (1) (Resident #1) of three (3) residents reviewed. Specifically, the facility failed to ensure the physician was notified when Resident #1 refused medications that included Metoprolol Succinate SR 24-hour 50 milligrams daily ordered for hypertension in June, July, and August 2025, and Levofloxacin 500 milligrams daily, ordered for pneumonia in August 2025.

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not immediately consult with and or notify resident's physician of a significant change in the resident's physical, mental, or psychosocial status for 1 (Resident #115) of 2 residents reviewed. Specially, Resident #115 had a history of chronic respiratory failure, had increased congestion and cough. Resident's health care proxy expressed concern to Registered Nurse #4. Registered Nurse #4 assessed Resident #115 and was noted with altered mental status, decrease in oxygen saturation from 98% to 94%, and abnormal lung sounds. There was no documented evidence that the physician was notified of the change in condition including change in mental status and respiratory distress. There were no new orders to manage resident symptoms. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and cared for in a manner that promotes maintenance or enhancement of his or her quality of life for 6 (Resident #'s 2, 12, 28, 44, 97, and 114) of 35 residents reviewed. Specifically, (a.) Resident #'s 2, 12, 28, and 114 were provided plastic flatware with their meals instead of silver flatware. (b.) Residents #44 and #97 were not talked to in a dignified manner by staff providing care. This is evidenced by: A facility policy Dignity and Quality of Life Policy, not dated, documented that each resident shall be cared for in a manner that promoted and enhanced quality of life, dignity, respect, and individuality. Under the policy section procedure/implementation it was documented that: [...]

Inspectors wroteBased on observation and interviews conducted during the recertification survey, the facility did not provide effective housekeeping and maintenance services on 1 of 3 resident units and the building exterior. Specifically, the exterior of the building and walls were not clean. This is evidenced by: During observation on 12/03/2024 at 11:17 AM, the walls beneath the hand sanitizer dispensers attached to the walls outside room #s 366, 374, 337, 387, and by the elevator on unit 3 had multiple streak stains around the dispenser that descended to the baseboard. During observations on 12/04/2024 at 5:29 PM, the walls beneath the hand sanitizer dispensers attached to the walls outside room #s 237, 266, 274, 279, and 287 had multiple streak stains that descended to the baseboard. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure pain management was provided to each resident in accordance with professional standards of care for 3 (Resident #'s 22, 25, and 317) of 4 residents reviewed for pain management. Specifically over a two-month period, the facility did not evaluate their existing pain and the cause(s), and managing or preventing pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. This resulted in residents' pain symptoms not being relieved to the extent possible. This is evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews during an abbreviated survey (NY00353512), the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, the facility's staffing minimum staffing levels were not met each day from 12/02/2024 through 12/10/2024 per facility assessment. This is evidenced by: Upon entrance to the facility on [DATE] there were 118 residents residing on 3 units. The Facility assessment dated 2024 and based on a resident population profile from 7/23/2023 to 7/23/2024 documented, the facility's staffing plan for direct residential care. The assessment documented that the facility strived to have at a maximum for staff the following: [...]

Inspectors wroteBased on observations, record reviews, and interviews during the recertification survey, the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Specifically, the facility nursing staff did not document unit narcotics were counted by two licensed staff members and signed as appropriately done on the facility provided narcotic record sheets. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews during a recertification survey, the facility did not ensure residents were free of any significant medication errors for 4 (Resident #s 3, 12, 22, and 25) of 30 residents reviewed. Specifically, for Resident #'s 3, 12, 22 and 25, the facility did not ensure accurate medication administration and documentation of Oxycodone (narcotic pain medication). This is evidenced by: The Policy and Procedure titled, Medication Administration, revised 6/2024, documented medications would be administered by a licensed and/or registered nurse. All medications and treatments would be administered and documented using the electronic medical record. [...]

Inspectors wroteBased on observation, interview, and record review during a recertification and complaints survey (NY00349706, NY00352500, NY00353512, and NY00359446), the facility did not ensure it was administered in a manner that enabled the facility to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 9 (Resident #'s 18, 22, 25, 96, 101, 103, 108, 317, and 319) of 9 residents reviewed. Specifically, for Resident #'s 18, 22, 25, 96, 101, 103, 108, 317, and 319, the facility was unable to provide documented proof of electronic medication administration that could identify the actual time the medication was administered to each resident that would support medication was given as ordered. This was evidenced by: [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification survey, the facility did not ensure residents received services in the facility with reasonable accommodation for 1(Resident #86) of 30 residents reviewed. Specifically, the facility did not ensure Resident #86 had a call device they were able to use and was accessible to the resident. This is evidenced by: Resident #86 was admitted to the facility with diagnoses of end stage renal disease, generalized muscle weakness, and need for assistance with personal care. The Minimum Data Set (an assessment tool) dated 9/16/2024, documented the resident was cognitively intact, could be understood, and understand others. The resident had upper extremity impairment on both sides. [...]

Inspectors wroteBased on record review and interviews during a recertification survey, the facility did not ensure that Comprehensive Care Plans were reviewed and revised to meet the needs of each resident for 2 (Residents #16 and #79) of 30 residents reviewed. Specifically, Resident #16 and Resident #79 had multiple falls and the patient centered Comprehensive Care Plans were not updated to reflect number of falls with corresponding interventions and goals to prevent falls. This is evidenced by: The facility's Policy and Procedure titled Care Planning, Minimum Data Set (is a standardized assessment tool that measures health status in nursing home residents) Assessments and Minimum Data Set Interviews effective 4/2015 and last revised 2/2024, documented PHILOSOPHY: [...]

Inspectors wroteBased on observations, record review, and interviews during the recertification survey, the facility did not ensure a dependent resident was provided with appropriate treatment and services to maintain or improve their language and communication for 1 (Resident #367) of 1 reviewed for Activities of Daily Living. Specifically, nursing staff did not provide Resident #367 with adequate, consistent interpreter services in accordance with professional standards of care. This was evidenced by: The facility's Policy and Procedure titled Communication effective 6/19/2029 and reviewed 3/2024, documented its Purpose: To provide our residents who communicate with non-oral communication devices, sign language, or who speak a language other than the dominate language of the facility (English) the highest practicable level of quality of life and the resources to achieve just that. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 (Resident #49, and #367) of 4 residents reviewed. Specifically, Residents #49, and #367 did not consistently attend meaningful, accommodating activities to maintain their highest practicable quality of life. This is evidenced by: The Facility's Policy and Procedure titled Activity Assessment and Programming, undated, documented, The purpose of this policy was to establish a framework for meaningful, individualized activities that promote physical, cognitive, emotional, and social well-being of each resident. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey, the facility did not ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 2 (Resident #s 114 and 172) of 2 residents reviewed. Specifically, for Resident #s 114 and 172, the facility did not ensure (a.) multiuse feeding sets (syringe/bottle) were labeled with the date opened and disposed of within 24 hours; (b) opened multiuse bottles of formula were labeled with the date/time opened and discarded within 48 hours. This is evidenced by: The Policy and Procedure titled, Tube Feeding and Tube Care, reviewed 6/2024, documented the policy was written to provide guidance and general guidelines for administration of enteral feedings by the licensed nurse. [...]

Inspectors wroteBased on observations, record review, and interviews during a recertification survey, the facility did not ensure that each resident received respiratory care consistent with professional standards of practice for 1 (Resident #86) of 3 residents reviewed. Specifically, Resident #86's oxygen tubing was not changed on 12/01/2024 as ordered by the physician. This is evidenced by: The Policy and Procedure titled, Oxygen Therapy - Mask and Nasal Cannula, revised 5/2024, documented all oxygen must be prescribed and dispensed in accordance with federal, state, and local laws and regulations. Oxygen administration would be monitored by the licensed nurse and documented on the Treatment Administration Record and in the electronic medical record. [...]

Inspectors wroteBased on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice, for 2 of 2 medication rooms reviewed (200 unit and 300 unit), and 3 of 3 medication carts reviewed (200, 300, and 400 units). Specifically, (a.) opened medications had no open and/or expiration dates; (b.) opened stock eye drops were not labeled with resident's name; (c.) medication refrigerator temperature was outside of therapeutic range; (d.) non-medication items were stored in narcotic cabinet; (e) a narcotic box was not secured with double lock; and (d) open cups of food were stored in medication cart. This is evidenced by: The facility's Policy and Procedure tilted Medication Storage Date Revised: [...]

Inspectors wroteBased on record review and interviews during a recertification and abbreviated survey (Case# NY00349706), the facility did not ensure it promptly notified the ordering physician of laboratory results that fell outside of clinical reference ranges per the ordering physician's orders for 1 (Resident #269) of 1 resident reviewed. Specifically, the ordering physician was not notified when Resident #269's blood sugar results were outside of the clinical reference range on 7/11/2024, 7/12/2024, 7/18/2024 and 7/19/2024. This is evidenced by: Resident #269 was admitted to the facility with diagnoses of type 1 diabetes without complications, urinary tract infection, and muscle weakness. The Minimum Data Set (an assessment tool) dated 10/10/2024, documented the resident was cognitively intact. The resident was able to make themselves understood and understood others. [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case # NY00295962 and NY00319632), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but not later than two (2) hours after the allegation was made to the State Survey Agency for 2 of 2 qualifying reportable incident and accident investigations. Specifically, when Resident #2 and Resident #3 were observed with injuries of an unknown origin, the facility conducted investigations into the incidents, however, never reported them to the New York State Department of Health.

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case #NY00302737), the facility did not ensure sufficient nursing staff were available to provide nursing services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not ensure that a resident was permitted to return to an available bed in the location in which they previously resided. Specifically, Resident #10 was sent to the hospital on 9/09/2022 for evaluation, and not permitted to return after medically cleared to return back to facility. The facility stated they could not provide 1:1 care to the resident upon a readmission from the hospital until such time a safe discharge could be secured. This is evidenced by: [...]

Inspectors wroteBased on record review and interviews during an abbreviated survey (Case # NY00294993), the facility did not provide needed care and services that were resident centered and in accordance with professional standards of practice to meet each resident's physical, mental, and psychosocial needs for 1 (Resident #1) of 7 residents reviewed. Specifically, Resident #1 order for urinalysis with culture and sensitivity on 5/02/2022 was not obtained in a timely manner with urine culture obtained on 05/10/2022, and the provider was not notified when staff's attempt to obtain a urine sample was unsuccessful. This is evidenced by: The Policy and Procedure titled, Lab Services Protocol, last revised May 2023, documented Licensed Practical Nurses/ Registered Nurses were to ensure collection of ordered specimens. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, the facility did not ensure that on 3 of 3 resident units' walls and floors were clean and/or in good repair. This is evidenced as follows: During observations on 01/14/22 at 10:30AM, the bathroom in resident room [ROOM NUMBER], the right foot-peddle to the bed pan washer was laying on the floor under the sink, and the floor was heavily soiled with dirt and a brown build-up. During observations on 01/14/22 at 12:45 PM and on 01/19/22 at 9:15 AM, walls were scraped or had unpainted spackling in resident room #'s 258, 366, 379, 443, 437, 456, 474, 483, and #489 and the 3rd floor common area. The floors were soiled with dirt or food debris in resident room #'s 437, 456, and #489. [...]

Inspectors wroteBased on observation, manufacturer's directions review, and staff interview during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, the automatic dishwashing machine final rinse was not sanitizing, the concentration of quaternary ammonium compound (QAC) utilized to manually sanitize food contact equipment was less than that required by the manufacturer, and 3 of 3 kitchenettes required cleaning and repairs. This is evidenced as follows: The main kitchen and resident unit kitchenettes were inspected on 01/13/22 at 09:30 AM. The concentration of sanitizing chemical in the final rinse of the automatic dishwashing machine final rinse was zero (0) parts per million (ppm) of available chlorine. [...]

Inspectors wroteBased on observation, interview and record review during a recertification survey the facility did not ensure treatment with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #55) of 2 residents reviewed for dignity. Specifically, for Resident #55, the facility did not ensure facility staff responded to the residents call light from the time it was turned on at 10:35 AM until 11:20 AM (forty five minutes). Nine staff members were observed walking past the resident's call light during this time period. This was evidenced by: The Policy & Procedure titled Call Lights and dated 06/2021, documented, the purpose of call bells was to respond to residents request for assistance in a timely manner and meet their immediate needs. [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the recertification survey, the facility did not ensure prompt efforts were made to resolve a grievance for 1 (Resident #84) of 3 residents reviewed for dental services. Specifically, for Resident #84, the facility did not ensure the facility's process for missing property was followed when the resident's representative reported the facility lost the resident's dentures and that the resident could not eat without them. Additionally, the resident representative was not appropriately apprised of the progress toward a resolution and as of 1/20/2022, Resident #84 had not been seen by the dentist to initiate the process of getting new dentures. This is evidenced by: Resident #84: [...]

Inspectors wroteBased on observation, record review and interview during the recertification survey, the facility did not ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #84) of 3 residents reviewed for ADLs. Specifically, for Resident #84, who was dependent on staff for ADL care, the facility did not ensure the resident's fingernails were cleaned and trimmed in accordance with the resident's preference and comprehensive care plan. This is evidenced by: Resident #84: Resident #84 was admitted to the facility with the diagnoses of cerebral infarction, dementia with behavioral disturbance, and major depressive disorder. [...]

Inspectors wroteBased on record review and interviews during the recertification survey, the facility did not ensure residents diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for 1 (Resident #19) of 2 residents reviewed for dementia care. Specifically, the facility did not ensure that person-centered care plans with individualized interventions that included and supported the residents' dementia care needs were developed. This is evidenced by: Resident #19: Resident #19 was admitted to the facility with the diagnoses of Parkinson's disease, dementia, and hypertension. The Minimum Data Set (MDS-an assessment tool) dated 10/15/2021, documented the resident had severe cognitive impairment and was sometimes able to make self understood and understand others. [...]

Inspectors wroteBased on record review and interview during a recertification survey, the facility did not ensure as needed (PRN) orders for psychotropic drugs were limited to 14 days, unless the attending physician or prescribing practitioner believed it was appropriate for the PRN order to be extended beyond 14 days, they should document their rationale in the resident's medical record and indicate the duration for the PRN order for 1 (Resident #71) of 6 residents reviewed for unnecessary medications. Specifically, for Resident #71, the facility did not ensure a PRN lorazepam (Ativan- antianxiety medication) was not ordered for more than 14 days without a documented rationale and duration from the attending physician or prescribing practitioner. This is evidenced by: Resident #71: [...]

Inspectors wroteBased on observation and interview during a recertification survey, the facility did not maintain an infection prevention and control program (IPCP) to prevent the development and transmission of disease and infection for 1 (3rd floor) of 3 units observed for dining. Specifically, the facility did not ensure staff assisted residents on the 3rd floor with hand hygiene before meals. This is evidenced by: The facility Policy and Procedure titled Infection Control Program Manual dated 9/2021, documented standard precautions for infection control were used for the care of all residents regardless of their diagnoses or presumed infection status. Hands were washed after touching blood, body fluids, secretions, excretions, and contaminated items. During an observation on 1/14/2022 at 9:04 AM, breakfast trays were being passed to residents on the 3rd floor. [...]

Inspectors wroteBased on observation, record review, and interviews during a recertification survey, the facility did not develop and implement, or provide the resident and their representative with a summary of the baseline care plan for 8 (Resident #'s 3, 37, 40, 55, 65, 67, 90 and #219) of 12 residents reviewed. Specifically: for Resident #'s 3 and 55, the facility did not ensure summaries of the baseline care plans were provided to the resident and the resident's representative; and for Resident #65, the facility did not ensure development and implementation of a baseline care plan. This is evidenced by: The Policy and Procedure (P&P) titled Care Planning, MDS (Minimum Data Set) assessment and MDS Interviews dated 7/2019, stated a baseline care plan is initiated upon 48 hours of admission and a summary of the resident's baseline care plan will be provided to the resident and their representative. [...]

Inspectors wroteBased on observation, record review and interviews during the recertification survey, the facility did not ensure an ongoing program to support residents in their choice of activities for 3 (Resident #'s 25, 77, and #87) of 3 residents reviewed for activities. Specifically, the facility did not ensure residents were provided, an ongoing program to support them in their choice of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, based on the comprehensive assessment, care plan and preferences of the resident.

Inspectors wroteBased on observations, record review and interview during the recertification survey, the facility did not ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for 1 (Resident # 90) of 1 resident reviewed for dialysis. Specifically, the facility did not ensure there was resident-specific communication between the dialysis center and the facility. This was evidenced by: Resident #90: The resident was admitted to the facility on [DATE], with a diagnosis of end stage renal disease, dependence on renal dialysis and diabetes. The Minimum Data Set (MDS - an assessment tool) documented the resident was cognitively intact and is able to make self-understood and can understand others. A review of the policy titled Dialysis Care and Management of Residents on Dialysis dated 7/2019, documented to maintain communication with dialysis. [...]