Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mountainside Residential Care Center during CMS and state inspections, most recent first.
Two residents with severe cognitive impairments were involved in an incident of sexual abuse, where one resident was found inappropriately touching another. The facility's policy mandates protection from such abuse, but preventive measures were lacking. Staff intervened immediately, but the deficiency highlights a failure in ensuring resident safety.
The facility failed to report resident-to-resident sexual abuse incidents within the required 2-hour timeframe. Two incidents involving residents with cognitive impairments were reported late and incorrectly to the New York State Department of Health. Interviews revealed a misunderstanding of the reporting requirements, with staff believing they had 24 hours instead of the mandated 2 hours.
The facility failed to provide adequate mental health services to two residents with mental disorders. One resident, who experienced a traumatic incident, did not receive the required mental health referral. Another resident, exhibiting concerning behavior, did not receive psychiatric services. The facility lacked psychiatric support, and medical staff were uncomfortable managing psychotropic medications.
A resident with dementia was injured when a windowpane fell inward as they attempted to close it. The window had been identified as a hazard, but the facility failed to repair it properly, leading to the resident's fall and head injury. The maintenance department only locked the window instead of fixing the broken clips, despite a work order indicating the need for immediate repair.
The facility failed to maintain a clean and safe environment for residents on the second and third floors, as observed during a recertification survey. Resident rooms and common areas were not adequately cleaned or maintained, with issues such as unsecured closet doors, stained carpeting, and unsanitary bathroom conditions. Residents reported infrequent cleaning, and the Director of Maintenance confirmed the need for daily cleaning to prevent infection spread. Despite documented issues in environmental rounding reports, only one room had been addressed, and the facility was understaffed in housekeeping.
The facility did not thoroughly investigate incidents involving two residents, one with a hip fracture and another with facial bruising, both with severe cognitive impairment. Despite the severity of the injuries, no documented investigations were found to determine the root causes or rule out abuse or neglect, indicating a lapse in adherence to facility policies.
A resident with anxiety disorder was prescribed Ativan PRN without a stop date, and the facility failed to document indications for use and effectiveness. The facility's policy required a 14-day review of PRN psychotropic drugs, which was not followed. Interviews revealed insufficient documentation of the resident's behavior and non-pharmacological interventions attempted.
A resident with chronic obstructive pulmonary disease had a nebulizer mask that was not properly stored, as it was repeatedly observed uncovered on the bedside table. Facility staff, including an LPN, RN, and the DON, acknowledged that the mask should be stored in a clean plastic bag, but no facility policy on infection control was provided.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, specifically sexual abuse, as observed during an abbreviated survey. On the specified date, one resident was found in another resident's room with their hand down the front of the resident's gown, holding their breast and attempting to kiss them. Both residents involved had severe cognitive impairments and were unable to consent to such interactions. The facility's policy clearly states that residents should be free from all forms of sexual abuse, including any form of sexual contact without consent, especially when residents are incapable of giving informed consent. The incident was witnessed by a Certified Nurse Aide who intervened immediately and removed the offending resident from the room. The resident who was touched was unable to recall the incident, and it was noted that they had difficulty communicating. The facility's documentation, including the Minimum Data Set and Comprehensive Care Plans, indicated that both residents had severe cognitive impairments, which should have prompted the facility to implement preventive measures to protect them from such incidents. Interviews with staff revealed that the facility was aware of the cognitive impairments of both residents and the potential for abuse. Despite this knowledge, the facility did not have adequate measures in place to prevent the incident from occurring. The staff's immediate response to the incident was appropriate, but the lack of preventive measures and supervision prior to the incident contributed to the deficiency. The facility's failure to ensure the safety and protection of residents from abuse highlights a significant oversight in their care protocols.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report allegations of resident-to-resident sexual abuse within the required timeframe of 2 hours, as mandated by regulations. Specifically, the facility did not report a witnessed incident of sexual abuse between two residents, both of whom were not cognitively intact, within the required 2-hour window. Additionally, another incident involving suspected sexual abuse between two residents, one of whom was not cognitively intact, was also not reported within the required timeframe. The facility's policy required immediate reporting or within 24 hours, but the incidents were reported later than the required 2 hours. The incidents were reported incorrectly and late to the New York State Department of Health. The first incident, which occurred on July 7, 2024, was reported on July 10, 2024, and the second incident, which occurred on July 8, 2024, was reported on July 11, 2024. The reports were submitted via email attachment instead of the required Health Commerce System form. Interviews with the Director of Nursing and the Interim Administrator revealed a misunderstanding of the reporting timeframe, with both believing they had 24 hours to report incidents, contrary to the 2-hour requirement for abuse allegations.
Inadequate Mental Health Services for Residents
Penalty
Summary
The facility failed to provide appropriate treatment and services to residents diagnosed with mental disorders, as evidenced by the cases of two residents. One resident, who was cognitively intact according to a recent assessment, experienced a traumatic incident involving another resident. The care plan for this resident required notification of a mental health provider if signs of post-traumatic stress disorder were observed, but there is no evidence that such a referral was made. The incident report and surveyor's observations indicated severe cognitive impairment, which contradicted the assessment, suggesting a lack of accurate documentation and follow-up on the resident's mental health needs. Another resident, diagnosed with depression and severe cognitive impairment, exhibited escalating sexual activity and opportunistic behavior. Despite these concerns, there was no documented evidence that the resident received psychiatric services. The facility's Director of Nursing acknowledged the absence of psychiatric services or a psychologist to address these issues, and the medical staff expressed discomfort in managing psychotropic medications. This lack of specialized mental health support contributed to the deficiency in providing adequate care for residents with mental disorders.
Failure to Address Window Hazard Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment for a resident, resulting in an accident that caused harm. A windowpane on the third-floor care unit, previously identified as a potential hazard, fell inward when a resident attempted to close it. This incident led to the resident sustaining a laceration on their scalp, which required medical attention and staples to close the wound. The resident had severe cognitive impairment due to dementia, which limited their ability to understand the hazard posed by the window. The facility's policies and procedures, including the Near Miss Reporting Tool and the Maintenance Work Request System, were not effectively implemented. A work order had been placed two days prior to the incident, identifying the window as a safety concern that needed immediate repair. However, the maintenance department only locked the window instead of fixing the broken clips, which allowed the windowpane to fall. The failure to properly address the urgent repair request contributed to the resident's injury. Interviews with staff revealed that the window had been marked as needing repair for a long time, and the resident's cognitive limitations made them unable to comprehend the signage indicating the hazard. Despite the known risk, the facility did not take adequate measures to prevent the accident, resulting in harm to the resident. The incident highlights a lapse in the facility's maintenance and safety protocols, as well as a failure to prioritize and address environmental hazards effectively.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents on the second and third floor care units. Observations, record reviews, and interviews during a recertification survey revealed that resident rooms and common spaces were not adequately cleaned, sanitized, or maintained. The facility's policy on residential room cleaning, last revised in October 2022, outlined specific procedures for cleaning and disinfecting resident units, including bathrooms and floors. However, residents reported that their rooms were not being cleaned regularly, with housekeeping staff only emptying trash bins and not performing thorough cleaning. During observations, several deficiencies were noted, including unsecured closet doors, stained and ripped carpeting on walls, and unsanitary bathroom conditions with brown stains in toilets and dust accumulation. Residents expressed concerns about the infrequent cleaning of their rooms, with some stating that their rooms were cleaned only once or twice a week. The Director of Maintenance confirmed that the carpeting on the walls could not be properly sanitized and needed replacement. Additionally, common areas such as shower rooms and sitting areas had visible signs of disrepair and unsanitary conditions, including missing grout, cracked caulking, and stained furniture. The facility's maintenance work request system, last revised in July 2024, was not effectively addressing these issues, as there were no existing work orders for some of the observed deficiencies. The Director of Maintenance acknowledged the need for daily cleaning and sanitization to prevent infection spread but noted that the housekeeping department was understaffed. Environmental rounding reports from earlier in the year documented similar issues with stained and soiled carpeting on walls, yet only one room had been addressed by the time of the survey. The Director of Nursing also recognized the risk of infection due to the carpeting on walls and emphasized the importance of daily cleaning and monthly deep cleaning of resident environments.
Failure to Investigate Alleged Violations
Penalty
Summary
The facility failed to thoroughly investigate alleged violations involving two residents, leading to a deficiency in their response to incidents. Resident #34, who had severe cognitive impairment and was admitted with dementia, suffered an unwitnessed fall resulting in a left hip fracture. Despite the severity of the injury, there was no documented evidence of an investigation to determine the root cause or rule out abuse or neglect. The Director of Nursing at the time of the survey was unaware of why an investigation was not conducted, as they were not in the position when the incident occurred. Similarly, Resident #56, who had severe cognitive impairment and was admitted with Alzheimer's disease, was found with unexplained facial bruising and swelling. Although an initial report was submitted, no follow-up investigation was documented to ascertain the cause of the injury. The previous Director of Nursing reportedly completed investigations on paper, but no records were found. The current Director of Nursing acknowledged that all allegations of abuse, neglect, and injuries of unknown origin should be investigated, highlighting a lapse in the facility's adherence to their policy and procedures.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure proper management and monitoring of a resident's medication regimen, specifically concerning the use of psychotropic medications. A resident with a history of nontraumatic subarachnoid hemorrhage, diabetes, and anxiety disorder was prescribed Ativan on an as-needed basis for anxiety. However, the medication orders did not include a stop date, and there was insufficient documentation regarding the indications for its use and the effectiveness of the medication. The facility's policy required that PRN psychotropic drugs be reviewed by a physician every 14 days, but this was not adhered to in the case of the resident. The resident's medication administration records showed multiple administrations of Ativan over two months, with only two progress notes documenting the reasons for its use and the outcomes. Interviews with nursing staff and a physician assistant revealed that there was a lack of documentation on the resident's behavior before and after administering the medication, as well as non-pharmacological interventions attempted. The physician assistant confirmed that the Ativan prescription should have been reassessed after 14 days, but this process was not followed, leading to a deficiency in the resident's care.
Inadequate Infection Control for Nebulizer Mask
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for a resident requiring respiratory care. The resident, who was admitted with chronic obstructive pulmonary disease, type 2 diabetes mellitus, and gastro-esophageal reflux disease, was observed to have a nebulizer mask that was not properly stored. The Minimum Data Set indicated that the resident was cognitively intact and able to communicate effectively. Despite this, the nebulizer mask was repeatedly observed on the bedside table, uncovered and not stored in a clean plastic bag as recommended by the National Institute of Health guidelines. During multiple observations over several days, the nebulizer mask was found on the bedside table next to the nebulizer machine, not bagged or covered. Interviews with facility staff, including a Licensed Practical Nurse, a Registered Nurse, and the Director of Nursing, confirmed that the nebulizer mask should be cleaned after each use and stored in a clean plastic bag. However, there was no facility policy provided on infection control practices, contributing to the deficiency in maintaining proper infection prevention measures.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 54 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Margaretville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Delhi Rehabilitation And Nursing Center | 17.4 mi | ★★★★★ | 0 | 0 |
| Robinson Terrace | 18.5 mi | ★★★★★ | 6 | 0 |
| Roscoe Regional Rehab & Residential H C F | 19.1 mi | ★★★★★ | 28 | 0 |
| Sullivan County Adult Care Center | 24.5 mi | ★★★★★ | 10 | 1 |
| Achieve Rehab And Nursing Facility | 25 mi | ★★★★★ | 10 | 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 July 2026) and official state health department websites.