Public Record
Kirkhaven
From CMS
Facility profile
- CMS overall rating
- 1 / 5
- Certified beds
- 147
- Avg. residents per day
- 134.3
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 44
- Inspections on file
- 9
- Last inspection
- 2026-03-18
*CMS
*CMS
*CMS
Citations
44 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0803Generalpotential for harm
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.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0550Seriousactual harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0761Generalpotential for harm
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.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0578Generalpotential for harm
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.
- 0644Generalpotential for harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0685Generalpotential for harm
Assist a resident in gaining access to vision and hearing services.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0805Generalpotential for harm
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0744Generalpotential for harm
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- 0781Generalpotential for harm
Have restrictions on the use of portable space heaters.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0341Generalpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0901Generalno actual harm
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
- 0561Generalpotential for harm
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- 0600Generalpotential for harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0029Generalno actual harm
Develop a communication plan.
- 0291Generalpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0916Generalno actual harm
Have a battery powered remote alarm panel in a location accessible by operating personnel.
- 0698Generalpotential for harm
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- 0223Generalpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0372Generalpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
FAQ
Questions and answers
- What is Kirkhaven?
- Kirkhaven is a Medicare- and Medicaid-certified nursing home in Rochester, NY, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 335668.
- What is the CMS rating for Kirkhaven?
- Kirkhaven has a CMS overall rating of 1 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Kirkhaven have?
- Kirkhaven is certified for 147 beds. It serves an average of 134.3 residents per day.
- How many citations does Kirkhaven have?
- Kirkhaven has 44 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Kirkhaven last inspected?
- Kirkhaven was last inspected on March 18, 2026. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/335668-kirkhaven