Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

North Westchester Restorative Therapy & Nrsg Crt

Mohegan Lake, NY · 120 certified beds · Last Life Safety survey August 7, 2024

CMS Certification Number 335342 · first certified February 1972

Ownership

Operated by PARAGON HEALTHNET · For profit - Limited Liability company

No change of ownership on CMS record since January 1, 2016, when the records begin.

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within NY

25 citations — more than 85% of the 593 certified nursing homes in NY. Compared within NY rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 7 citations; the earlier surveys in the window averaged 9. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Past the typical window (January 2026 to September 2026). Most NY facilities have been surveyed by February 2027. This facility’s last Life Safety survey was August 2024. Facilities in NY are typically surveyed 18–25 months after the last one (median 22), measured over 523 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

2 of the 25 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 25 Life Safety citations above. The Physical Environment Index

F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in NY, and nationally. Surveyors differ markedly between states, so the NY figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	25
Median facility in NY	13
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
January 15, 2019	2
November 10, 2021	16
August 7, 2024	7

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0712	Have simulated fire drills held at unexpected times.	3	2024-08-07
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	2	2024-08-07
K-0281	Install proper backup exit lighting.	2	2021-11-10
K-0920	Ensure proper usage of power strips and extension cords.	2	2024-08-07
E-0015	Address subsistence needs for staff and patients.	1	2021-11-10
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	1	2024-08-07
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	1	2021-11-10
K-0224	Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.	1	2021-11-10

What the citations cover

Citations by CMS category

Smoke Deficiencies 8
Miscellaneous Deficiencies 6
Egress Deficiencies 5
Gas, Vacuum, and Electrical Systems Deficiencies 4
Other 2

Citations by CMS category
Category	Citations
Smoke Deficiencies	8
Miscellaneous Deficiencies	6
Egress Deficiencies	5
Gas, Vacuum, and Electrical Systems Deficiencies	4
Emergency Preparedness Deficiencies	2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

August 7, 2024 — 7 citations

Citations issued on August 7, 2024
Tag	What the surveyor checks	Status
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (August 23, 2024)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (August 22, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (August 28, 2024)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (August 28, 2024)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (August 28, 2024)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (August 28, 2024)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (August 21, 2024)

November 10, 2021 — 16 citations

Citations issued on November 10, 2021
Tag	What the surveyor checks	Status
E-0015	Address subsistence needs for staff and patients.	Deficient, Provider has date of correction (January 18, 2022)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (January 18, 2022)
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (January 18, 2022)
K-0224	Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.	Deficient, Provider has date of correction (January 18, 2022)
K-0281	Install proper backup exit lighting.	Deficient, Provider has date of correction (January 18, 2022)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (January 18, 2022)
K-0347	Properly provide smoke detection systems in areas open to corridors.	Deficient, Provider has date of correction (January 18, 2022)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (January 18, 2022)
K-0374	Install smoke barrier doors that can resist smoke for at least 20 minutes.	Deficient, Provider has date of correction (January 18, 2022)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (January 18, 2022)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (January 18, 2022)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (January 18, 2022)
K-0781	Have restrictions on the use of portable space heaters.	Deficient, Provider has date of correction (January 18, 2022)
K-0917	Ensure electrical receptacles or cover plates have distinctive color or marking.	Deficient, Provider has date of correction (January 18, 2022)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (January 18, 2022)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (January 18, 2022)

January 15, 2019 — 2 citations

Citations issued on January 15, 2019
Tag	What the surveyor checks	Status
K-0281	Install proper backup exit lighting.	Deficient, Provider has date of correction (February 19, 2019)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (February 19, 2019)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.