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
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 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.