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 Elcor Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that multiple resident rooms and shared bathrooms were not maintained in a sanitary, comfortable condition, with sticky, malodorous floors and a shared bathroom repeatedly observed with urine, liquid on the floor, and strong odor despite facility policies assigning daily cleaning to housekeeping and bodily fluid cleanup to nursing staff. A resident with dementia and severe cognitive impairment in a shared room was repeatedly observed in bed without a privacy curtain, even while other roommates had curtains and another resident was seated facing the bed, and staff acknowledged that privacy curtains are required and should not be absent for more than a day.
Two residents who were cognitively intact but dependent on staff for ADLs did not receive consistent grooming and hygiene assistance as required by facility policy and their care plans. One resident with necrotizing fasciitis, diabetes, and chronic pain was repeatedly observed with long chin hair and dirty fingernails, with no documented showers, facial hair removal, nail care, or hand hygiene before meals over an extended period, and no records of refusals or reattempts. Another resident with hemiplegia, heart failure, and diabetes, requiring two-person assistance for showers and hygiene, had multiple dates with no documented hygiene care or showers, reported unfulfilled requests for shaving, and was repeatedly observed with significant beard growth. Staff interviews described expectations for regular shaving offers, documentation of refusals, and reattempts of missed care, but the clinical records did not reflect that these practices occurred.
Two residents were exposed to accident hazards when staff did not follow facility policies for medication administration and smoking safety. For one resident with mild dementia, diabetes, COPD, and dysphagia, an LPN prepared multiple oral and inhaled medications and left them unattended at the bedside, despite no assessment or MD order for self-administration and policies requiring an IDT determination before bedside medications are allowed. For another resident with hemiplegia, hemiparesis, and dementia, the required interdisciplinary Smoking/Tobacco Safety Screen was incomplete, even though the care plan called for it and a prior note documented the resident leaving the building early in the morning to smoke and having half-smoked cigarettes on the room floor. Surveyors later observed a cigarette on the floor of this resident’s room, and the resident reported keeping cigarettes and a lighter in the room and going outside to smoke, while the OT and DON confirmed the smoking safety assessment had not been fully completed.
The facility failed to provide suitable, nourishing snacks consistent with resident needs and preferences, offering only limited items such as crackers, pudding, applesauce, and soda, with no meaningful alternatives. A resident with protein-calorie malnutrition and depression, for whom snacks between meals were very important, had a care plan that did not address snack interventions or preferences and reported only receiving pudding without options and not consistently receiving ordered double portions. Another resident with dysphagia, CHF, and hypertension reported that preferred snacks like sandwiches, cookies, and ice cream were no longer available, leaving only basic items. Multiple CNAs, an LPN, and dietary staff confirmed that snack choices had been reduced for cost reasons, residents complained daily, and staff sometimes bought snacks with personal funds. Resident Council and Food Committee records documented ongoing, unresolved complaints about limited snack variety and inconsistent stocking of items such as bread and peanut butter.
Surveyors found that the facility did not follow its own kitchen cleaning schedule, with damaged and ajar ventilation hood filters over the cook top, heavy grease and food debris on the oven and cook top surfaces, and a broken floor section under a steamer containing standing water and food debris. These unsanitary conditions persisted on re-observation. During meal service, disposable plates and utensils were used on the tray line for multiple units because of a shortage of non-disposable plates and silverware, which the Food Service Director attributed to missing items and back-ordered replacements. A resident reported that it would be preferable to have real silverware and plates during meals.
The facility did not implement an effective pest control program on one resident unit, as pest control records showed no documented inspection or treatment of resident rooms despite a policy stating that resident floors would be included in monthly and as-needed extermination rounds. On the Colonial Ridge South unit, surveyors observed multiple small black flies on the walls of two resident bathrooms, along with sticky floors and a foul odor. A family member reported that the flies had been present for some time and previously reported, and described using towels to swat them. The Director of Maintenance stated that the bathrooms lacked exhaust, was not aware of flies in resident rooms, and indicated reliance on the pest control vendor for all inspections and treatments.
Six cognitively intact residents with significant medical conditions were observed smoking on facility property, storing smoking materials in unsecured locations, and discarding cigarette butts outside, despite a facility policy prohibiting smoking. Facility staff did not conduct smoking safety assessments or care planning, and did not provide receptacles for cigarette disposal, contributing to an environment with accident hazards.
Surveyors found that several cognitively intact residents experienced disrespectful and undignified treatment from staff, including being ignored during care, spoken to in a 'nasty' or uncaring manner, addressed with inappropriate terms, and exposed to staff using foul language or answering personal cell phones during care. Facility leadership acknowledged awareness of some of these behaviors, but staff did not consistently uphold residents' rights to dignity and respect.
Two residents with mental health diagnoses reported physical and verbal abuse by nursing staff, including one incident resulting in visible bruising. Facility leadership documented and investigated the allegations but did not report them to state authorities, relying on their interpretation of state guidelines that allowed them to rule out the allegations within two hours.
Unsanitary Resident Areas and Lack of Privacy Curtain in Shared Room
Penalty
Summary
The deficiency involves the facility’s failure to maintain a sanitary, orderly, and comfortable environment in multiple resident units and bathrooms, contrary to its own cleaning policies. Observations on several dates showed sticky, malodorous floors in multiple rooms on Colonial Ridge South, and a shared bathroom used by a cognitively intact resident had brown liquid in the toilet bowl and large quantities of clear, malodorous liquid on the floor. Subsequent observations of the same shared bathroom revealed yellow liquid and paper in the toilet bowl, yellow liquid on the toilet seat, and persistent malodorous liquid on the floor, with the resident reporting that the bathroom was frequently in an unsanitary condition. Facility staff interviews revealed that housekeeping was responsible for once-daily cleaning and sanitizing of bathrooms and rooms, while nursing staff were expected to clean bodily fluids and unsanitary bathrooms and then notify housekeeping for disinfection. The deficiency also includes failure to ensure privacy and a homelike environment for a resident in a shared room who did not have a privacy curtain in place, despite facility policy stating residents have the right to privacy through the use of privacy curtains in shared rooms. This resident had dementia, severe cognitive impairment, and required assistance with personal hygiene and dressing. Over multiple observations, the resident was seen in bed or sleeping in a shared room without a privacy curtain, while other residents in the same room had curtains present, and at one point another resident was seated facing the bed. Staff, including a CNA, an LPN Unit Director, and the Administrator, acknowledged that residents in shared rooms should have privacy curtains and that a curtain should not be absent for more than a day, confirming that the resident’s lack of a privacy curtain was inconsistent with facility expectations and policy.
Failure to Provide and Document Required Grooming and Hygiene Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs), specifically grooming and personal hygiene, to residents who were unable to perform these tasks independently. Facility policies required staff to assist with self-care needs such as hair combing, bathing, grooming, shampooing, shaving, and nail care, including soaking hands and using a nail brush to remove debris. Despite these policies, documentation and observations showed that required hygiene care, including showers, facial hair removal, nail care, and hand hygiene before meals, was not consistently provided or documented, and refusals or reattempts were not recorded. One resident, who had diagnoses including necrotizing fasciitis, type 2 diabetes, and chronic pain, was assessed as cognitively intact and needing substantial assistance with personal hygiene, including hair combing and shaving, without exhibiting rejection of care. The resident’s care plan called for staff assistance with baths or showers on specific evenings and with hygiene before and after meals. However, review of progress notes and Point of Care documentation over a one-month period revealed no evidence that the resident received showers, facial hair removal, or nail care, and there was no documentation of refusals or reattempts. Multiple observations showed the resident with approximately one-inch chin hair, visible debris under fingernails, and no hand hygiene offered before meals, while staff interviews indicated that the resident did not refuse grooming or nail care and would accept assistance if offered. Another resident, with diagnoses including hemiplegia and hemiparesis following cerebral infarction, chronic diastolic heart failure, and diabetes, was also cognitively intact and required staff assistance with showering and personal hygiene without rejecting care. The resident’s care plan and Kardex directed staff to provide showers and hygiene care with two-person assistance on a weekly schedule. Point of Care documentation over several weeks showed multiple dates with no recorded hygiene care and no documentation of refusals or reattempts, and the Treatment Administration Record showed no evidence that showers were provided during the review period. The resident reported requesting a shave several days earlier and again after a shower without receiving follow-up, and repeated observations showed approximately one-inch beard growth. Staff interviews confirmed expectations that residents be asked each shift about shaving, that refusals be documented, and that missed hygiene care be reattempted and reported, but records did not show that these expectations were met.
Failure to Prevent Medication and Smoking-Related Accident Hazards
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible and to provide adequate supervision to prevent accidents for two residents. For one resident with mild dementia, diabetes, COPD, and a care plan noting risk for aspiration and choking related to dysphagia, surveyors observed multiple prepared medications left unattended on the overbed table, including gabapentin, metformin, duloxetine, iron, lactulose, Protonix, a nasal spray, and an inhaler. The resident’s record contained no assessment or physician order for self-administration of oral or inhaled medications, despite facility policies requiring an interdisciplinary assessment and physician order before medications may be left at the bedside. An LPN acknowledged leaving the medications with the resident and stated they should not have done so, and both the RN Manager and DON confirmed that medications should not be left with residents unless they are assessed and ordered for self-administration. The second issue concerns unsafe smoking practices and incomplete smoking safety assessment for a resident with hemiplegia, hemiparesis following a stroke, and dementia, who was documented as cognitively intact. Facility smoking policy required an interdisciplinary assessment deeming a resident safe to smoke unsupervised, secure storage of ignition devices, staff notification prior to smoking, and smoking only in designated areas at least 30 feet from the building. The resident’s care plan required completion of a Smoking/Tobacco Safety Screen, but the screen contained only one LPN manager’s electronic signature and was missing four required interdisciplinary signatures. A prior progress note documented that the resident exited the facility at 4:00 AM to smoke after obtaining the exit door code and had half-smoked cigarettes on the room floor with a smell of freshly lit cigarettes. During observations, a cigarette was seen on the floor of the resident’s room, and the resident reported keeping cigarettes and a lighter in the room and going outside to smoke. The OT and DON confirmed the Smoking/Tobacco Safety Screen was not completed and that the resident did not have a completed evaluation for safe smoking.
Failure to Provide Suitable, Nourishing Snacks Consistent With Resident Needs and Preferences
Penalty
Summary
The deficiency involves the facility’s failure to ensure suitable, nourishing snacks were available and provided in accordance with resident needs, preferences, and care plans. Surveyors found that snacks being distributed consisted primarily of pudding, graham crackers, saltine crackers, applesauce, and soda, with no meaningful alternatives when those items were not desired or appropriate. Observation of the nourishment room showed only limited beverages, crackers, and an almost empty freezer, confirming the restricted snack inventory. Staff interviews revealed that previously available items such as cookies, fig newtons, cheese crackers, and ice cream had been discontinued, and that residents complained daily about the lack of variety and availability. One resident with protein-calorie malnutrition, anxiety disorder, and major depressive disorder was cognitively intact and had an assessment indicating it was very important to have snacks between meals. The resident’s care plan addressed potential nutritional deficit with double portions at meals but did not include any interventions related to snacks or snack preferences. Dietary documentation showed a one-time update of food preferences without ongoing assessment or follow-up regarding snacks. This resident reported only receiving pudding for snacks without additional options, stated that no one had discussed snack preferences, and produced a meal ticket showing an order for two sandwiches when only one was received. Another cognitively intact resident with dysphagia, congestive heart failure, and hypertension reported that snacks were not regularly offered and that preferred items such as sandwiches, cookies, and ice cream were no longer available, leaving only crackers and applesauce as options. Multiple CNAs, an LPN, and the dietary clerk confirmed that snack choices were limited to crackers, pudding, applesauce, and similar items, and some staff stated they purchased snacks with personal funds due to the facility’s limited offerings. The administrator acknowledged that snack availability and resident preferences had been an ongoing concern, that snack options were reduced due to cost without exploring alternatives, and that prior efforts to obtain and follow up on resident preferences were ineffective. Resident Council and Food Committee documentation over several months showed repeated resident complaints about snack availability and variety, with inconsistent stocking of items such as bread and peanut butter and no documented effective resolution.
Failure to Maintain Sanitary Kitchen Conditions and Adequate Dishware for Meal Service
Penalty
Summary
Surveyors identified that the facility failed to follow its own kitchen cleaning schedule and maintain sanitary conditions in the main kitchen. Record review showed the facility had a written cleaning schedule requiring quarterly ventilation hood cleaning, daily floor cleaning, and semi-annual oven and range cleaning in May and November, but there was no documentation that these tasks were completed as required. During observations, the ventilation hood filters over the cook top were found damaged and ajar, allowing grease and vapors to bypass the filtration system, and there were significant soiled black areas of grease and food debris on the backsplash, front, and sides of the oven and cook top units. The Food Service Director reported not being aware that the hood filters were damaged or improperly fitted and was unsure how often deep cleaning of the cooking equipment was performed. Additional observations showed an approximately three-foot by three-foot area of broken floor tiles under the steamer with standing water and food debris present. On a subsequent observation date, the damaged ventilation hood filters, broken flooring with standing water and debris, and heavily soiled oven and cook top units remained unchanged. During meal service observations, disposable plates and utensils were being used on the kitchen tray line for meals delivered to two units because there were not enough non-disposable plates and silverware available. The Food Service Director stated that more plates had been ordered about a month earlier and were on back order, and estimated the kitchen was short about 60 pieces of silverware and 100 plates, noting that plates and silverware would go missing. A resident eating lunch at a nurses' station stated it would be nice to use real silverware and plates during meals.
Failure to Implement Effective Pest Control in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program for one of eight resident units reviewed, specifically the Colonial Ridge South unit. The facility’s undated pest control policy stated that a technician from a contracted licensed extermination service would make monthly and as-needed visits, including rounds to resident floors, administrative offices, common areas, pantries, day rooms, utility areas, and complaint sites. However, review of weekly pest control records from late November through early April showed no documented inspection or treatment of resident rooms, and there was no additional pest control documentation available after early April. During observations on the Colonial Ridge South unit, surveyors noted multiple small black flies in resident bathrooms. In one resident room bathroom, four small black flies were seen on the wall, the bathroom floor was sticky, and there was a foul odor. A resident’s family member reported that the flies had been present for an ongoing period, had previously been reported to the facility, and that they used towels in the bathroom to swat the flies. In a shared bathroom between two other resident rooms, three small black flies were observed on the wall, with similarly sticky floors and a foul odor. The Director of Maintenance stated that the residents’ bathrooms in the Colonial Ridge building did not have exhaust, that they were not aware of flies in resident rooms, and that the pest control vendor was expected to handle all treatments and inspections.
Failure to Assess and Care Plan for Resident Smoking in Violation of Facility Policy
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for six residents identified as cigarette smokers. Despite the facility's policy prohibiting smoking on campus, observations revealed that these residents were smoking on facility property, including areas near entrances and dumpsters. Cigarette butts and smoking paraphernalia, such as lighters and cigarettes, were found in residents' rooms and on the ground outside. Some residents stored cigarette butts in their pockets and later disposed of them offsite. The facility did not provide cigarette receptacles, and staff reported that safety assessments and care planning for smoking were not conducted because the facility is designated as smoke-free. Interviews with facility leadership confirmed that no smoking assessments or care plans were in place for the identified residents, and that smoking materials were not consistently secured as required by the facility's admission agreement. The residents involved had medical conditions such as peripheral vascular disease, congestive heart failure, cerebral infarction, and conversion disorder with seizures, and were documented as cognitively intact. The lack of assessment, care planning, and secure storage of smoking materials contributed to the deficiency, as did the absence of designated smoking areas or receptacles for cigarette disposal.
Failure to Ensure Respectful and Dignified Treatment of Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure residents were treated with dignity and respect, as required by policy and regulation. Multiple residents, all cognitively intact, reported negative interactions with staff across several units. One resident stated that staff do not like them and are not nice, while another reported being repeatedly ignored by a registered nurse during care, with their questions about the care process going unanswered. Another resident's family member overheard staff using foul language in the resident's presence. Additional residents described staff as speaking to them in a disrespectful or 'nasty' manner, being short or uncaring, and using inappropriate terms such as 'sweetie,' 'honey,' or 'baby.' One resident reported that staff talked down to them and answered personal cell phones during care, including while changing incontinence briefs. Interviews with facility leadership confirmed awareness of some of these issues, with the Director of Resident Care Services acknowledging that staff should not use terms like 'honey' or 'baby' and that staff had been spoken to about their demeanor. The Assistant Director of Nursing stated that new employees receive a handbook covering resident rights, including the right to be treated with dignity. Despite these policies, the observations and resident interviews demonstrated that staff did not consistently uphold residents' rights to respectful and dignified treatment.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by policy and regulation. For two residents, one with schizoaffective and bipolar disorders and another with bipolar and conversion disorders, allegations of physical and verbal abuse were made against nursing staff. In one case, a resident reported being dragged down the hall by a nurse, resulting in visible bruising to the knees. In the other case, a resident reported feeling verbally abused by a nurse. Both allegations were documented by staff and discussed with supervisory personnel. Despite these reports, facility leadership, including the Administrator, Director of Resident Care Services, Assistant Director of Nursing, and Director of Nursing, determined that the allegations were not reportable to the New York State Department of Health. They based this decision on their interpretation of the 2016 state complaints manual, concluding that if an allegation is ruled out within two hours, it does not require reporting. As a result, the facility did not report the allegations to the appropriate authorities as required by state law and facility policy.
What surveyors are citing around you — mapped
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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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Horseheads
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethany Nursing Home & Health Related Facility Inc | 2.1 mi | ★★★★★ | 0 | 0 |
| St. Joseph's Hospital - Skilled Nursing Facility | 5.7 mi | ★★★★★ | 3 | 0 |
| Chemung County Health Center - Nursing Facility | 5.7 mi | ★★★★★ | 0 | 0 |
| Corning Center For Rehabilitation And Healthcare | 10 mi | ★★★★★ | 0 | 0 |
| Schuyler Hospital Inc And Long Term Care Unit | 13 mi | ★★★★★ | 0 | 0 |
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