Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Paramount At Somers Rehab And Nursing Center during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of constipation was repeatedly flagged for not having bowel movements, but the facility failed to initiate its bowel protocol or document interventions as required. Despite ongoing alerts and care plan directives, staff did not consistently follow up or record the effectiveness of administered treatments, leading to the resident's hospital admission for severe constipation and related complications.
A resident's representative reported missing personal items to facility staff, but the grievance was not documented or followed up according to policy. Communication breakdowns and lack of staff awareness of the grievance process resulted in the resident's concern not being properly addressed.
A resident with significant care needs was discharged without all necessary information being sent to the home care agency, resulting in a delay in the initiation of home care services. The facility did not provide required documentation such as demographics and orders, causing the agency to be unable to process and start services as expected.
A resident with a documented diagnosis of constipation did not have a care plan addressing this issue initiated in a timely manner. Despite repeated documentation of constipation and related symptoms, the facility delayed implementing its bowel protocol and did not consistently administer or monitor prescribed interventions. Staff interviews confirmed that care plan initiation and review processes were not followed as required, resulting in the resident being discharged to the hospital with severe complications related to constipation.
A resident with a history of stroke and Parkinson's disease experienced a sudden onset of slurred speech, which was reported by nursing staff to an NP. The NP initially ordered rest and IV fluids, suspecting dehydration, and only arranged for hospital transfer after continued symptoms and at the request of the resident's representative. The resident was later diagnosed with bilateral scattered infarcts. Facility staff and the medical director did not immediately recognize or act on the potential for acute stroke, resulting in delayed hospital evaluation.
Surveyors found that two residents did not have physician-ordered follow-up orthopedic consultations properly documented or scheduled after initial consults for hip fractures. Staff interviews revealed that orders for follow-up visits were not consistently entered into the electronic medical record, and communication about these appointments was often verbal rather than documented. As a result, both residents were discharged without the recommended follow-up care being arranged or recorded.
A nurse crushed and administered an extended-release Morphine tablet, clearly labeled 'do not crush,' to a resident with chronic pain and respiratory conditions. The resident became lethargic and exhibited opioid overdose symptoms, requiring Naloxone to reverse the effects. Facility policy requiring label checks and adherence to administration instructions was not followed, resulting in actual harm.
Two residents experienced falls, but their care plans were not updated to reflect the incidents as required. One resident with severe cognitive impairment fell from a Hoyer lift, and another with muscle weakness and ambulatory dysfunction had an unwitnessed fall resulting in injury. Staff interviews revealed inconsistent understanding of the need to revise care plans after such events.
A resident with severe cognitive impairment and total dependence for transfers fell from a mechanical lift during a transfer by two CNAs. The fall occurred when a strap on the Hoyer pad slipped or detached, causing the resident to strike their head on the lift. Staff interviews revealed inconsistencies in the transfer process, and the facility's investigation found that the equipment was intact but may not have been properly secured or monitored during the lift.
Two residents in an LTC facility were exposed to accident hazards due to inadequate supervision and safety protocol failures. One resident, with a pureed diet order, consumed inappropriate food and required suctioning after aspirating, while another had an uninspected electric air mattress overlay brought in by a private aide. Staff were unaware of supervision responsibilities and safety checks for personal equipment, leading to these deficiencies.
A resident's privacy was compromised due to a broken window shade and torn screen in their room, which faced the staff parking lot. Despite the resident's complaints and the facility's policy to maintain windows, the issue persisted for over a week. Staff were aware but did not report the problem, and the Director of Maintenance was only informed days later. The deficiency was noted during a recertification survey.
A resident with severe cognitive impairment did not receive necessary ADL care from facility staff, as a private duty aide, against facility policy, provided all care. The aide's involvement was not reported by staff, leading to a lack of documented evidence of care. The facility failed to ensure adherence to care plans and proper documentation.
A facility failed to maintain an adequate stock of prescribed gastrostomy tubes, leading to complications in the care of a resident with a feeding tube. The resident required an 18-gauge gastrostomy tube, but the facility ran out of stock, resulting in the use of an incorrect size and a temporary Foley catheter. The inventory management system was inadequate, and the purchasing process was delayed, contributing to the deficiency.
The facility experienced significant staffing shortages, particularly on night shifts and weekends, affecting resident care. Residents reported falls and delayed response times to call bells, while staff confirmed the lack of sufficient aides impacted care quality. Despite efforts to address the issue, including using agencies and offering incentives, the facility remained understaffed on multiple occasions.
The facility failed to maintain proper labeling and expiration management of medications. Unlabeled Ascor was found in a refrigerator on the [NAME] Unit, and expired Nexium was found in a medication cart on the Westminister Unit. Staff interviews revealed a lack of clarity on medication discontinuation and removal processes.
The facility's main kitchen failed to store food properly due to faulty insulation door seals on the walk-in freezer, leading to ice accumulation. The facility's policy required regular maintenance checks, but the seals were not functioning properly, causing a gap and ice formation. The Food Services Director acknowledged the issue and had requested repairs.
A resident with severe cognitive impairment and a history of aggression was physically abused by a CNA in a long-term care facility. The incident, captured on surveillance video, showed the CNA hitting the resident, resulting in an abrasion. The CNA had a prior disciplinary record and was the only aide on duty at the time. The facility's investigation found reasonable cause for abuse, leading to the CNA's termination.
A resident's Designated Representative was not informed about the risks and benefits of a newly prescribed medication, Depakote, or alternative treatment options before administration. The resident, who was severely cognitively impaired and had a history of aggression, began receiving Depakote following a recommendation from a Psychiatry NP. Despite the facility's policy requiring family notification for medication changes, there was no documented evidence of such communication. The Medical Doctor claimed to have discussed the medication regimen with the Designated Representative but did not document the conversation.
A facility failed to maintain a clean and homelike environment in a dementia unit, where a strong urine odor was pervasive. The unit lacked a night housekeeper, leaving nursing staff to manage accidents until morning. Carpets were cleaned weekly, but the odor persisted due to residents' incontinence and humid weather, highlighting a deficiency in environmental maintenance.
A resident with severe cognitive impairment and multiple diagnoses experienced a fall, but the facility failed to update the Comprehensive Care Plan (CCP) as required. The care plan, which included interventions for fall prevention, was not revised after the incident, despite protocols stating that care plans must be reviewed post-fall. Interviews revealed confusion over responsibilities for updating care plans, contributing to the deficiency.
A resident with dementia in an LTC facility exhibited increasing aggression and wandering behaviors, but their care plan was not updated to address these issues. Despite staff awareness and training, the care plan remained unchanged, and the medical doctor was not informed of escalating behaviors. Staffing challenges were noted by the DON.
The facility did not conduct a comprehensive assessment to determine necessary resources for the [NAME] Unit, a specialized dementia care area. The assessment failed to identify the unit's specific needs and appropriate staffing levels. Observations revealed insufficient night shift staffing, with only 2 CNAs and 1 LPN for 40 residents, some requiring two-person assistance. Despite staff concerns, no staffing changes were made.
Failure to Initiate and Document Bowel Protocol for Resident with Constipation
Penalty
Summary
A resident with moderate cognitive impairment and a history of constipation was admitted to the facility with diagnoses including constipation and sepsis. The resident was frequently incontinent of bowel and bladder, and a care plan was in place to monitor and manage bowel movements, including initiating a bowel protocol if no bowel movement occurred in two days. Despite this, the resident was repeatedly flagged on the facility's bowel list report in June, July, and August for not having bowel movements, but the facility's bowel protocol was not initiated as required by facility guidelines. The resident's medication orders for constipation were inconsistently managed. Senna was ordered and then discontinued after the resident declined it, and Colace was started later. There was no documentation that the bowel protocol was initiated during multiple periods when the resident had no bowel movements, as indicated by clinical alerts. When the resident finally received a dose of Milk of Magnesia, there was no documented evidence of its effectiveness. The lack of follow-up and documentation persisted despite the resident being seen by nurse practitioners and other staff, and despite ongoing alerts indicating the absence of bowel movements. After discharge, the resident was admitted to the hospital with severe sepsis and was found to have large amounts of stool in the rectum and rectal mural thickening on imaging, consistent with severe constipation. Interviews with staff revealed inconsistent practices regarding monitoring, documentation, and initiation of the bowel protocol. Staff acknowledged that alerts were available and discussed, but there was no evidence that appropriate interventions were consistently implemented or documented for this resident.
Failure to Document and Address Resident Grievance Regarding Missing Property
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's right to voice grievances and to make prompt efforts to resolve them, as required by policy. The representative of a resident with moderate cognitive impairment and multiple care needs reported several missing items, including a fleece blanket and a nail manicure kit, to the Patient Relations Concierge. Despite this report, there was no documented evidence that a grievance was filed or that any follow-up was provided to the resident's representative regarding the missing items. The facility's grievance policy requires that grievances be documented and addressed promptly, but this process was not followed in this instance. Interviews revealed that the Patient Relations Concierge received the complaint and attempted to notify the Assistant Administrator and Director of Social Services via WhatsApp, but did not receive a response and was unaware of the official grievance process. The Director of Social Services, who is designated as the grievance officer, stated they were not informed of the issue until much later and confirmed that no grievance documentation existed in the resident's chart. The Administrator acknowledged that the grievance should have been documented and processed according to policy, but this did not occur. Communication breakdowns and lack of staff awareness of the grievance process contributed to the failure to address the resident's grievance appropriately.
Failure to Provide Complete Discharge Information Delays Home Care Services
Penalty
Summary
The facility failed to ensure that all necessary resident information was conveyed to the home care agency at the time of discharge, resulting in a delay in the initiation of home care services for one resident. The resident, who had a history of right femur fracture, depression, muscle weakness, moderate cognitive impairment, and required significant assistance with activities of daily living, was scheduled for discharge with home care services. The discharge planning documentation indicated that arrangements should be made with community resources to support the resident's independence post-discharge. However, the home care agency did not receive all required documentation, including the resident's demographics and orders specifying needed disciplines, which prevented timely initiation of services. Interviews revealed that the facility typically sends discharge referrals two to three weeks before discharge, but the documentation is not maintained in the electronic medical record and is instead kept in paper form. The home care agency representative confirmed that only clinical information was received, and the absence of demographic and insurance information delayed the start of home care services. As a result, the resident's home care services were not initiated until several days after discharge, contrary to the usual practice of starting services within 48 hours.
Failure to Develop and Implement Timely Care Plan for Constipation
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan to address constipation for one resident. The resident was admitted with multiple diagnoses, including a documented diagnosis of constipation, but no care plan addressing constipation was in place until more than two weeks after admission. Despite the facility's policy requiring timely care plan development and the presence of a bowel protocol, the resident experienced multiple episodes without a bowel movement, as documented in the facility's bowel alert lists and medication administration records. The bowel protocol was not initiated until much later, and there was no evidence that interventions were consistently implemented or monitored for effectiveness. The resident's medical records showed repeated documentation of constipation, complaints of discomfort, and requests for stool softeners. Orders for medications such as Senna and Colace were made, but there was inconsistency in their administration and follow-up. The medication administration records did not reflect refusals or consistent use of prescribed laxatives, and there was a lack of documentation regarding the effectiveness of interventions when they were eventually provided. Nursing and medical progress notes indicated ongoing issues with constipation, but the facility did not initiate the bowel protocol in a timely manner, nor did they update the resident's diagnosis list to reflect active constipation. Interviews with facility staff, including LPNs and the DON, revealed that care plans are expected to be initiated at admission and reviewed by registered nurses and the interdisciplinary team. However, in this case, the care plan for constipation was delayed, and the diagnosis was not properly carried over or updated in the resident's records. The resident was eventually discharged and admitted to the hospital with severe sepsis, where imaging revealed significant stool retention and colitis. The deficiency was attributed to the facility's failure to ensure timely and effective care planning and intervention for constipation as required by policy and regulation.
Failure to Provide Timely Hospital Transfer for Resident with Acute Neurological Changes
Penalty
Summary
A deficiency occurred when the facility failed to ensure that services provided met professional standards of quality for a resident with a history of stroke, peripheral vascular disease, and Parkinson's disease. The resident, who had moderate cognitive impairment and required significant assistance with activities of daily living, experienced a sudden onset of slurred speech. This change was first noted by an LPN, who notified the nursing supervisor and a nurse practitioner (NP). The NP instructed staff to place the resident in bed for rest. Despite continued slurred speech, the NP initially ordered intravenous fluids and lab work, suspecting dehydration, and later requested a speech evaluation. The resident's symptoms persisted into the following day, with ongoing slurred speech and general weakness. The NP was again notified and, after further discussion and at the request of the resident's representative, ordered the resident to be transferred to the hospital to rule out a stroke. The resident was subsequently admitted to the hospital with a diagnosis of bilateral scattered infarcts. Documentation and interviews revealed that the NP and medical director did not immediately suspect a stroke and opted to treat in place, attributing symptoms to possible dehydration or other non-stroke causes. The medical director indicated that unless symptoms worsened or failed to improve, the standard practice was to continue treatment in the facility rather than transfer to the hospital. Interviews with facility staff and the resident's representative highlighted delays in recognizing the severity of the resident's symptoms and in transferring the resident for appropriate evaluation and treatment. The NP did not consult the medical director regarding the case, and the medical director did not question the NP's decisions. The facility's approach did not align with timely intervention for potential stroke symptoms, as required by professional standards of care.
Failure to Document and Schedule Physician-Ordered Follow-Up Consultations
Penalty
Summary
Surveyors identified that the facility failed to ensure physicians reviewed residents' total programs of care and documented progress notes and orders at each required visit for two out of three residents reviewed for follow-up consultation visits. Specifically, one resident admitted after a right hip fracture had an orthopedic consultation recommending a follow-up visit and x-ray in six weeks. However, there was no documented evidence that a physician's order for the follow-up was entered, nor was the appointment scheduled before the resident was discharged home. The resident's discharge instructions included a recommendation to follow up with orthopedics post-discharge, but the required in-facility follow-up was not arranged or documented. Another resident, admitted after a left hip fracture, was also scheduled for an orthopedic follow-up consultation. The consultation report specified a follow-up appointment, but there was no documented physician's order for this visit. The resident was discharged without having the follow-up orthopedic appointment completed. Review of the medical record and staff interviews confirmed the absence of documentation regarding the follow-up consultation, and it was noted that the resident would sometimes cancel appointments, but this was not consistently documented in the medical record. Interviews with facility staff, including the unit clerk, LPN, nurse practitioner, and medical director, revealed inconsistent practices regarding the scheduling and documentation of follow-up consultations. The nurse practitioner stated that recommendations from consultations were verbally communicated to nursing staff, but orders were not entered into the electronic medical record. The medical director acknowledged that orders and progress notes for consultations should be documented and that the current process allowed for lapses in scheduling and documentation, leading to missed appointments.
Crushed Extended-Release Morphine Administered, Resulting in Harm
Penalty
Summary
A deficiency occurred when a nurse administered a crushed extended-release Morphine Sulfate tablet to a resident, despite the medication being clearly labeled as 'do not crush.' The nurse, who was responsible for medication administration, stated that the resident was known to spit out medications and could become verbally disruptive if pain medication was not given on time. In an effort to ensure the resident received their pain medication, the nurse crushed all of the resident's medications, including the extended-release Morphine, and administered them together. The facility's policy required nurses to check pharmacy labels and follow all instructions, including not crushing medications labeled as such, but this protocol was not followed in this instance. Following administration, the resident was found lethargic in bed by a speech language pathologist, who alerted nursing staff. The resident exhibited decreased responsiveness, decreased respirations, wheezing, and pinpoint pupils. Initial assessments by nursing staff and the physician led to the administration of Solumedrol and Lasix for respiratory symptoms, as the resident had a history of chronic obstructive pulmonary disease and pulmonary hypertension. It was only after further inquiry that the nurse disclosed the error of crushing the extended-release Morphine, prompting the administration of Naloxone to reverse the effects of the opioid overdose. The resident returned to baseline shortly after receiving Naloxone, and the incident was reported to the physician and the resident's representative. Interviews with staff confirmed that the nurse was aware of the 'do not crush' instruction but proceeded due to being in a rush and wanting to address the resident's pain. The facility's policy on narcotic handling and administration was not adhered to, resulting in actual harm to the resident.
Failure to Update Care Plans Following Resident Falls
Penalty
Summary
The facility failed to ensure that comprehensive care plans were updated and revised following actual falls for two out of four residents reviewed for falls. For one resident with severe cognitive impairment, dementia, and total dependence for mobility and transfers, the care plan was not updated to reflect a fall from a Hoyer lift during a transfer by two CNAs. Although the care plan was later updated with staff education and a physical therapy evaluation, there was no documented evidence that the actual fall event was incorporated into the fall risk care plan as required by facility policy. Another resident, who was cognitively intact but had muscle weakness, ambulatory dysfunction, and required assistance with mobility, experienced an unwitnessed fall in their room resulting in a laceration and skin tears. The care plan for this resident, which identified fall risk due to their physical limitations, was not updated to include the details of the fall incident. Interviews with staff revealed a lack of awareness and inconsistent practices regarding the requirement to update care plans immediately after a fall, with some staff relying on progress notes rather than revising the care plan itself.
Resident Fall During Mechanical Lift Transfer Due to Improper Supervision and Equipment Attachment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dementia, and total dependence for transfers fell from a mechanical lift during a transfer. The resident, who was bedridden and required assistance for all activities of daily living, was being transferred by two Certified Nurse Aides (CNAs) using a Hoyer lift. The facility's fall prevention policy required a comprehensive approach to safety, including environmental adjustments and individualized interventions for residents at risk of falls. During the transfer, one CNA was preparing the resident's chair while the other CNA attached the Hoyer pad to the lift. As the resident was being lifted, they fell out of the Hoyer pad and struck their head on the leg of the lift. Upon investigation, it was found that one of the straps on the Hoyer pad had slipped or become detached during the lifting process, resulting in the resident's fall. Interviews with staff revealed inconsistencies in the sequence of actions, with one CNA stating they were not in position when the transfer began and the other indicating they had attached all the necessary clips. Further interviews with nursing staff and administration indicated that the Hoyer pad and equipment were intact, but the incident may have been caused by improper attachment or shifting of the resident during the transfer. The facility's investigation concluded that the strap may have come off due to the resident's movement or contact with the bed rail, but both CNAs believed they had followed proper procedures. The event demonstrated a failure to ensure the environment was free from accident hazards and that adequate supervision was provided during the transfer process.
Lack of Supervision and Safety Protocols in LTC Facility
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents. Resident #631, who had a physician order for a pureed diet with nectar thick liquids due to dysphagia, was able to consume thin liquids and a cookie while in a supervised area. This led to the resident requiring oral suctioning to clear their throat after aspirating. The incident occurred when the resident was left unsupervised in the common area, despite the care plan indicating the need for close supervision during meals. Staff members were unaware of who was responsible for supervising the area, leading to the resident's exposure to inappropriate food and drink. Resident #226 was found to have an electric air mattress overlay on their bed, which had not been inspected by the maintenance department for safety. The air mattress overlay was brought in by the resident's private duty aide without the facility's knowledge. The Director of Nursing and other staff members were unaware that the air mattress overlay was not provided by the facility and had not been checked for safety. The maintenance department was only informed of the equipment after the survey had begun, highlighting a lapse in the facility's protocol for inspecting electrical equipment brought in by visitors. Both incidents demonstrate a lack of adequate supervision and adherence to safety protocols within the facility. The failure to supervise Resident #631 in the common area and the oversight in inspecting Resident #226's air mattress overlay contributed to the deficiencies identified during the survey. These lapses in care and safety protocols put the residents at risk and indicate a need for improved communication and adherence to established procedures within the facility.
Failure to Maintain Resident Privacy Due to Broken Window Shade
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident, identified as Resident #66, by not maintaining the window in their room in a functional state. The window, which faced the staff parking lot, had a broken shade that could not be pulled down, and a torn insect screen. This situation persisted for over a week, during which Resident #66 expressed dissatisfaction and a desire for privacy. The resident's roommate also confirmed the issue, stating that the broken shade allowed light to shine through the room continuously, necessitating the use of a curtain between the beds for some privacy. Despite the facility's policy requiring windows to be maintained in a safe and functional order, the broken shade and screen were not addressed promptly. Certified Nurse Aide #21 acknowledged awareness of the issue but failed to report it for repair. The Director of Maintenance was unaware of the problem until several days later, at which point the shade was repaired. The Director of Nursing confirmed that residents should be provided privacy upon request, including having window shades closed during care. The deficiency was identified during a recertification survey, highlighting a failure to uphold the resident's right to a dignified existence and privacy.
Failure to Provide Necessary ADL Care
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living (ADL) received the necessary care and services to maintain good personal hygiene. The resident, who had severe cognitive impairment and required total assistance with eating, toileting, and personal hygiene, did not receive the required ADL care on multiple shifts as documented in the October 2024 Certified Nurse Aide documentation. A private duty aide, who was not permitted to provide care according to facility guidelines, stated they provided all care for the resident during their 8-hour daily shifts. Observations and interviews revealed that the private duty aide was performing tasks such as feeding, bathing, and applying protective cream, which were supposed to be done by the facility staff. Certified Nurse Aide #27 admitted that they documented care as provided even when it was not done by them, and they did not report the private duty aide's involvement to the nurses. The Director of Nursing and Licensed Practical Nurse Manager #22 confirmed that private duty aides were not allowed to provide care and that staff should have reported any non-compliance. The facility's failure to ensure proper documentation and adherence to care plans resulted in the resident not receiving the necessary care from the facility staff. The private duty aide's involvement, despite being against facility policy, was not adequately addressed by the staff, leading to a lack of documented evidence of care being provided by the certified nurse aides. This deficiency highlights a breakdown in communication and adherence to facility policies regarding the provision of care by private duty aides.
Failure to Maintain Adequate Stock of Prescribed Gastrostomy Tubes
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications. Specifically, the facility did not have the physician-prescribed gastrostomy tube size available for Resident #182, who was admitted with diagnoses including aphasia, respiratory failure, and gastrostomy status. The resident's care plan required a specific size of gastrostomy tube, but the facility ran out of the necessary 18-gauge gastrostomy tubes, leading to complications in the resident's care. On July 20, 2024, the resident's g-tube balloon broke, and the g-tube came out. The facility did not have the prescribed 18-gauge gastrostomy tube available, and attempts to use a 20-gauge tube were unsuccessful. As a temporary measure, an 18 French Foley catheter was inserted, and the resident was sent to the hospital for a new tube. On July 22, 2024, a 14-gauge gastrostomy tube was inserted because the facility still did not have the correct size in stock, which may have caused the resident's abdominal opening to become smaller. Interviews with facility staff revealed that the inventory management system was inadequate, as the Director of Housekeeping and Central Supply did not maintain records of inventory levels, leading to a shortage of the necessary gastrostomy tubes. The staff was unaware of how long the stock had been depleted, and the facility's purchasing process was delayed, contributing to the deficiency in care for Resident #182.
Staffing Shortages Impact Resident Care
Penalty
Summary
The facility failed to ensure sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Multiple residents and staff members reported that the facility was short-staffed, particularly on night shifts and weekends. The facility's staffing sheets from October 1 to October 31, 2024, revealed that the facility was understaffed on 19 out of 31 days, with only one Certified Nurse Aide scheduled on various units during night shifts. This staffing shortage led to delayed response times to call bells, with residents experiencing falls and other care issues as a result. Interviews with residents and staff highlighted the impact of the staffing shortages. One resident reported experiencing falls due to lengthy response times to call bells, while another resident noted that staff seemed rushed and took about 15 minutes to respond. Staff members, including Certified Nurse Aides and a Licensed Practical Nurse, confirmed the staffing issues, stating that the lack of sufficient aides affected the quality of care, resulting in skin issues and longer wait times for residents. The facility attempted to address the staffing challenges by utilizing agencies, offering incentives, and running a Certified Nurse Aide Training Program, but continued to struggle with maintaining adequate staffing levels.
Medication Labeling and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were maintained in accordance with accepted professional standards, specifically regarding labeling and expiration dates. During an observation of the medication storage room refrigerator on the [NAME] Unit, two boxes of Ascor were found in a plastic bag without a resident name or pharmacy label, while another bag containing three boxes of Ascor was properly labeled. A Licensed Practical Charge Nurse confirmed that all Ascor was ordered for the same resident and should have been in the labeled bag. Additionally, on the Westminister Unit, a blister pack containing 27 capsules of Nexium DR 40 mg was found in a medication cart. The blister pack was labeled for a resident who was no longer receiving the medication, and it had an expiration date of 6/6/24, with a handwritten date of 10/28/24. A Registered Nurse stated that the medication had been discontinued, but they were unsure when. They explained that discontinued or expired medications should be removed from the cart, scanned by the Director of Nursing, and returned to the pharmacy. The Director of Nursing confirmed that the Pharmacy Consultant checks medication carts monthly, and Unit Managers and Charge Nurses conduct weekly checks.
Improper Food Storage Due to Faulty Freezer Seals
Penalty
Summary
The facility failed to ensure proper storage of food in accordance with professional standards for food service safety in the main kitchen. During a recertification survey, it was observed that the walk-in freezer had ice accumulation on the inside door surface, the freezer's floor, and the inner plastic curtain. The facility's policy, dated 8/21/20, required daily maintenance tasks, including door seal inspections to ensure proper functioning, and monthly insulation inspections. However, the freezer's insulation door seals were not attaching properly, leaving a gap between the door and the door's frame, which led to the formation of ice inside the freezer. The Food Services Director confirmed the issue and stated that a request had been placed with a contractor to fix the door seals.
Resident Abuse by CNA in LTC Facility
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, as evidenced by an incident captured on surveillance video. On the night of the incident, a Certified Nursing Assistant (CNA) was observed approaching a resident from behind and subsequently hitting the resident on the shoulder, which led to a physical altercation between the two. The CNA continued to hit the resident with a closed fist, causing the resident to fall to the floor and sustain an abrasion to the nose. This incident resulted in actual harm to the resident, although it was not deemed immediate jeopardy. The resident involved in the incident was admitted to the facility with diagnoses of Lyme disease and unspecified dementia without behavioral disturbance. The resident was assessed as severely cognitively impaired and had a history of physical aggression towards others. The facility had a comprehensive care plan in place for the resident, which included interventions for managing physical aggression and wandering behavior. However, on the night of the incident, the resident was agitated and wandering into other residents' rooms, requiring constant redirection. The CNA involved in the incident had a previous disciplinary record for not appropriately handling a resident-to-resident altercation. On the night of the incident, the CNA was the only aide on the floor, as the other CNA was on break. The Licensed Practical Nurse (LPN) on duty had informed the Nursing Supervisor about the resident's escalating behavior but did not receive a timely response. The LPN later activated a code to request assistance, but by that time, the altercation had already occurred. The facility's investigation concluded that there was reasonable cause to believe that abuse had occurred, leading to the termination of the CNA involved.
Failure to Inform Designated Representative of Medication Changes
Penalty
Summary
The facility failed to ensure that a resident's Designated Representative was informed in advance about the risks and benefits of a newly prescribed medication, Depakote, and alternative treatment options. This deficiency was identified during a survey conducted from July 23, 2024, to July 24, 2024. The resident, who was severely cognitively impaired and had a history of physical aggression, was administered Depakote without the Designated Representative being notified. The facility's policy required family notification regarding changes in medication, but there was no documented evidence that this occurred prior to the administration of Depakote. The Designated Representative had previously expressed concerns about medication changes and had refused an antidepressant due to inadequate explanation from the Psychiatrist. Despite this, the resident began receiving Depakote on July 13, 2024, following a recommendation from a Psychiatry Nurse Practitioner. The Medical Doctor involved stated they discussed the medication regimen with the Designated Representative but did not document the conversation or recall the exact date. The Assistant Director of Nursing indicated that both the Medical Doctor and the unit nurse should notify the Designated Representative of medication changes, but this did not happen in this case.
Deficiency in Maintaining a Clean Environment in Dementia Unit
Penalty
Summary
The facility failed to ensure a clean, comfortable, and homelike environment for residents in the [NAME] Unit, as evidenced by a strong pervasive odor of urine throughout the unit, including in resident rooms. Observations were made on multiple occasions, noting the intense odor upon entering the unit and specific rooms, as well as a sticky wooden floor and a musty damp smell in each resident room. The unit, which houses residents with dementia, had both carpeted and wooden floors, and the odor was particularly strong in certain rooms. Interviews with staff revealed that the unit did not have a housekeeper at night, and nursing staff attempted to clean floors when residents had accidents. However, deep cleaning was only performed when housekeeping staff arrived in the morning. The carpets were cleaned weekly, but the unit's condition was exacerbated by the residents' incontinence and the humid weather. The housekeeping director noted that the unit required constant cleaning due to the residents' conditions, and the administrator stated that carpets were shampooed weekly, with spot cleaning available as needed. Despite these efforts, the odor persisted, indicating a deficiency in maintaining a clean and homelike environment.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to ensure that the Comprehensive Care Plans (CCP) were reviewed and revised in a timely manner for a resident who was at risk for falls. Specifically, the care plan for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's Disease and Bipolar Disorder, was not updated following a fall incident. The resident had a history of falls, and the care plan included interventions such as encouraging the resident to stay in supervised settings, wearing non-skid footwear, and providing reality orientation. However, after a fall on April 2, 2024, where the resident hit their head, there was no documented evidence that the care plan was reviewed or revised. Interviews conducted during the survey revealed a lack of clarity regarding responsibilities for updating care plans. A Licensed Practical Nurse (LPN) stated that they were not responsible for initiating or updating care plans, which was the responsibility of the unit managers. The Assistant Director of Nursing confirmed that LPN Unit Managers are responsible for initiating and updating care plans, but they must be reviewed and signed by a Registered Nurse. Despite this protocol, the care plan for the resident in question was not updated following the fall incident, indicating a lapse in the facility's adherence to its care plan policy.
Failure to Update Dementia Care Plan for Resident
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. This deficiency was identified during a survey, where it was found that the resident's comprehensive care plan was not reviewed and revised to address increasing dementia-related behaviors. The resident, who was admitted with diagnoses of Lyme disease and unspecified dementia, exhibited physical aggression and wandering behaviors, which were not adequately addressed in their care plan. The resident's care plan, initiated in May and updated in July, included goals and interventions to manage behavioral symptoms and impaired cognition. However, despite documented episodes of aggression, wandering, and agitation, there was no evidence that the care plan was reviewed or revised to include individualized approaches to these behaviors. Nursing notes and psychiatric consultations documented the resident's ongoing agitation, restlessness, and exit-seeking behaviors, yet the care plan remained unchanged. Interviews with staff revealed that while they were aware of the resident's behaviors and had received dementia care training, they were not responsible for updating care plans. The medical doctor responsible for the unit was not alerted to any escalation of behaviors, and the facility's staffing issues were acknowledged by the Director of Nursing. Despite these challenges, the facility did not take the necessary steps to update the resident's care plan to address their changing needs.
Inadequate Facility Assessment and Staffing on Dementia Unit
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment to determine the necessary resources for competent resident care, particularly on the [NAME] Unit, a specialized dementia unit. The assessment did not identify the unit as a specialized dementia care area nor did it define the staffing assignments required for its day-to-day operations. The facility's policy on facility assessment was intended to guide decisions on budget, staffing, training, equipment, and supplies, but there was no documented evidence that these needs were addressed for the [NAME] Unit. During the survey, it was observed that the night shift staffing on the [NAME] Unit was insufficient, with only 2 Certified Nursing Assistants and 1 Licensed Practical Nurse for 40 residents, some of whom required two-person assistance and others who wandered at night. The lack of housekeeping staff during the night shift led to nursing staff having to manage cleaning tasks, which was not ideal. Despite concerns raised by staff about the need for more personnel, no changes were made to the staffing schedule. The Administrator acknowledged responsibility for managing the Facility Assessment but relied on the Director of Nursing for insights into resident acuity and staffing needs.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 234 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Somers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waterview Hills Rehabilitation And Nursing Center | 1.9 mi | — | 0 | 0 |
| Salem Hills Rehabilitation And Nursing Center | 1.9 mi | — | 1 | 0 |
| North Westchester Restorative Therapy & Nrsg Crt | 8.7 mi | — | 1 | 0 |
| Yorktown Rehabilitation & Nursing Center | 8.9 mi | — | 1 | 0 |
| Putnam Ridge | 9.6 mi | — | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.