Cycle 1
Health 2024-12-10 · Fire 2024-12-10
15 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Amsterdam, NY
Capstone Center For Rehabilitation And Nursing
2-star overall rating with 1-star inspections with $47,879 in total fines with 15 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
302 Swart Hill Road, Amsterdam, NY
(518) 842-6790
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
115
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Upstate Services Group
Operator or chain grouping
Approved since
1976-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.46
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.15
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.36
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.09
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,234
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9878
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.23
Baseline 17.68% · Performance 18.08% · Measure score 7.23 · Achievement 7.23 · Improvement 0
Healthcare-associated infections
1.93
Baseline 6.49% · Performance 7.26% · Measure score 1.93 · Achievement 1.93 · Improvement 0
Total nurse turnover
3.66
Baseline 50.60% · Performance 48.72% · Measure score 3.66 · Achievement 3.66 · Improvement 0.23
Adjusted total nurse staffing
0.60
Baseline 3.29 hours · Performance 3.25 hours · Measure score 0.60 · Achievement 0.60 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.82% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 7.41% · Lower 95% interval 6.23% |
| Discharge to community | 36.05% |
50.57%
14.5 pts worse
|
Worse than the National Rate · Eligible stays 63 · Observed rate 23.81% · Lower 95% interval 25.2% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 95.35% |
95.27%
0.1 pts better
|
Numerator 41 · Denominator 43 |
| Falls with major injury | 2.33% |
0.77%
1.6 pts worse
|
Numerator 1 · Denominator 43 |
| Discharge self-care score | 38.71% |
53.69%
15 pts worse
|
Numerator 12 · Denominator 31 |
| Discharge mobility score | 45.16% |
50.94%
5.8 pts worse
|
Numerator 14 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 4.65% |
2.29%
2.4 pts worse
|
Numerator 2 · Denominator 43 · Adjusted rate 3.86% |
| Healthcare-associated infections requiring hospitalization | 7.26% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 8.57% · Lower 95% interval 3.57% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 118 |
| Staff flu vaccination coverage | 79.84% |
42%
37.8 pts better
|
Numerator 103 · Denominator 129 |
| Discharge function score | 45.16% |
56.45%
11.3 pts worse
|
Numerator 14 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 27.59% |
25.2%
2.4 pts better
|
Numerator 8 · Denominator 29 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
91.2%
0.2 pts worse
|
93.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.6% · Q2 90.6% · Q3 93.5% · Q4 94.2% · 4Q avg 91.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
95.3%
3.8 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.9% |
3.0%
0.1 pts better
|
3.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 3.8% · Q3 3.7% · Q4 2.9% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.8% |
18.5%
16.7 pts better
|
11.4%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.0% · Q3 1.9% · Q4 2.0% · 4Q avg 1.8% |
| Percentage of long-stay residents who lose too much weight | 3.4% |
6.1%
2.7 pts better
|
5.4%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 3.8% · Q3 3.8% · Q4 2.0% · 4Q avg 3.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.3% |
13.5%
3.8 pts worse
|
19.6%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 16.3% · Q3 21.0% · Q4 17.6% · 4Q avg 17.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.8% |
14.8%
1 pts better
|
16.7%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 12.0% · Q3 12.5% · Q4 12.3% · 4Q avg 13.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.4% |
15.1%
4.7 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 8.4% · Q3 9.2% · Q4 16.7% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.7% |
15.5%
3.8 pts better
|
14.9%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 8.0% · Q3 11.7% · Q4 15.2% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.6%
0.5 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 1.9% · Q4 1.6% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.4%
1.2 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.3% |
20.8%
2.5 pts worse
|
19.8%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 24.2% · Q3 27.5% · Q4 19.6% · 4Q avg 23.3% |
| Percentage of long-stay residents with pressure ulcers | 9.3% |
6.9%
2.4 pts worse
|
5.1%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 9.7% · Q3 6.3% · Q4 11.2% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.0% |
76.7%
2.3 pts better
|
81.7%
2.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 64.0% · Q2 88.0% · Q3 85.4% · Q4 79.8% · 4Q avg 79.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.6% |
9.7%
4.1 pts better
|
12.0%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.6% · Observed 5.4% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 89.7% |
78.8%
10.9 pts better
|
79.7%
10 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 89.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.6% |
20.6%
5 pts better
|
23.9%
8.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 16.2% · Expected 24.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-01-21 · Fire 2022-01-21
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-10-22 · Fire 2019-10-22
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-10
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-01-29
E · Potential for more than minimal harm
2024-12-10
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-01-29
E · Potential for more than minimal harm
2024-12-10
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-01-29
E · Potential for more than minimal harm
2022-01-21
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-03-15
D · Potential for more than minimal harm
2022-01-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-03-15
E · Potential for more than minimal harm
2019-10-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-10-22
E · Potential for more than minimal harm
2019-10-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-12-21
E · Potential for more than minimal harm
2019-10-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-12-21
E · Potential for more than minimal harm
2019-10-22
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-12-21
Inspection history
Recent health citations
G · Actual harm
2024-12-10
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-01-29
E · Potential for more than minimal harm
2024-12-10
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-29
E · Potential for more than minimal harm
2024-12-10
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-01-29
E · Potential for more than minimal harm
2024-12-10
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-01-29
E · Potential for more than minimal harm
2024-12-10
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-01-29
E · Potential for more than minimal harm
2024-12-10
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-01-29
E · Potential for more than minimal harm
2024-12-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-29
E · Potential for more than minimal harm
2024-12-10
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-10
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-10
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-10
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-10
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-10
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-12-10
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-01-29
D · Potential for more than minimal harm
2024-05-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-06-26
D · Potential for more than minimal harm
2024-05-28
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-08-04
D · Potential for more than minimal harm
2024-03-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-18
E · Potential for more than minimal harm
2022-01-21
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-03-01
E · Potential for more than minimal harm
2022-01-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-03-01
D · Potential for more than minimal harm
2022-01-21
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-03-01
D · Potential for more than minimal harm
2022-01-21
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-03-01
D · Potential for more than minimal harm
2022-01-21
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-03-01
D · Potential for more than minimal harm
2022-01-21
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2022-03-04
D · Potential for more than minimal harm
2022-01-21
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-03-01
D · Potential for more than minimal harm
2022-01-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-01
E · Potential for more than minimal harm
2019-10-22
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-12-10
D · Potential for more than minimal harm
2019-10-22
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-12-10
D · Potential for more than minimal harm
2019-10-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2019-12-10
Penalties and ownership
What sits behind the stars
$47,879
2024-12-10
Fine
Fine · fine $47,879
Fine
Ownership
Koenig, Uri
5% Or Greater Direct Ownership Interest · Individual
Steif, Efraim
5% Or Greater Direct Ownership Interest · Individual
Edwards, Jessica
W-2 Managing Employee · Individual
Rehman, Hafeez
Contracted Managing Employee · Individual
Wuertzer, Amy
Corporate Officer · Individual
Nearby options
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#2
Wilkinson Residential Health Care Facility
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2-star overall rating with 2-star inspections with 9 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Baptist Health Nursing And Rehabilitation Center
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1-star overall rating with 2-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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