Paramount at Somers: Crushed Opioid Causes Overdose - NY
The incident unfolded on February 20, 2025. When staff called the medical director, they told him Resident #4 was having respiratory symptoms. That was true. It was also, according to the medical director, essentially all they told him.
He ordered Lasix and Solumedrol. The resident had extensive chronic obstructive pulmonary disorder, and respiratory symptoms pointed him toward the lungs. He had no reason to think otherwise. Nobody told him about the crushed medication.
The medical director arrived at the facility about five minutes after he had ordered Naloxone, the opioid-reversal drug. He got there, looked at the situation, and asked staff directly: had this resident received any narcotic medication? That question, which he had to ask himself, is what finally surfaced the answer. Yes. And it had been crushed.
Crushing an extended-release opioid destroys the mechanism that controls how the drug enters the body. A pill engineered to release its contents gradually over hours delivers everything at once instead. The result is an acute overdose.
The medical director told inspectors he had not been informed initially that Resident #4 received crushed extended-release medication. He learned it only because he thought to ask.
Federal inspectors cited the facility for causing actual harm to the resident under F0760, which covers medication errors. The citation notes that few residents were affected.
Licensed Practical Nurse #4 told inspectors that Resident #4 did return to baseline soon after receiving the Naloxone treatment. The medical director confirmed the same: the resident had no ill effects from the medication and came around quickly.
That outcome was fortunate. It was not guaranteed. Naloxone works by blocking opioid receptors, but its effects wear off faster than many opioids do, and a resident who has received a full crushed dose of an extended-release drug can slip back into overdose after the reversal agent clears their system. The medical director's presence at the facility, and his decision to ask the right question, compressed the timeline enough that it did not come to that.
What the inspection record does not show is who crushed the medication, or why. It does not show whether anyone at the facility recognized what had happened before the medical director arrived and asked. It does not show what, if anything, was said to the resident or their family about what had occurred.
What it does show is a physician standing in a nursing home, five minutes after ordering an emergency opioid reversal, learning for the first time that the crisis he was managing had a cause that staff had not mentioned when they called him.
Resident #4 was in chronic pain. The extended-release formulation existed precisely because of that, because sustained pain requires sustained medication, delivered in a controlled way. Crushing it eliminated that control entirely.
The resident came back quickly with the Naloxone, the medical director said. They returned to baseline. In the language of inspection reports, there were no ill effects.
But the resident had stopped breathing normally in a nursing home bed, needed an emergency reversal drug, and the doctor managing their care had to piece together what happened by asking the staff himself. That is the baseline they returned to.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Paramount At Somers Rehab and Nursing Center from 2025-09-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
The Paramount At Somers Rehab And Nursing Center in Somers, NY was cited for violations during a health inspection on September 10, 2025.
The incident unfolded on February 20, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.