North Westchester Restorative: Missed Lab Order - NY
The order had been placed on December 11, 2024, at 6:30 in the morning. It appeared on the Treatment Administration Record for December 11, December 12, and December 13. On December 12, Licensed Practical Nurse #3 signed the record for both the 7 a.m. to 7 p.m. shift and the 7 p.m. to 7 a.m. shift to indicate the sample had not been collected. They wrote no note documenting that anyone had been told.
When inspectors interviewed LPN #3 on March 26, 2026, the nurse acknowledged knowing about the order and acknowledged not writing any note to the Nurse Practitioner or physician. Their explanation: a Nurse Practitioner was in the building every day and was "usually aware of the resident's status."
Usually aware is not the same as actually aware.
The unit manager, LPN Unit Manager #1, described the situation as "case-by-case" when asked whether nurses should notify a provider if a stool sample goes uncollected. That framing, that it depends, stood in direct conflict with what both the Medical Director and the Nurse Practitioner told inspectors.
The Medical Director, who was also the primary physician, said the expectation was clear: if a stool sample had not been collected by the day after the order was placed, nurses should call. The Medical Director then acknowledged not knowing whether the Nurse Practitioner on duty had been told, and did not remember being informed that the sample was never collected.
Nurse Practitioner #1 was more direct. When they order a lab test, they said, they expect nurses to make sure it gets done and to inform the provider of the results. If they had known the stool sample was not collected, they said, they might have added additional orders and would have reminded the nurses to collect it. They described the responsibility as belonging to the entire staff.
The stool sample, ordered by a provider who expected results, never came. The provider who expected to be told it wasn't collected was not told. The unit manager responsible for overseeing nursing practice treated the notification question as optional. Three days passed.
The inspection was triggered by a complaint and conducted on March 26 and 27, 2026. Inspectors classified the violation under the standard governing resident care and treatment, with a harm level of minimal harm or potential for actual harm, affecting a small number of residents.
The clinical record for Resident #124 does include a note from around the same period documenting that the resident had refused evening medications due to stomach issues, that their appetite was poor but fluid intake was good, and that they had vomited after drinking water too quickly. Staff encouraged smaller sips, kept the call bell in reach, and noted no acute distress.
What the record does not contain is any note from LPN #3 explaining why the ordered stool sample went uncollected, or any documentation that a physician or Nurse Practitioner was ever told.
The Nurse Practitioner told inspectors that without the sample, without the results, they could not evaluate the resident's condition or decide on next steps. That is what the test was for. Someone ordered it because they needed to know something. Nobody made sure they found out.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Westchester Restorative Therapy & Nrsg Crt from 2026-03-30 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for North Westchester Restorative Therapy & Nrsg Crt
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Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 17, 2026 · Our methodology
NORTH WESTCHESTER RESTORATIVE THERAPY & NRSG CRT in MOHEGAN LAKE, NY was cited for violations during a health inspection on March 30, 2026.
The order had been placed on December 11, 2024, at 6:30 in the morning.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at NORTH WESTCHESTER RESTORATIVE THERAPY & NRSG CRT?
- The order had been placed on December 11, 2024, at 6:30 in the morning.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in MOHEGAN LAKE, NY, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from NORTH WESTCHESTER RESTORATIVE THERAPY & NRSG CRT or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 335342.
- Has this facility had violations before?
- To check NORTH WESTCHESTER RESTORATIVE THERAPY & NRSG CRT's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.