Paramount Somers: Fall Care Plan Failures - NY

The incident occurred March 10, 2024, at The Paramount at Somers Rehab and Nursing Center. Federal inspectors found Resident #3 sitting on the bed facing the door, touching the left side of their face, with their wheelchair positioned nearby.

The resident had a laceration to their left eyebrow and two small skin tears on the left forearm from the fall. Despite these injuries, staff never updated the resident's fall risk care plan to reflect the incident.

Resident #3 had been identified as high-risk for falls since February 7, 2024. Their care plan documented risks including ambulatory dysfunction, muscle weakness and joint pain. Interventions included keeping the call bell and personal items within reach, investigating fall causes, evaluating patterns if multiple falls occurred, maintaining the bed in the lowest position and keeping the environment clutter-free.

But after the March fall that left the resident injured, none of these precautions were reassessed or modified.

The Director of Nursing defended the facility's approach during an August 18, 2025 interview. They stated the facility doesn't list falls on care plans, instead writing progress notes corresponding with incidents and implementing interventions dated from the day of the incident.

The Director claimed the care plan for another resident was properly updated with staff education and a Physical Therapy evaluation the day after their fall, calling this the appropriate care plan update.

However, a registered nurse at the facility contradicted this approach. During a September 2, 2025 telephone interview, Registered Nurse #1 stated care plans should be updated immediately following a fall.

"If a resident has an actual fall, the care plan has to be updated depending on what led to the fall," the nurse explained. They said the fall risk care plan would need updating, along with any care plan related to the cause of the fall, such as behavioral issues.

The nurse acknowledged that while unit managers typically handle care plan updates, the nursing staff works as a team and could update care plans as well.

The contradiction between the Director of Nursing's stated policy and the registered nurse's understanding of proper protocol highlighted confusion within the facility about fall prevention requirements.

Federal regulations require nursing homes to ensure each resident receives care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. This includes preventing accidents and minimizing unavoidable accidents.

When falls do occur, facilities must evaluate what happened and adjust care plans accordingly to prevent future incidents. The failure to update Resident #3's care plan after their injurious fall represented a missed opportunity to enhance their safety.

The inspection found the facility's approach fell short of regulatory standards for accident prevention and care plan maintenance. By treating falls as isolated incidents requiring only progress notes rather than systematic care plan reviews, the facility potentially left residents vulnerable to repeat injuries.

Resident #3's case demonstrated the real-world consequences of inadequate fall prevention protocols. The person experienced pain and injury that might have been prevented with proper care plan updates and enhanced safety measures following their previous fall.

The laceration to the eyebrow and skin tears on the arm served as visible reminders of what can happen when nursing homes fail to learn from residents' accidents and adjust their care accordingly.

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.

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