Inspection Reports for North Westchester Restorative Therapy and Nursing Center
3550 Lexington Ave, Mohegan Lake, NY 10547, NY, 10547
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
92% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: May 23, 2025
Visit Reason
The inspection was conducted as an abbreviated survey to assess compliance with care planning, medication administration, and documentation standards at the nursing facility.
Findings
The facility failed to develop and implement comprehensive care plans with measurable objectives for residents, ensure medication administration and refusals were properly documented and communicated to physicians, and maintain complete and accurate medical records, including documentation of an alleged abuse incident.
Deficiencies (3)
Failure to develop and implement a complete care plan that meets all the resident's needs with measurable timetables and actions.
Failure to provide appropriate treatment and care according to orders, resident’s preferences and goals, including proper documentation and physician notification of medication refusals.
Failure to safeguard resident-identifiable information and maintain complete and accurate medical records, including lack of documentation of nursing or medical assessment after an alleged abuse incident.
Report Facts
Residents reviewed for care planning: 3
Residents reviewed for medications: 3
Residents affected by deficiencies: 1
Residents affected by deficiencies: 2
Residents affected by deficiencies: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding medication refusal documentation and notification procedures |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding medication refusal procedures and documentation |
| Nurse Practitioner | Nurse Practitioner | Interviewed regarding medication refusal reporting and resident assessment |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan implementation, medication refusal notification, and documentation of alleged abuse incident |
| Registered Nurse #3 | Registered Nurse | Interviewed regarding documentation of alleged abuse incident |
| Social Worker | Social Worker | Reported alleged abuse incident to Director of Nursing and provided written statement |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 3
Date: May 23, 2025
Visit Reason
Complaint Survey with 3 health citations and no life safety citations; deficiencies related to care plan, quality of care, and resident records, all corrected by July 23, 2025.
Findings
Complaint Survey with 3 health citations and no life safety citations; deficiencies related to care plan, quality of care, and resident records, all corrected by July 23, 2025.
Deficiencies (3)
Develop/implement comprehensive care plan
Quality of care
Resident records - identifiable information
Inspection Report
Abbreviated Survey
Deficiencies: 2
Date: Jan 27, 2025
Visit Reason
The inspection was conducted as an abbreviated survey to assess compliance with federal regulations regarding resident rights to access medical records and infection prevention and control practices during a suspected Norovirus outbreak.
Findings
The facility failed to provide a resident's legal representative with requested medical records within the required 2 working days, resulting in a delay from 5/28/2024 to 7/8/2024. Additionally, the facility did not ensure proper isolation of residents with a communicable infection during a Norovirus outbreak, leading to the spread of infection between roommates.
Deficiencies (2)
Failure to provide resident's legal representative with copies of medical records within 2 working days as required by federal regulations.
Failure to isolate residents with communicable infection to prevent spread during Norovirus outbreak.
Report Facts
Charge per page for medical records: 0.75
Number of residents suspected to have Norovirus: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medical records request process and infection control practices. | |
| Administrator | Interviewed regarding medical records request process and facility policy adherence. | |
| Registered Nurse #1 | Interviewed regarding monitoring and cohorting of residents during Norovirus outbreak. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Jan 27, 2025
Visit Reason
Complaint Survey with 2 health citations; deficiencies in infection prevention & control and right to access/purchase copies of records, corrected by March 12, 2025.
Findings
Complaint Survey with 2 health citations; deficiencies in infection prevention & control and right to access/purchase copies of records, corrected by March 12, 2025.
Deficiencies (2)
Infection prevention & control
Right to access/purchase copies of records
Inspection Report
Recertification
Deficiencies: 5
Date: Aug 7, 2024
Visit Reason
The inspection was conducted as a recertification survey and abbreviated survey to assess compliance with regulatory requirements, including abuse prevention, care planning, medication administration, and reporting.
Findings
The facility failed to fully implement abuse prevention protocols for Resident #34, including not removing the accused Certified Nurse Aide from all resident care pending investigation and failing to timely report the abuse allegation to the New York State Department of Health. The facility also failed to develop and implement a care plan for smoking cessation for Resident #257. Additionally, medication management deficiencies were found for Residents #48 and #261, including failure to provide ordered pain medication Hydromorphone (Dilaudid) and diabetes medication Jardiance due to pharmacy delays and lack of timely reorder, resulting in missed doses and refusal of wound care.
Deficiencies (5)
Failure to implement protection component of abuse prohibition protocol for Resident #34, allowing Certified Nurse Aide #1 to continue providing care pending investigation.
Failure to timely report alleged abuse to New York State Department of Health for Resident #34.
Failure to develop and implement a care plan addressing physician ordered nicotine patch and smoking cessation for Resident #257.
Failure to provide ordered pain medication Hydromorphone (Dilaudid) to Resident #48 on 7/30/24 due to medication unavailability, resulting in refusal of wound care.
Failure to provide ordered diabetes medication Jardiance to Resident #261 on 7/27/24 due to medication unavailability and lack of timely reorder or physician notification.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication doses missed: 1
Medication doses missed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Named in abuse allegation and failure to remove from resident care pending investigation |
| Registered Nurse Supervisor #3 | Registered Nurse Supervisor | Reported abuse allegation and removed CNA #1 from Resident #34 assignment |
| Director of Nursing | Director of Nursing | Conducted grievance investigation, interviewed staff, and provided statements on abuse and medication issues |
| Former Administrator | Former Administrator | Provided statements on handling of abuse allegation and staff removal |
| Social Worker | Social Worker | Responsible for initiating smoking care plans and interviewed regarding care plan failure |
| Pharmacy Director | Pharmacy Director | Interviewed regarding medication availability and reorder issues |
| Medical Doctor | Medical Doctor | Interviewed regarding medication reorder communication and expectations |
| Licensed Practical Nurse #11 | Licensed Practical Nurse | Texted Medical Doctor to request medication refill for Resident #48 |
| Licensed Practical Nurse #16 | Licensed Practical Nurse | Reported medication unavailability to supervisor and resident refusal of wound care |
| Licensed Practical Nurse #15 | Licensed Practical Nurse | Administered last dose of Jardiance to Resident #261 and reordered medication |
| Registered Nurse Supervisor #6 | Registered Nurse Supervisor | Supervised medication administration on 7/27/24 and reported missing medications |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Aug 7, 2024
Visit Reason
The inspection was a recertification survey conducted from 7/31/24 to 8/7/24 to assess compliance with regulatory standards in areas including respiratory care, pharmaceutical services, medication administration, pain management, and food safety.
Findings
The facility was found deficient in multiple areas including failure to maintain oxygen concentrator equipment as ordered, medication administration errors with unavailable medications leading to missed doses and resident refusal of care, inadequate pain management, and improper food storage practices such as undated opened food items and unlabeled products.
Deficiencies (4)
Oxygen concentrator filter was not removed and cleaned weekly as ordered, leading to dusty equipment affecting respiratory care for Resident #308.
Medications Hydromorphone (Dilaudid) and Jardiance were not administered as ordered due to unavailability, causing missed doses for Residents #48 and #261.
Resident #48 refused wound care treatment due to unavailability of pain medication Hydromorphone (Dilaudid).
Food items including Feta Cheese, milk, Tortellini, Croissants, and diet ginger ale were stored without proper dating or labeling in refrigerators, freezer, and dry storage.
Report Facts
Residents reviewed for respiratory care: 4
Residents reviewed for pharmacy services: 1
Residents reviewed for drugs/medications: 4
Quantity of Hydromorphone tablets delivered: 90
Medication doses missed: 1
Medication doses missed: 1
Dates of survey: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #13 | Licensed Practical Nurse | Observed oxygen concentrator filter condition and stated cleaning responsibilities. |
| Licensed Practical Nurse #14 | Licensed Practical Nurse | Admitted to forgetting to wash oxygen concentrator filter during night shift. |
| Director of Nursing | Director of Nursing | Provided statements on oxygen concentrator maintenance, medication availability, and nursing responsibilities. |
| Pharmacy Director | Pharmacy Director | Provided information on medication ordering, delivery delays, and backorder status. |
| Medical Doctor | Medical Doctor | Commented on medication ordering procedures and communication with nursing staff. |
| Registered Nurse Supervisor #6 | Registered Nurse Supervisor | Supervised medication administration and noted missing medications on 7/27/24. |
| Licensed Practical Nurse #15 | Licensed Practical Nurse | Reordered Jardiance medication for Resident #261 and commented on pharmacy delivery delays. |
| Licensed Practical Nurse #16 | Licensed Practical Nurse | Reported unavailability of Hydromorphone on 7/30/24 and resident refusal of wound care. |
| Licensed Practical Nurse #11 | Licensed Practical Nurse | Notified Medical Doctor via text about low Hydromorphone supply on 7/29/24. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 16
Date: Aug 7, 2024
Visit Reason
Complaint Survey with 10 health citations and 7 life safety citations; multiple deficiencies including department criminal history review, care plan, food sanitation, abuse prevention, accident hazards, pain management, pharmacy services, reporting violations, medication errors, respiratory care, and various life safety code issues, all corrected by late August/September 2024.
Findings
Complaint Survey with 10 health citations and 7 life safety citations; multiple deficiencies including department criminal history review, care plan, food sanitation, abuse prevention, accident hazards, pain management, pharmacy services, reporting violations, medication errors, respiratory care, and various life safety code issues, all corrected by late August/September 2024.
Deficiencies (16)
Department criminal history review
Develop/implement comprehensive care plan
Food procurement,store/prepare/serve-sanitary
Free from abuse and neglect
Free of accident hazards/supervision/devices
Pain management
Pharmacy srvcs/procedures/pharmacist/records
Reporting of alleged violations
Residents are free of significant med errors
Respiratory/tracheostomy care and suctioning
Corridor - doors
Electrical equipment - power cords and extens
Exit signage
Fire drills
Portable fire extinguishers
Subdivision of building spaces - smoke barrie
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Feb 21, 2023
Visit Reason
Covid-19 Survey with 1 health citation related to reporting to national health safety network; deficiency not corrected at time of report.
Findings
Covid-19 Survey with 1 health citation related to reporting to national health safety network; deficiency not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 3, 2022
Visit Reason
Covid-19 Survey with 1 health citation related to reporting to national health safety network; deficiency not corrected at time of report.
Findings
Covid-19 Survey with 1 health citation related to reporting to national health safety network; deficiency not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Deficiencies: 0
Date: Nov 10, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for a nursing home facility inspection.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 16
Date: Nov 10, 2021
Visit Reason
Complaint Survey with 17 life safety citations; deficiencies included egress doors, electrical equipment and systems, fire alarm and drills, smoke detection, smoking regulations, sprinkler system, physical environment, portable heaters, and subsistence needs for staff and patients; all corrected by January 18, 2022.
Findings
Complaint Survey with 17 life safety citations; deficiencies included egress doors, electrical equipment and systems, fire alarm and drills, smoke detection, smoking regulations, sprinkler system, physical environment, portable heaters, and subsistence needs for staff and patients; all corrected by January 18, 2022.
Deficiencies (16)
Egress doors
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Ep testing requirements
Fire alarm system - testing and maintenance
Fire drills
Horizontal sliding doors
Illumination of means of egress
Maintenance, inspection & testing - doors
Physical environment
Portable space heaters
Smoke detection
Smoking regulations
Sprinkler system - maintenance and testing
Subdivision of building spaces - smoke barrie
Subsistence needs for staff and patients
Inspection Report
Annual Inspection
Census: 34
Deficiencies: 6
Date: Jan 15, 2019
Visit Reason
The inspection was a recertification survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including oral hygiene care for residents, medication administration errors exceeding 5%, improper labeling and storage of drugs, unsanitary kitchen conditions, failure to wear beard restraints by dietary staff, improper garbage disposal leading to pest harborage risk, and inadequate hand hygiene during medication administration.
Deficiencies (6)
Failure to provide necessary oral hygiene care to a resident with severe cognitive impairment, observed with substantial food residue on teeth.
Medication error rate exceeded 5%, with 2 errors out of 31 opportunities (6.45%).
Drugs and biologicals in medication carts and emergency boxes were not properly labeled or stored; included undated insulin pen and expired medications.
Food contact and non-food contact equipment and kitchenware were not maintained in sanitary condition; dietary employees not wearing beard guards.
Garbage dumpsters were overflowing and the surrounding area was littered, creating unsanitary conditions and potential pest harborage.
Staff failed to follow proper hand hygiene during medication pass; nurse did not sanitize hands prior to medication administration.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 6
Residents affected: 3
Medication error rate: 6.45
Medication opportunities: 31
Medication errors: 2
Residents affected: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication error and hand hygiene findings |
| LPN #2 | Licensed Practical Nurse | Named in medication storage and labeling findings |
| Food Service Director | Interviewed regarding kitchen sanitation and garbage disposal | |
| Food Service Manager | Interviewed regarding kitchen sanitation | |
| Director of Nursing | DON | Interviewed regarding medication storage and emergency box checks |
| Dietary Aid #1 | Dietary Aid | Named in beard restraint deficiency |
| Dietary Aid #2 | Dietary Aid | Named in beard restraint deficiency |
| Administrator | Interviewed regarding garbage disposal and pest control issues | |
| Director of Maintenance | DOM | Interviewed regarding garbage disposal and pest control issues |
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