Inspection Reports for
The Paramount at Somers Rehabilitation and Nursing Center
Route 100, Somers, NY, 10589
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
14.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
182% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Abbreviated Survey
Deficiencies: 6
Date: Dec 11, 2025
Visit Reason
The visit was an abbreviated survey to assess compliance with regulatory requirements related to resident grievances, discharge planning, care planning, quality of care, treatment, and physician oversight.
Findings
The facility failed to ensure residents' rights to voice grievances and timely resolution, delayed discharge planning documentation causing delayed home care services, incomplete care planning for constipation leading to hospitalization, inadequate quality of care for stroke symptoms, failure to initiate bowel protocol timely resulting in severe constipation and hospitalization, and lack of physician review and documentation of follow-up consultation visits.
Deficiencies (6)
F 0585: The facility did not ensure a resident's right to voice grievances and failed to make prompt efforts to resolve grievances for Resident #1 whose missing items were not properly addressed or documented.
F 0628: The facility failed to provide all relevant resident information necessary to meet Resident #1's needs at discharge, resulting in delayed initiation of home care services.
F 0656: The facility did not develop and implement a comprehensive care plan for Resident #1's constipation until over two months after admission, contributing to severe sepsis hospitalization.
F 0658: The facility failed to provide professional quality care for Resident #8 by delaying hospital transfer for stroke symptoms until after the resident's representative demanded it.
F 0684: The facility did not ensure Resident #1 received appropriate treatment for constipation, failing to initiate bowel protocol timely despite multiple alerts and no documentation of medication effectiveness.
F 0711: The facility failed to ensure physician review and documentation of follow-up consultation visits for Residents #1 and #10, resulting in missed or unscheduled orthopedic follow-ups.
Report Facts
Residents reviewed for grievances: 3
Residents reviewed for discharge planning: 3
Residents reviewed for constipation care: 4
Residents reviewed for quality of care: 3
Residents reviewed for follow up consultation: 3
Dates of no bowel movement alerts for Resident #1: 22
Date of survey completion: Dec 11, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Practitioner #2 | Nurse Practitioner | Involved in Resident #1's care and follow-up consultation visits |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Provided statements regarding bowel protocol and alerts |
| Director of Nursing | Director of Nursing | Provided statements regarding care plan reviews and bowel management |
| Medical Director | Medical Director | Provided statements regarding stroke care and consultation follow-up expectations |
| Patient Relations Concierge #1 | Patient Relations Concierge | Involved in grievance process for Resident #1 |
| Nurse Practitioner #3 | Nurse Practitioner | Involved in Resident #8's stroke care |
| Registered Nurse #1 | Registered Nurse | Reported Resident #8's symptoms to Nurse Practitioner #3 |
| Unit Clerk #1 | Unit Clerk | Responsible for scheduling follow-up appointments |
Inspection Report
Abbreviated Survey
Deficiencies: 3
Date: Sep 10, 2025
Visit Reason
The facility was surveyed due to an abbreviated survey focusing on compliance with care plan updates, accident hazard prevention, and medication administration safety.
Findings
The facility failed to update comprehensive care plans after resident falls, did not ensure a safe environment free from accident hazards during resident transfers, and had a significant medication error involving administration of crushed extended-release Morphine resulting in actual harm to a resident.
Deficiencies (3)
F 0657: The facility did not update the comprehensive care plans for 2 of 4 residents after actual falls occurred, failing to revise fall risk care plans accordingly.
F 0689: The facility failed to maintain a safe environment and provide adequate supervision to prevent accidents, resulting in a resident falling from a mechanical lift and striking their head.
F 0760: The facility failed to prevent a significant medication error when a resident was administered crushed extended-release Morphine, causing lethargy and respiratory depression requiring Naloxone administration.
Report Facts
Residents reviewed for falls: 4
Residents reviewed for medication administration: 4
Medication error date: Feb 20, 2025
Suspension duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Administered crushed extended-release Morphine causing medication error |
| Certified Nurse Aide #1 | Certified Nurse Aide | Involved in resident fall from Hoyer lift |
| Certified Nurse Aide #2 | Certified Nurse Aide | Involved in resident fall from Hoyer lift and suspended for two days |
| Registered Nurse #2 | Registered Nurse | Assessed resident after medication error and coordinated care |
| Director of Nursing | Director of Nursing | Provided statements regarding care plan updates and medication error |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided statements regarding fall incident investigation |
| Administrator | Administrator | Provided statements regarding fall incident and medication error |
| Speech Language Pathologist #1 | Speech Language Pathologist | Noted resident lethargy after medication error and alerted nursing staff |
| Medical Director | Medical Director | Ordered treatment after medication error and provided interview |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Nov 7, 2024
Visit Reason
The inspection was conducted as part of the recertification and abbreviated surveys to assess compliance with regulatory standards and resident care quality at The Paramount at Somers Rehab and Nursing Center.
Findings
The facility was found deficient in accommodating resident preferences regarding electric wheelchair use, ensuring appropriate post-incident nursing assessments, maintaining a safe environment free from accident hazards, providing proper gastrostomy tube supplies, and staffing levels adequate to meet resident needs.
Deficiencies (5)
10NYCRR 415.5(e)(1) - The facility did not assess Resident #212 for safe use of an electric wheelchair despite requests and policy requirements.
10 NYCRR 415.12 - Resident #631 did not receive a documented Registered Nurse assessment after choking on food not on their diet plan, requiring oral suctioning.
10 NYCRR 415.12 - The facility failed to ensure accident hazards were minimized for Residents #631 and #226, including unsupervised eating and uninspected electrical air mattress overlay.
10 NYCRR 415.12(g)(2) - The facility lacked the physician-prescribed 18-gauge gastrostomy tube for Resident #182, resulting in use of inappropriate tube sizes and hospital transfer.
10NYCRR 415.13(A)(1) (i-iii) - The facility did not consistently provide sufficient nursing staff to meet resident needs, with documented understaffing on multiple days and shifts.
Report Facts
Days understaffed: 19
Staffing rating: 1
Resident census: 50
Resident census: 39
Gastrostomy tube order quantity: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse Unit Manager #8 | Licensed Practical Nurse Unit Manager | Named in gastrostomy tube supply and incident documentation. |
| Registered Nurse Supervisor #9 | Registered Nurse Supervisor | Documented resident assessment and gastrostomy tube issues. |
| Nurse Practitioner #2 | Nurse Practitioner | Ordered gastrostomy tube replacements and hospital transfer. |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing and nursing assessment deficiencies. |
| Administrator | Facility Administrator | Interviewed regarding wheelchair policy and staffing. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 21
Date: Nov 7, 2024
Visit Reason
Complaint Survey with 9 health and 12 life safety deficiencies, mostly Level 2 severity, all corrected by early 2025.
Findings
Complaint Survey with 9 health and 12 life safety deficiencies, mostly Level 2 severity, all corrected by early 2025.
Deficiencies (21)
ADL care provided for dependent residents
Food procurement,store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Label/store drugs and biologicals
Quality of care
Reasonable accommodations needs/preferences
Resident rights/exercise of rights
Sufficient nursing staff
Tube feeding mgmt/restore eating skills
Aisle, corridor, or ramp width
Discharge from exits
Electrical equipment - power cords and extens
Elevators
Exit signage
Fire alarm system - testing and maintenance
Fire drills
Gas equipment - cylinder and container storag
Hazardous areas - enclosure
Stairways and smokeproof enclosures
Standards of construction for new existing nh
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Nov 7, 2024
Visit Reason
The inspection was conducted as a recertification survey and abbreviated surveys from 10/31/24 to 11/07/24 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity and privacy, inadequate assistance with activities of daily living, environmental safety hazards, improper feeding tube management, insufficient nursing staffing, medication management issues, and food storage safety concerns.
Deficiencies (7)
F 0550: The facility did not ensure Resident #66 was treated with dignity and privacy as their window shade and insect screen were broken and unrepaired for over a week.
F 0677: Resident #226 did not receive necessary activities of daily living care on multiple shifts due to interference from a private duty aide who was not permitted to provide care.
F 0689: The facility failed to maintain a safe environment for residents #631 and #226, including inadequate supervision leading to choking and use of an uninspected electrical air mattress overlay.
F 0693: The facility did not have the physician-prescribed 18-gauge gastrostomy tube available for Resident #182, resulting in use of smaller tubes and hospital transfer.
F 0725: The facility did not provide sufficient nursing staff consistently to meet resident needs, with documented understaffing on multiple days and shifts.
F 0761: Expired medications were found in medication carts and unlabeled medications in storage refrigerators, indicating failure to maintain drugs according to professional standards.
F 0812: The kitchen walk-in freezer door seals were not attaching properly, causing ice formation on the floor, door, and plastic curtain inside the freezer.
Report Facts
Days understaffed: 19
Certified Nurse Aide staffing: 1
Medication expiration date: 2023
Tube feeding volume: 2489
Tube feeding frequency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #21 | Aware of broken window shade for Resident #66 but did not report it. | |
| Director of Maintenance | Repaired Resident #66's window shade after being notified on 11/5/24. | |
| Director of Nursing | Stated residents should be provided privacy and acknowledged private duty aides should not provide care. | |
| Certified Nurse Aide #27 | Reported private duty aide provided care to Resident #226 and that staff should report this. | |
| Licensed Practical Nurse Manager #22 | Spoke to staff about private duty aide noncompliance and nursing documentation. | |
| Certified Nurse Aide #4 | Observed Resident #631 aspirating thin liquids and called for nurse assistance. | |
| Licensed Practical Nurse #3 | Documented choking incident of Resident #631 and assisted with suctioning. | |
| Director of Housekeeping and Central Supply | Reported running out of 18-gauge gastrostomy tubes and inventory issues. | |
| Nurse Practitioner #2 | Ordered gastrostomy tube replacements and managed Resident #182's tube issues. | |
| Registered Nurse Supervisor #9 | Documented gastrostomy tube clogging and replacement. | |
| Staffing Coordinator | Reported staffing challenges and use of agencies. | |
| Certified Nurse Aide #20 | Reported short staffing on night shifts and impact on resident care. | |
| Licensed Practical Nurse #18 | Reported short staffing affecting resident care and call bell response times. | |
| Registered Nurse #17 | Reported discontinued medication found in medication cart. | |
| Food Service Director | Reported walk-in freezer door seal issues causing ice formation. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Aug 7, 2024
Visit Reason
Complaint Survey with 6 health deficiencies including a Level 3 severity for free from abuse and neglect; all deficiencies corrected by September 12, 2024.
Findings
Complaint Survey with 6 health deficiencies including a Level 3 severity for free from abuse and neglect; all deficiencies corrected by September 12, 2024.
Deficiencies (6)
Care plan timing and revision
Facility assessment
Free from abuse and neglect
Right to be informed/make treatment decisions
Safe/clean/comfortable/homelike environment
Treatment/service for dementia
Inspection Report
Abbreviated Survey
Deficiencies: 6
Date: Jul 23, 2024
Visit Reason
The abbreviated survey was conducted to assess compliance with regulatory requirements related to resident rights, environment, abuse prevention, care planning, dementia care, and facility-wide assessment.
Findings
The facility failed to ensure residents were fully informed about treatment risks and alternatives, maintain a clean and homelike environment, prevent physical abuse by staff, update comprehensive care plans timely, provide appropriate dementia care, and conduct a facility-wide assessment identifying specialized unit needs and staffing.
Deficiencies (6)
F 0552: The facility did not ensure Resident #1's Designated Representative was informed in advance of the risks and benefits of Depakote or alternative treatment options prior to medication administration.
F 0584: The facility did not ensure a clean, comfortable, and homelike environment on the dementia unit, evidenced by a strong pervasive odor of urine throughout the unit and resident rooms.
F 0600: The facility failed to protect Resident #1 from physical abuse by Certified Nursing Assistant #1, who was seen on video hitting and pushing the resident, causing actual harm.
F 0657: The facility did not ensure Resident #2's At Risk for Fall Comprehensive Care Plan was reviewed and revised after a fall incident on 04/02/2024.
F 0744: The facility did not ensure Resident #1's dementia care plan was reviewed and revised to address increasing dementia-related behaviors including wandering, restlessness, agitation, and exit-seeking.
F 0838: The facility did not conduct a facility-wide assessment identifying the dementia unit as specialized or define staffing assignments necessary for day-to-day operation of the unit.
Report Facts
Residents on dementia unit: 40
Residents requiring 2-person assistance: 6
Residents who wander at night: 4
Deficiency count: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in physical abuse finding involving Resident #1. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Charge nurse during Resident #1's agitation and involved in monitoring and reporting behaviors. |
| Registered Nurse #1 | Nursing Supervisor | Nursing Supervisor on night shift during abuse incident and involved in investigation. |
| Medical Doctor #1 | Physician | Responsible for Resident #1's medication and care, interviewed about medication communication. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding notification procedures and care plan responsibilities. |
| Director of Nursing | Director of Nursing | Interviewed about staffing issues, abuse prevention, and facility-wide education. |
| Administrator | Administrator | Interviewed about facility rounds, staffing, and abuse prevention efforts. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Sep 18, 2023
Visit Reason
The visit was an abbreviated survey to evaluate compliance with regulatory requirements related to Certified Nursing Assistant (CNA) performance reviews.
Findings
The facility failed to ensure that annual performance reviews were completed for seven of nine CNAs reviewed. Interviews with the Director of Nursing and Administrator confirmed that annual performance evaluations were not performed.
Deficiencies (1)
F 0730: The facility did not complete annual performance reviews for seven CNAs as required by policy. The facility was unable to provide documented evidence of these reviews for CNA #'s 4,5,6,7,8,9, and 10.
Report Facts
Number of CNAs without annual performance reviews: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding lack of annual CNA performance evaluations. | |
| Administrator | Interviewed regarding lack of annual CNA performance evaluations. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Sep 18, 2023
Visit Reason
Complaint Survey with 1 health deficiency related to nurse aide performance review; corrected by November 2, 2023.
Findings
Complaint Survey with 1 health deficiency related to nurse aide performance review; corrected by November 2, 2023.
Deficiencies (1)
Nurse aide peform review-12 hr/yr in-service
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 9, 2023
Visit Reason
The visit was conducted as an abbreviated survey to assess compliance with regulations regarding the use of bed rails (side rails) in the facility.
Findings
The facility failed to ensure that residents or their representatives were informed of the risks and benefits of bed rails and that informed consent was obtained prior to installation for 65 of 242 residents reviewed. Additionally, care plans and proper documentation regarding the number and use of side rails were incomplete or missing for several residents.
Deficiencies (1)
F 0700: The facility did not ensure informed consent was obtained or risks and benefits communicated to residents or representatives for bed rail use for 65 of 242 residents reviewed. Care plans and side rail reviews were incomplete or not timely for residents #4, #20, and #27.
Report Facts
Residents reviewed for side rails: 242
Residents without documented informed consent: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA #1) | Interviewed regarding side rail use and protocol | |
| Certified Nursing Assistant (CNA #3) | Interviewed regarding side rail use and protocol | |
| Director of Nursing (DON) | Interviewed regarding side rail evaluation and assessments | |
| Administrator | Interviewed regarding facility policy on side rails | |
| Licensed Practical Nurse Manager (LPNM) | Interviewed regarding side rail evaluations and consent process |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Mar 9, 2023
Visit Reason
Complaint Survey with 1 health deficiency related to bedrails; corrected by May 5, 2023.
Findings
Complaint Survey with 1 health deficiency related to bedrails; corrected by May 5, 2023.
Deficiencies (1)
Bedrails
Inspection Report
Deficiencies: 0
Date: Aug 23, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for The Paramount at Somers Rehab and Nursing Center, summarizing the results of a regulatory survey completed on 2022-08-23.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 7
Date: Aug 23, 2022
Visit Reason
Complaint Survey with 7 life safety code deficiencies including discharge from exits and sprinkler system issues; all corrected by October 17, 2022.
Findings
Complaint Survey with 7 life safety code deficiencies including discharge from exits and sprinkler system issues; all corrected by October 17, 2022.
Deficiencies (7)
Discharge from exits
Electrical equipment - power cords and extens
Electrical systems - essential electric syste
Gas equipment - cylinder and container storag
Sprinkler system - installation
Sprinkler system - maintenance and testing
Standards of construction for new existing nh
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Feb 13, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to implement advance directives properly, incomplete significant change assessments for pressure ulcers, inadequate care plans for residents with complex needs, insufficient dialysis care and monitoring, failure to implement pharmacist recommendations for medication management, lapses in infection prevention and control practices, and unsafe mechanical equipment conditions related to boiler exhaust odors.
Deficiencies (7)
F 0578: The facility did not ensure advance directives were implemented according to residents' wishes; DNR orders were not properly indicated on wristbands for 3 residents.
F 0637: The facility failed to complete a significant change Minimum Data Set assessment within 14 days for a resident with two Stage 3 pressure ulcers.
F 0656: The facility did not develop and implement complete care plans with measurable goals for residents' renal, respiratory, and behavioral needs.
F 0698: The facility failed to provide safe dialysis care including daily assessment of dialysis access for thrill and bruit and pre/post dialysis monitoring.
F 0756: The facility did not ensure pharmacist recommendations for blood sugar monitoring parameters were implemented for a resident receiving insulin and diabetes medications.
F 0880: The facility failed to ensure proper hand hygiene during meal service and wound care, and did not follow physician orders for wound irrigation.
F 0908: The facility did not maintain mechanical equipment in safe operating condition; diesel exhaust odors were noted from a boiler serving resident units.
Report Facts
Residents reviewed for advance directives: 5
Stage 3 pressure ulcers documented: 2
Hemodialysis days without pre/post assessments: 5
Fingerstick blood sugar monitoring frequency: 4
Boiler installation date: 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Confirmed facility policy on DNR wristband yellow dot | |
| RN #3 | Interviewed regarding missing ID bracelet for Resident #224 | |
| MDS Coordinator | Interviewed about delayed significant change MDS assessment | |
| Nurse Manager (NM#1) | Interviewed about Resident #141's spitting behavior and respiratory care | |
| RN #2 | Interviewed about lack of post dialysis assessments for Resident #128 | |
| RN Unit Manager | Interviewed about care plan and fingerstick blood sugar monitoring | |
| LPN #3 | Observed and interviewed regarding improper wound care and hand hygiene | |
| Director of Building Services | Interviewed about boiler exhaust odor and maintenance |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 0
Visit Reason
Three inspections with no citations.
Findings
Three inspections with no citations.
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