Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Westchester Restorative Therapy & Nrsg Crt during CMS and state inspections, most recent first.
A resident with bowel incontinence and new-onset loose, watery stools and nausea had a physician and NP order for a stool bacterial detection panel with C. difficile and a GI PCR, along with PRN Zofran. Over subsequent shifts, documentation showed the resident remained incontinent of bowel and that the ordered stool collection was repeatedly marked on the TAR as "not administered, unable to obtain" by LPNs, despite multiple incontinence episodes. There was no documentation that the NP or physician were notified that the ordered stool specimen had not been collected, even though facility policy required practitioner notification when orders were not carried out and the physician and NP later stated they expected to be informed if a lab test they ordered was not completed.
Surveyors found that two residents did not receive care in accordance with professional standards when prescribed medications were either not administered or refused, and staff failed to notify the physician or document these refusals as required by facility policy. Interviews confirmed that staff did not consistently follow procedures for reporting and documenting medication refusals.
A resident with physical impairments and multiple diagnoses did not have a care plan addressing risk for abuse in place prior to an incident where a CNA allegedly threw a remote at them. The required care plan was only initiated after the event, despite facility policy mandating timely development of comprehensive care plans.
A resident reported that a CNA threw a remote control at them, but there was no documentation in the medical record of any nursing or medical assessment following the allegation. Staff interviews confirmed that such incidents were not recorded in the resident's chart, contrary to facility policy requiring documentation of incidents and assessments.
During a Norovirus outbreak, a facility failed to isolate a resident with a suspected infection, leading to the spread of the virus to their roommate. Despite available beds, the infected resident was not moved, resulting in the roommate developing symptoms and eventually passing away from acute respiratory failure. Interviews revealed that the facility did not follow proper isolation protocols, contributing to the rapid spread of the virus.
A resident's legal representative requested medical records, but the facility delayed providing them beyond the required timeframe. The request was made via email, and although the necessary authorization form was submitted, the records were not sent until several weeks later. Interviews revealed that the delay was due to the Director of Nursing's review process and the need for clarification on the requestor's identity.
A facility failed to maintain an oxygen concentrator for a resident with chronic respiratory conditions, as the filter was not cleaned weekly per policy. During an observation, the filter was found heavily dusted, and staff interviews revealed the task was missed by the night nurse. The DON confirmed the importance of this task to prevent debris accumulation.
Two residents in an LTC facility did not receive their prescribed medications due to unavailability. One resident, with chronic pain and pressure ulcers, missed a dose of Hydromorphone, leading to refusal of wound care. Another resident with Type 2 Diabetes did not receive Jardiance due to delayed reordering. Staff interviews revealed systemic issues in medication management and communication.
The facility failed to store food according to professional standards, with undated and unlabeled items found in the walk-in refrigerator, cook's refrigerator, and freezer. The Director of Food Services was unaware of these issues, which violated the facility's policy requiring proper labeling and dating of food items.
Failure to Collect Ordered Stool Specimen and Notify Practitioner of Uncompleted Lab Test
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards and practitioner orders when a stool specimen was not collected as ordered, and the ordering practitioners were not notified. The facility’s policy dated 05/2025 required that when a physician or other authorized practitioner’s order is not carried out as ordered, delayed, modified, or discontinued, the practitioner must be notified. Resident #124 had diagnoses including moderate persistent asthma, essential hypertension, and spinal stenosis, and was documented as always incontinent of bowel and dependent on staff for toileting and hygiene per the care guide, care plan, and admission MDS. On 12/11/2024, the resident developed loose, watery stools and nausea, and the physician and NP were notified, resulting in orders for a stool bacterial detection panel with C. difficile and Zofran as needed. On 12/11/2024, nursing documentation showed that the resident had an episode of loose watery stool in the morning, with the physician notified and an order given to collect stool for testing. Later that day, an RN documented that the resident had nausea and loose stool, that the NP was made aware, and that stool collection and Zofran were ordered. The NP progress note that evening documented watery stool, ordered a GI PCR to rule out gastroenteritis, and planned to monitor the resident, noting stable vitals and a mildly elevated white blood count. The functional abilities record showed the resident was incontinent of bowel on multiple shifts on 12/11/2024, 12/12/2024, and 12/13/2024. The Treatment Administration Record for December 2024 documented the stool test order on 12/11/2024 and 12/12/2024, with entries by LPN #2 and LPN #3 indicating the stool collection was “not administered, unable to obtain.” Despite repeated incontinence episodes that could have provided opportunities to obtain a specimen, there was no documented evidence that the NP or physician were notified that the ordered stool sample had not been collected. A nursing progress note on 12/12/2024 at 2:24 A.M. documented that the resident was alert, able to make needs known, had poor appetite, good fluid intake, an episode of emesis after drinking water too fast, and was feeling better afterward, but did not address the outstanding stool order. During interviews, LPN #3 acknowledged awareness of the stool collection order and documented “not administered” on two shifts but did not write a note indicating that the NP or physician had been informed that the specimen was not obtained. The LPN Unit Manager stated that whether to notify the NP or physician when a stool sample was not collected was handled on a case-by-case basis. In contrast, the Medical Director/Primary Physician and NP #1 both stated they expected to be informed if a lab test they ordered, such as a stool specimen, was not completed, and NP #1 indicated they might have added additional orders and reminded staff to collect the stool if they had known it was not obtained.
Failure to Notify Physician and Document Medication Refusals
Penalty
Summary
Surveyors identified that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two out of three residents reviewed for medication administration. For one resident with diagnoses including moderate persistent asthma and essential hypertension, the medication administration record showed that a prescribed blood pressure medication was not administered on a specific date, with documentation indicating 'within normal limits' despite no hold parameters being present in the physician's order. Additionally, this resident refused asthma and blood pressure medications on several occasions, but there was no documented evidence that the physician was notified of these refusals as required by facility policy. Another resident, with severe cognitive impairment and diagnoses including dementia and major depressive disorder, refused all oral medications during a shift. The record lacked documentation that the physician was informed of these refusals, contrary to the facility's medication refusal policy. The policy specifies that after three refusals, the physician or appropriate practitioner must be notified and the refusal documented in the resident's record. Interviews with facility staff, including nurses and the Director of Nursing, confirmed that the expected process is to notify the physician or nurse practitioner of medication refusals and to document these events in the resident's chart. However, staff acknowledged that these steps were not consistently followed, with one nurse stating that failure to document a refusal was an oversight. The survey findings indicate that the facility did not adhere to its own policies or professional standards regarding medication administration and documentation.
Failure to Develop Comprehensive Care Plan Addressing Abuse Risk
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan that addressed all of a resident's needs, specifically regarding risk for abuse. The resident in question had multiple diagnoses, including pyogenic arthritis, depression, and bipolar disorder, and was cognitively intact but physically impaired, requiring assistance with mobility, transfers, and toileting. Despite these vulnerabilities, there was no documented evidence that a care plan addressing risk for abuse was in place prior to an alleged incident in which the resident reported that a certified nurse aide threw a television remote at them, striking them in the face. The facility's policy required that a comprehensive care plan be developed within 14 to 21 days of admission, but review of the records showed that the risk for abuse care plan was not initiated until after the alleged incident occurred. Prior to this, the only care plan in place addressed communication needs, with interventions to anticipate and validate the resident's needs. The lack of a timely and comprehensive care plan addressing abuse risk constituted a failure to meet regulatory requirements.
Failure to Document Abuse Allegation and Assessment in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident following an allegation of abuse. Specifically, after a resident reported to their representative that a Certified Nurse Assistant threw a television remote control at them, resulting in the remote hitting their face, there was no documented evidence in the resident's medical chart of any nursing or medical assessment related to the incident. The facility's documentation policy requires that all information related to a resident's care, including incidents and changes in condition, be recorded in the medical record. However, there were no progress notes, body audit forms, or physician assessments documented in the resident's chart regarding the allegation or subsequent evaluation. Interviews with facility staff revealed that such incidents are typically documented in incident reports and kept in a separate file by the Director of Nursing, rather than being included in the resident's medical record. The Social Worker, who was informed of the allegation, did not document an assessment in the medical chart, and the Nurse Practitioner was not asked to assess the resident after the incident. The lack of documentation in the medical record was inconsistent with the facility's own policy and regulatory requirements.
Failure to Isolate Resident Leads to Norovirus Spread
Penalty
Summary
The facility failed to ensure proper isolation of a resident with a suspected communicable infection, leading to the spread of Norovirus. Resident #2 was identified as having a suspected case of Norovirus during an outbreak in the facility. Despite the availability of open beds, Resident #2 was not moved to a separate room, and continued to share a room with Resident #1, who initially did not display any symptoms of the infection. Resident #1, who had diagnoses including Cervical Disc Disorder, Asthma, and Spinal Stenosis, was cognitively intact and required assistance with daily activities. Despite being placed on contact precautions, Resident #1 developed symptoms of Norovirus after remaining in the same room with Resident #2. The facility's policy required isolation or cohorting of infected residents, but this was not implemented effectively, as Resident #1 was not moved to an available bed to prevent cross-contamination. Interviews with the Director of Nursing and a Registered Nurse revealed that the facility did not move residents during the outbreak, despite guidance to separate symptomatic and asymptomatic residents. The Director of Nursing acknowledged that Resident #1 could have been moved to prevent infection, but stated that the virus was spreading rapidly. The facility's failure to isolate Resident #2 or move Resident #1 contributed to the spread of Norovirus, ultimately resulting in Resident #1's death from acute respiratory failure.
Plan Of Correction
Plan of Correction: Approved March 6, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** **Plan of Correction FTAG 880** I. Immediate Action a. Resident #1 expired in the facility on [DATE]. Resident #2 is no longer residing in the facility and has been discharged to home on [DATE]. The Facility acknowledges that all residents on contact precautions/Isolation have the potential to be affected by this practice. b. The Director of Nursing received 1:1 re-education on [DATE] by the Regional Nurse on the Policy Infection Prevention and Control Program with emphasis on ensuring that all residents with a communicable infection, contact isolation are isolated immediately to prevent further spreading of the infection, utilizing all means, including room changes and cohorting as appropriate to ensure all residents' optimum health is maintained. II. Identification of Others a. An audit was conducted on [DATE] by the Infection Preventionist for residents on contact precautions/isolation to ensure all residents requiring contact isolation was in place and room placement was appropriate. No negative findings. III. System Changes a. The Policy and Procedure Titled Infection Prevention and Control Program dated [DATE] was reviewed on [DATE] and [DATE] by the Medical Director, Director of Nursing, Infection Preventionist, and the Administrator with no changes made. b. The Administrator, Assistant Administrator, Nursing Administration, Social Workers, Admissions personnel, and all nursing staff will be educated by the Educator/Designee on the Policy Titled Infection Prevention and Control Program dated [DATE] with emphasis on infection control, ensuring all residents with a communicable infection are isolated immediately to prevent further spreading of the infection utilizing cohorting and room change as appropriate to ensure all residents' optimal health is maintained. c. Registered Nurse #1 will be reeducated upon return to the facility [DATE] by the Staff Educator/designee on the Policy Infection Prevention and Control Program with emphasis on ensuring that residents with a communicable infection, contact isolation are isolated immediately to prevent further spreading of the infection, utilizing room change and cohorting to ensure all residents' optimum health is maintained. IV. Quality Assurance a. An audit tool was created by the Director of Nursing to review all residents placed on contact precautions to ensure staff are following infection control techniques, including isolating residents immediately, cohorting, and initiating room change when appropriate and completing patient-specific care plan with completed goals and interventions. b. Audits will be completed by the Infection Preventionist weekly x 8, then monthly x 2 months and quarterly thereafter until 100% compliance is achieved. c. All negative findings will be brought to the attention of the Director of Nursing immediately. All negative findings will be immediately addressed by the DNS/designee with an onsite teaching/Inservice and disciplinary action as needed. d. All results of the audits will be brought to the QAPI committee quarterly x 4 (to review and discuss any unfavorable patterns that may prevent achieving 100% compliance). V. Person Responsible Director of Nursing Completion Date: (MONTH) 12th, 2025
Delay in Providing Medical Records to Resident's Representative
Penalty
Summary
The facility failed to provide a resident's legal representative with access to the resident's medical records within the required timeframe, as per federal regulations. The representative of a resident requested copies of the resident's complete medical and physical therapy records via email on May 28, 2024. The facility acknowledged the request and informed the representative that an Authorization for Release of Health Information form was needed. The representative submitted the required form on June 16, 2024, but the facility did not provide the requested records until July 8, 2024, which was beyond the stipulated two working days' notice. Interviews with facility staff revealed that the delay was partly due to the Director of Nursing's responsibility to review all medical record requests before they were processed, which was a directive from the previous Administrator. The Director of Nursing acknowledged awareness of the two-day turnaround requirement but cited other facility priorities as a reason for the delay. The Administrator mentioned the need for clarification regarding the requestor's identity and the specifics of the request, as the representative had not been in contact with the facility during the resident's stay. The Administrator also admitted to not being fully familiar with the medical record request process, which contributed to the delay in fulfilling the request.
Plan Of Correction
Plan of Correction: Approved February 20, 2025 Plan of Correction F573 I. Immediate Action a. Resident #3 is no longer residing in the facility and was discharged to NYP(NAME) Valley on 5/1/24. b. The Director of Nursing received a 1:1 education on 2/19/25 by the Regional Nurse on the Facility Medical Record Policy with emphasis on ensuring all written request for copies of the medical records by the resident/resident legal representative within 2 working days advance notice to the facility is followed. c. The Medical Record Personnel received a 1:1 education on 2/19/25 by the Regional Nurse on the Medical Record Policy with emphasis on ensuring all written request for copies of the medical records by the resident / resident legal representative within 2 working days advance notice to the facility is followed. d. The Facility Administrator received a 1:1 Inservice on 2/19/25 by the Regional Nurse on the Facility Medical Record Policy with emphasis on ensuring all written request for copies of the medical records by the resident resident/legal representative within 2 working days advance notice to the facility is followed. II. Identification of Others a. An audit was conducted on 2/19/25 by the Administrator for all request for medical records by the resident/resident legal representative within the last 14 days with no negative findings. b. The facility acknowledges that all resident who request for medical record has the potential to be affected by this practice. III. System Changes a. The Facility Medical Record Policy dated 9/2024 was reviewed on 2/19/25 by the Medical Director, Administrator, Director of Nursing with no changes made. b. The Administrator, the Assistant Administrator, DNS, ADNS and Medical Record Personnel will be reeducated on the Facility Medical Record Policy. IV. Quality Assurance a. An audit tool was created by the Administrator to audit all medical record request to ensure they are sent out timely. b. Audits will be completed by the Medical Record Personnel weekly x 4, monthly x 2 months and quarterly x 3 quarters. c. All negative findings will be brought to the attention of the Administrator immediately. All negative findings will be immediately addressed by the Administrator /Designee with an onsite teaching/Inservice and disciplinary action as needed. d. All results of the audits will be brought to the QAPI committee quarterly x 4 to review and discuss any unfavorable patterns that may prevent achieving 100% compliance. V. Person Responsible Administrator Completion date: (MONTH) 12, 2025
Failure to Maintain Oxygen Equipment as Per Policy
Penalty
Summary
The facility failed to maintain oxygen equipment in accordance with professional standards and manufacturer specifications for a resident requiring respiratory care. Specifically, the oxygen concentrator filter for a resident with chronic respiratory conditions was not cleaned weekly as per the physician's order and facility policy. The resident had diagnoses including Chronic Respiratory Failure with Hypoxia and Chronic Obstructive Pulmonary Disease, necessitating regular oxygen therapy. The facility's policy required the oxygen concentrator filter to be washed weekly, but during an observation, the filter was found to be heavily dusted, indicating it had not been cleaned as required. Interviews with staff revealed that the task of cleaning the filter was assigned to the night nurse, but it was not completed. A Licensed Practical Nurse admitted to forgetting to wash the filter during their shift, and the Director of Nursing confirmed the importance of this task, acknowledging that failure to perform it could lead to debris accumulation. Despite staff being educated on the procedure, the deficiency occurred, highlighting a lapse in adherence to the established maintenance schedule for the oxygen concentrator.
Medication Unavailability Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to provide necessary pharmaceutical services to meet the needs of its residents, as evidenced by two specific incidents involving medication unavailability. Resident #48, who was admitted with chronic pain and multiple pressure ulcers, did not receive the prescribed Hydromorphone (Dilaudid) on 7/30/24 due to the medication not being reordered in a timely manner. The Director of Nursing and the Pharmacy Director both acknowledged that the medication should have been ordered a few days prior to running out. The failure to provide the medication led to Resident #48 refusing wound care treatment due to unmanaged pain. Similarly, Resident #261, who was admitted with Type 2 Diabetes Mellitus, did not receive the prescribed Jardiance on 7/27/24 because it was unavailable. The medication was not reordered in advance, despite the insurance only covering a 14-day supply at a time. The Director of Nursing and the Pharmacy Director both indicated that the medication should have been reordered by 7/24/24 to ensure timely delivery. The lack of communication and timely action resulted in Resident #261 missing a dose of their diabetes medication. Interviews with staff, including the Director of Nursing, Pharmacy Director, and Medical Doctor, revealed systemic issues in medication management, such as failure to reorder medications in advance and inadequate communication with physicians. The facility's policy on medication administration, which requires timely and accurate administration, was not adhered to, leading to significant medication errors and unmet resident needs.
Food Storage Deficiency in Facility
Penalty
Summary
The facility failed to ensure that food was stored in accordance with professional standards for food service safety during a recertification survey. Observations revealed that the walk-in refrigerator contained an open container of Feta Cheese and a 64 oz jug of Cream O Land whole milk, both of which were not dated when opened. Additionally, the cook's daily/ready-to-use refrigerator also contained an undated 64 oz jug of Cream O Land whole milk. In the walk-in freezer, there were unlabeled plastic bags of Tortellini and Croissants that were not dated when opened. Furthermore, the dry storage room contained trays of diet ginger ale without expiration dates. The facility's policy, revised on May 12, 2021, required all food stored in facility refrigerators to be properly wrapped, labeled, and dated, including the received date and use by or expiration date. During an interview, the Director of Food Services admitted to being unaware of the undated items and acknowledged that opened items must be dated and labeled. The Director also stated that the frozen Tortellini and Croissants should be kept in their original packaging and dated when opened. The lack of adherence to these procedures led to the deficiency noted in the survey.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mohegan Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Emerald Peek Rehabilitation And Nursing Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Cortlandt Healthcare | 2.4 mi | ★★★★★ | 1 | 0 |
| Yorktown Rehabilitation & Nursing Center | 2.7 mi | ★★★★★ | 3 | 0 |
| New York State Veterans Home At Montrose | 6.3 mi | ★★★★★ | 4 | 0 |
| Springvale Nursing & Rehabilitation Center | 6.9 mi | ★★★★★ | 29 | 0 |
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