D+
50/100Kirkhaven Inspection Report, Violations & Safety Grade (Rochester, New York)
254 Alexander Street, Rochester, New York 14607
Phone: 5854611991
CMS Overall:1/5
Overview & Bed Count
Certified Beds
147
Avg Residents/Day
130
Ownership
Non profit - Corporation
Provider Type
Medicare and Medicaid
County
Monroe
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall1/5
Health1/5
Staffing1/5
Quality3/5
Nurse Staffing Check
| Metric | This Facility | New York Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.39 | 0.73 | -0.34 |
| Total Nurse Hours per Resident per Day | 2.99 | 3.69 | -0.70 |
| CMS Staffing Rating | 1/5 | 2.9/5 | - |
| Nursing Staff Turnover | N/A | 40.3% | - |
Health Citation History
30 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-03-18 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | E – Moderate Harm Potential |
| 2026-03-18 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | E – Moderate Harm Potential |
| 2026-03-18 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E – Moderate Harm Potential |
| 2026-03-18 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E – Moderate Harm Potential |
| 2026-03-18 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2026-03-18 | Nutrition and Dietary Deficiencies | Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | D – Moderate Harm Potential |
| 2025-12-08 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | G – Actual Harm |
| 2025-12-08 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | E – Moderate Harm Potential |
| 2025-12-08 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E – Moderate Harm Potential |
| 2025-12-08 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2025-07-16 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2024-12-09 | Resident Assessment and Care Planning Deficiencies | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | E – Moderate Harm Potential |
| 2024-12-09 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | E – Moderate Harm Potential |
| 2024-12-09 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2024-12-09 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2024-12-09 | Resident Rights Deficiencies | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | D – Moderate Harm Potential |
| 2024-12-09 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2024-12-09 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2024-12-09 | Quality of Life and Care Deficiencies | Assist a resident in gaining access to vision and hearing services. | D – Moderate Harm Potential |
| 2024-12-09 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2024-12-09 | Quality of Life and Care Deficiencies | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | D – Moderate Harm Potential |
| 2024-12-09 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | D – Moderate Harm Potential |
| 2023-03-16 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | E – Moderate Harm Potential |
| 2023-03-16 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2023-03-16 | Resident Rights Deficiencies | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D – Moderate Harm Potential |
| 2023-03-16 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2023-03-16 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2023-03-16 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2021-04-02 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2021-04-02 | Quality of Life and Care Deficiencies | Provide safe, appropriate dialysis care/services for a resident who requires such services. | D – Moderate Harm Potential |
Fire Safety Citation History
14 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2024-12-09 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2024-12-09 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | E – Moderate Harm Potential |
| 2024-12-09 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | E – Moderate Harm Potential |
| 2024-12-09 | Smoke Deficiencies | Install a fire alarm system that can be heard throughout the facility. | D – Moderate Harm Potential |
| 2024-12-09 | Miscellaneous Deficiencies | Have restrictions on the use of portable space heaters. | D – Moderate Harm Potential |
| 2023-03-16 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2023-03-16 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | E – Moderate Harm Potential |
| 2023-03-16 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | D – Moderate Harm Potential |
| 2023-03-16 | Emergency Preparedness Deficiencies | Develop a communication plan. | C – Minimal Harm Potential |
| 2023-03-16 | Electrical Deficiencies | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | C – Minimal Harm Potential |
| 2021-04-02 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2021-04-02 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | D – Moderate Harm Potential |
| 2021-04-02 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | D – Moderate Harm Potential |
| 2021-04-02 | Gas, Vacuum, and Electrical Systems Deficiencies | Have a battery powered remote alarm panel in a location accessible by operating personnel. | C – Minimal Harm Potential |
Total Penalties & Fines
$8,278
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-12-08 | Fine | $8,278 | - |
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the Rochester area at no cost.
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(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.