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 The Emerald Peek Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
The facility did not complete Annual Performance Reviews for its staff members as required by policy. During a survey, it was found that the facility could not provide reviews for five staff members. Interviews revealed that the facility had not conducted these appraisals for the past few years and was in the process of resuming them.
A facility failed to maintain a sanitary environment on the 3rd Floor, where a persistent urine odor was noted in shared bathrooms. Despite regular cleaning and the use of odor neutralizers, the smell persisted due to a resident's behavior of urinating outside the toilet. Staff were aware of the issue, but efforts to address it were ineffective.
A facility failed to complete a preadmission screening for a resident with mental disorders, as required by PASARR. The resident, diagnosed with chronic pain, bipolar disorder, and major depressive disorder, arrived but refused admission and was discharged the same day. The SCREEN form was missing critical sections, including the Level 1 Review for Possible Mental Illness and Level II Referrals. The Admission Director admitted the form was not reviewed for completion, and the DON confirmed that forms should be fully completed before accepting a resident.
An LPN in an LTC facility discontinued a resident's physician-ordered wound care treatment without consulting the provider, leading to untreated wounds. The resident had sacrococcygeal moisture-associated skin damage and a deep tissue injury to the right heel. The LPN acted on hearsay from the DON and failed to observe the resident's wounds or consult with the Wound Care Nurse Practitioner.
A facility failed to provide necessary wound care for a resident with pressure ulcers. An LPN discontinued physician-ordered treatments without consulting the Wound Care Nurse Practitioner, based on hearsay from the DON. The resident, who was severely cognitively impaired, had unresolved wounds on the right heel and coccyx, contrary to the LPN's actions. Observations confirmed the presence of open areas, and the Wound Care Nurse Practitioner was not informed of the treatment discontinuation.
A resident with cerebral infarction and aphasia was administered Tramadol 12 times despite a pain scale of less than 5, contrary to the prescribed order for a pain scale of 5-10. Facility staff interviews revealed confusion about the medication order, with a registered nurse unaware of the pain scale's relevance and an LPN Unit Manager suggesting a change from PRN to standing order. The physician and physician assistant confirmed the need for order clarification due to the resident's nonverbal status.
During a survey, it was found that injectable Ativan, a controlled substance, was not stored in a double-locked, permanently affixed compartment on the third floor. Instead, it was in a removable narcotic box inside the medication refrigerator. An LPN was unable to open the box with her keys, and the DON confirmed it should have been affixed, indicating a failure to adhere to the facility's medication storage policy.
A facility failed to maintain infection control practices when a CNA fed two residents with the same hand without sanitizing between, and an LPN administered medications to two residents without performing hand hygiene after touching items in the room. Both staff members acknowledged their lapses in following infection control protocols.
A resident with systemic lupus erythematosus did not receive prescribed methylprednisolone due to a communication breakdown between the facility and pharmacy. The ordered medication was unavailable, and alternative dosing was not effectively communicated. Additionally, the facility did not stock the medication in their emergency supply, and there was a lack of communication among nursing staff during shift changes, resulting in the resident's transfer to a hospital.
A resident with severe cognitive impairment and a history of brain hemorrhage required two-person assistance for bed mobility but frequently received only one-person assistance. During care, the resident fell from the bed, sustaining a lip laceration and a subdural hematoma. The resident was transferred to a hospital for further evaluation and later expired following surgery. The facility acknowledged a care plan violation and documentation discrepancies.
A facility failed to report an alleged abuse incident involving a resident to the New York State Department of Health within the required timeframe. The incident involved a resident with a bruise on the arm, which was attributed to a venipuncture. The facility conducted an internal investigation and concluded no abuse occurred. However, the administration mistakenly believed the Attorney General's office would report the allegation, leading to a deficiency.
Failure to Conduct Annual Performance Reviews
Penalty
Summary
The facility failed to ensure that Annual Performance Reviews were completed for its staff members at least once every 12 months, as required by their policy. During a recertification survey conducted from November 4 to November 8, 2024, it was found that the facility could not provide Annual Performance Reviews for five staff members. The facility's policy, dated October 1, 2024, mandates that each employee's job performance be reviewed annually. Interviews with the Assistant Director of Nursing/Nurse Educator and the Administrator revealed that the facility had not conducted these appraisals for the past few years and was in the process of resuming them. However, they were unable to provide the requested appraisals during the survey.
Persistent Urine Odor in Shared Bathrooms
Penalty
Summary
The facility failed to ensure a sanitary environment for residents on the 3rd Floor, as evidenced by a persistent strong odor of urine in shared bathrooms between certain rooms. Observations revealed that the caulking around the toilet bowls was stained, and broken tiles were present, contributing to the unsanitary conditions. Despite regular cleaning by housekeeping staff, the odor persisted, indicating that standard cleaning procedures were insufficient to address the issue. Interviews with staff, including a Certified Nursing Assistant and a Housekeeper, confirmed the presence of the odor and the challenges in eliminating it. The Housekeeper reported that the issue was brought to the attention of the Director of Environmental Services, who acknowledged the chronic nature of the problem. The resident in one of the rooms was identified as having a behavior of urinating in various areas, exacerbating the odor problem. Despite efforts to clean the area multiple times a day and using special odor neutralizers, the smell remained. The Director of Environmental Services and the Director of Nursing were aware of the issue, with the former having informed the Regional Director about the unresolved problem. The Director of Nursing was unaware of the specific behavior of the resident contributing to the odor, believing it to be a result of incontinence. Attempts to mitigate the smell through increased cleaning and offering more frequent showers to the resident were ineffective, leaving the issue unresolved at the time of the survey.
Incomplete PASARR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure a complete preadmission screening for a resident with a mental disorder, as required by the Preadmission Screening and Resident Review (PASARR) process. This deficiency was identified during a recertification survey, where it was found that the SCREEN DOH 695 form for a resident was incomplete. The resident, who had diagnoses including chronic pain, bipolar disorder, and major depressive disorder, arrived at the facility but refused admission and was discharged against medical advice on the same day. The incomplete form lacked responses to critical sections, including the Level 1 Review for Possible Mental Illness and Mental Retardation/Developmental Disability, as well as the Categorical Determination and Level II Referrals sections. Interviews with facility staff revealed that the Admission Director was responsible for reviewing the SCREEN forms for completion and determining the need for a Level II evaluation. However, the Admission Director admitted that the form for the resident in question was not reviewed for completion, and they were unaware of why it was not completed. The Director of Nursing also confirmed that SCREEN forms should be fully completed before accepting a resident, and any concerns should be discussed with the Interdisciplinary team. The failure to complete the necessary sections of the SCREEN form resulted in the deficiency, as the facility did not ensure that the resident's specialized service needs were assessed prior to admission.
LPN Discontinues Wound Care Without Physician Consultation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality, as evidenced by the actions of a Licensed Practical Nurse (LPN) who discontinued a physician-ordered wound care treatment for a resident without notifying the provider for an order to discontinue. The resident in question had diagnoses of sacrococcygeal moisture-associated skin damage and an in-house acquired deep tissue injury to the right heel. Despite having a comprehensive care plan that required treatments to be administered as ordered, the LPN discontinued the treatment based on hearsay from the Director of Nursing, without observing the resident's wounds or consulting with the Wound Care Nurse Practitioner or any physician. The deficiency was further highlighted when the LPN stated that the resident did not have any prescribed wound care treatment orders and had not been receiving wound treatment for their right heel or sacral area. However, upon observation, the resident's coccyx was found to have a small open excoriated area, and the right heel had red, moist skin with a skin flap and an open area. The Wound Care Nurse Practitioner confirmed that they had not been informed of the discontinuation and that the resident required ongoing wound treatment. The Director of Nursing also confirmed that it was not standard practice for LPNs to discontinue wound care treatments without consulting a physician or nurse practitioner.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. This deficiency was identified during a recertification survey, where it was found that an LPN discontinued a physician-ordered wound care treatment for a resident without notifying the provider or obtaining an order to discontinue. The resident, who was severely cognitively impaired, had a deep tissue injury to the right heel and moisture-associated skin damage to the coccyx region. Despite having a comprehensive care plan that required treatments to be administered as ordered, the LPN ceased the treatment based on hearsay from the Director of Nursing, without conducting a proper assessment or consulting the Wound Care Nurse Practitioner. The LPN stated that they did not observe the resident's wounds or speak with the Wound Care Nurse Practitioner before discontinuing the treatments. The Wound Care Nurse Practitioner confirmed that they were not informed of the discontinuation and would not have approved it, as the resident required ongoing wound treatment. Observations revealed that the resident's right heel had red, moist skin with an open area, and the coccyx had a small open excoriated area, indicating that the wounds had not resolved. The Director of Nursing acknowledged that it was not within the facility's policy or standard practice for LPNs to discontinue wound care treatments without consulting a physician or nurse practitioner.
Unnecessary Drug Administration Due to Miscommunication
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically concerning the administration of Tramadol. Resident #73, who had a diagnosis of cerebral infarction, aphasia, and type 2 diabetes, was prescribed Tramadol 50 milligrams every eight hours for a pain scale of 5-10. However, the medication was administered 12 times between November 1 and November 6, 2024, even when the resident's documented pain scale was less than 5, including instances where the pain scale was recorded as 0. The facility's policy required medication to be administered according to orders, and any concerns about dosage should be discussed with the attending physician or medical director. Interviews with facility staff revealed a lack of clarity and communication regarding the medication order. A registered nurse stated that they were unaware of the reason for including a pain scale in a standing order, given the resident's nonverbal status. The LPN Unit Manager suggested that the order might have changed from as needed (PRN) to a standing order, indicating a need for clarification. The physician confirmed that a standing order with a pain scale should have been followed, and if the pain scale was 0, the nurse should have contacted them before administering the medication. The physician assistant, who last signed off on the medication, acknowledged the resident's inability to provide a numeric pain scale and stated that the order should have been clarified by the nurse.
Controlled Substance Storage Deficiency
Penalty
Summary
The facility failed to provide separately locked, permanently affixed compartments for the storage of controlled substances on the third floor, as observed during a recertification survey. Specifically, injectable Ativan, a controlled substance, was not stored in a double-locked, permanently affixed compartment. Instead, it was found inside a clear plastic narcotic box within the medication refrigerator, which was not affixed to the refrigerator. This was contrary to the facility's policy on medication labeling and storage, which requires controlled substances to be separately locked in permanently affixed compartments. During the observation, an LPN attempted to open the narcotic box with her keys but was unable to do so. The box was then removed from the refrigerator, revealing six injectables of Ativan for a resident. When interviewed, the LPN could not explain why the narcotic box was not affixed. The Director of Nursing later confirmed that the narcotic box should have been permanently affixed and not removable, indicating a lapse in adherence to the facility's medication storage policy.
Infection Control Deficiencies During Resident Care
Penalty
Summary
The facility failed to maintain proper infection control and prevention practices during a recertification survey. Specifically, a Certified Nurse Aide was observed feeding two residents with dysphagia and dementia without performing hand hygiene between feeding each resident. The aide used the same hand to handle utensils for both residents, which was against the facility's infection control protocols. The aide later acknowledged the oversight, attributing it to a lack of sufficient staff to assist with feeding. Additionally, a Licensed Practical Nurse was observed administering medications to two residents without performing hand hygiene after touching various items in the residents' rooms. The nurse handled a wheelchair, a Hoyer lift pad, and a disposable incontinence pad without sanitizing hands before administering oral medications and eye drops. The nurse admitted to being aware of the infection control practices but forgot to adhere to them during the medication administration process.
Failure to Administer Prescribed Medication Due to Communication Breakdown
Penalty
Summary
The facility failed to provide medications as ordered by the prescriber for a resident diagnosed with systemic lupus erythematosus, among other conditions. Specifically, the resident did not receive the prescribed methylprednisolone on two consecutive days, as the medication was not acquired from the pharmacy and administered as ordered. The facility's policy required that medications be administered in a safe and timely manner, and if unavailable, the practitioner should be contacted for further instructions. However, there was no documentation of any such communication or notification to the physician regarding the unavailability of the medication. The deficiency was further compounded by a breakdown in communication between the facility and the pharmacy. The pharmacist noted that the ordered 2 mg tablets were unavailable and recommended an alternative dosing with 4 mg tablets, but this recommendation was not communicated effectively to the facility. Additionally, the facility did not stock the medication in their emergency supply, and there was a lack of communication among nursing staff during shift changes about the missing medication. This resulted in the resident not receiving the necessary medication, leading to their transfer to a hospital.
Failure to Provide Adequate Assistance Leads to Resident's Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident, leading to a fall and subsequent injury. The resident, who had a history of subarachnoid hemorrhage and severe cognitive impairment, required total assistance from two persons for activities of daily living, including bed mobility. Despite this requirement, the resident frequently received only a one-person assist, as documented in the Certified Nurse Aide task records. On the day of the incident, a Certified Nurse Aide was providing care alone when the resident fell from the bed, resulting in a lip laceration and a subdural hematoma. The incident occurred when the Certified Nurse Aide was repositioning the resident during an incontinence brief change and momentarily left the resident unattended to reach for supplies. The resident rolled off the bed and landed on the floor, sustaining a cut on the lip. The resident was assessed by a Registered Nurse Supervisor and later by the attending physician, who ordered a transfer to the emergency room due to the resident's use of blood thinners and the potential for head trauma. A CT scan at the hospital revealed a subdural hematoma, and the resident was transferred to another hospital for further neurological management. The resident's condition deteriorated, and they expired in the hospital following surgery for the subdural hematoma. Interviews with facility staff revealed that the Certified Nurse Aide was aware of the two-person assist requirement but did not follow the care plan. The Director of Nursing and Assistant Director of Nursing acknowledged a care plan violation and noted discrepancies in the documentation of the resident's assistance level, which was often incorrectly coded as a one-person assist. The facility did not interview other aides regarding their adherence to the care plan, considering the incident isolated to one aide.
Failure to Report Alleged Abuse to Health Authorities
Penalty
Summary
The facility failed to report an alleged abuse incident involving a resident to the New York State Department of Health within the required timeframe. The incident involved a resident who was suspected to have been abused, as indicated by a family member's concern about staff behavior and a bruise on the resident's arm. The facility's policy mandates immediate reporting of such allegations, but the facility did not report the incident to the Department of Health. Instead, the facility conducted an internal investigation and concluded there was no evidence of abuse, attributing the bruise to a venipuncture. The facility's administration misunderstood the reporting responsibilities, believing that the New York State Attorney General's office would notify the Department of Health. Interviews with the Director of Nursing, Administrator, and Assistant Director of Nursing revealed that the facility was aware of the allegation but did not fulfill the reporting requirement. The Attorney General's office confirmed that they did not inform the facility that they would report the allegation to the Department of Health. This miscommunication and failure to report the incident led to the deficiency cited in the survey.
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.
Illustrative
What surveyors actually found near you
We read the 414 citations issued within 25 miles in the last 12 months — including the 3 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 Peekskill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cortlandt Healthcare | 1.3 mi | ★★★★★ | 1 | 0 |
| Yorktown Rehabilitation & Nursing Center | 2.3 mi | ★★★★★ | 3 | 0 |
| North Westchester Restorative Therapy & Nrsg Crt | 2.4 mi | ★★★★★ | 1 | 0 |
| New York State Veterans Home At Montrose | 4 mi | ★★★★★ | 4 | 0 |
| Springvale Nursing & Rehabilitation Center | 4.7 mi | ★★★★★ | 29 | 0 |
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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.