Paramount at Somers: Resident Falls from Lift - NY
The incident occurred while two certified nurse aides were using a Hoyer lift to move a resident from bed to chair. Certified Nurse Aide #1 told inspectors she turned away to position the resident's chair closer for the transfer when she heard the fall behind her.
"They saw Resident #1 falling from the mechanical lift," the inspection report states.
The aide explained that Certified Nurse Aide #2 had already attached the lifting pad to the Hoyer machine and begun raising the resident. But the chair was positioned too far away, forcing the first aide to step away to reposition it.
"Certified Nurse Aide #2 basically, began to transfer the resident without them being in position," Certified Nurse Aide #1 told inspectors.
The resident fell when the Hoyer pad strap detached from the lifting mechanism during the transfer.
Mechanical lifts like the Hoyer require two staff members working in coordination. One operates the lift controls while the other guides and supports the resident during transfer. Both aides must be positioned properly before beginning the lift sequence.
The facility's investigation reached different conclusions about what caused the safety hook to fail. The Assistant Director of Nursing told inspectors on August 22 that "something caused the Hoyer pad strap to pop up and off the Hoyer machine."
She said both nursing aides insisted "they did the procedure the right way." The nursing director theorized that the resident may have brushed against the bed rail, pushing the hook upward and causing it to disconnect.
The Administrator offered another explanation during his interview the same day. He described both aides as "good aides" who "possibly did not know that the Hoyer pad hook came off the Hoyer machine."
"They think that possibly Resident #1's weight was shifted as they lifted/lowered the resident, and the Hoyer pad hook slipped off the Hoyer machine," according to his statement to inspectors.
Neither explanation addresses the fundamental safety issue identified by Certified Nurse Aide #1: her partner began the lift before she was positioned to assist.
The inspection report notes that Certified Nurse Aide #1 was "at the foot of the resident's bed" trying to move the chair when the transfer began. Standard procedure requires both aides to be stationed near the resident throughout the lifting process.
"When they are transferring a resident, they set the chair up so it is closer and not too far," the aide explained to inspectors about proper positioning.
The timing of the investigation also raises questions. The fall occurred before August 22, when administrators interviewed the staff involved. But inspectors didn't arrive until September 10, nearly three weeks later, suggesting the incident may have gone unreported to state authorities initially.
Federal regulations require nursing homes to immediately report any accident resulting in injury to residents. The inspection classified this violation as causing "minimal harm or potential for actual harm" affecting "few" residents.
The facility operates as a 180-bed rehabilitation and nursing center on Route 100 in Somers, about 50 miles north of New York City. The complaint-driven inspection focused specifically on this transfer incident and related safety procedures.
Hoyer lifts are essential equipment in nursing homes, designed to safely move residents who cannot bear their own weight. The devices use fabric slings that attach to an overhead boom via metal hooks. When properly secured, the system can lift residents weighing up to 400 pounds.
But the equipment requires careful attention to safety protocols. Both attachment points must be secured before lifting begins, and staff must maintain constant supervision of the resident throughout the transfer.
The incident at Paramount illustrates how quickly routine procedures can become dangerous when staff coordination breaks down. One aide stepping away for seconds to reposition furniture created the window for mechanical failure and resident injury.
The inspection found the facility violated New York state regulations governing resident care and safety procedures. The specific regulation, 10 NYCRR 415.12(h)(1), requires nursing homes to ensure residents receive proper care and treatment.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 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 occurred while two certified nurse aides were using a Hoyer lift to move a resident from bed to chair.
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.