D

Kirkhaven

254 Alexander Street, Rochester, NY 14607
Score: 46 / 100

CMS data shows Kirkhaven earning a D grade with a score of 46/100, placing it below most facilities in New York. Prospective residents and families should carefully review the specific areas of concern detailed below.

With 3.12 total nurse hours per resident per day, Kirkhaven falls below the national average of 3.8 hours. Families may want to ask about staffing levels during any facility visit.

Recent inspections identified 24 deficiencies at Kirkhaven. While none were classified as the most serious level, families should review the detailed inspection history below.

Score Breakdown

Overall CMS Rating 16 / 40 pts
2 ★ CMS rating
Health Inspections 10 / 25 pts
2 ★ inspection rating
Staffing 8 / 20 pts
2 ★ staffing rating
Quality Measures 12 / 15 pts
4 ★ quality measures

🏥 Staffing Details

Staff Type Hours/Resident/Day National Avg Comparison
Total Nursing 3.12 3.8 Below Average
Registered Nurses (RN) 0.31 0.7 Below Average
Licensed Practical Nurses (LPN) 1.05 0.7 Above Average
Certified Nursing Assistants (CNA) 1.76 2.4 Below Average
Weekend Total Nursing 2.85 3.8 Below Average
Weekend RN Hours 0.23 0.7 Below Average

🔍 Inspection & Deficiency History

24
Total Deficiencies
Dec 7, 2025
Most Recent Inspection
🟠 24 Moderate
View recent deficiencies (5 shown)
  • Tag 0550 Severity G
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    Dec 7, 2025 · Resident Rights Deficiencies
  • Tag 0677 Severity E
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    Dec 7, 2025 · Quality of Life and Care Deficiencies
  • Tag 0761 Severity E
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologi
    Dec 7, 2025 · Pharmacy Service Deficiencies
  • Tag 0658 Severity D
    Ensure services provided by the nursing facility meet professional standards of quality.
    Dec 7, 2025 · Resident Assessment and Care Planning Deficiencies
  • Tag 0684 Severity D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    Jul 15, 2025 · Quality of Life and Care Deficiencies

📊 Resident Outcome Measures

Based on CMS quality measure data. Lower percentages are better for most metrics.

Measure This Facility Nat'l Avg
Residents with pressure ulcers 7.9% 4.5% Worse
Falls with major injury 3.0% 3.0% Average
On antipsychotic medication 20.8% 14.5% Worse
Urinary tract infections 0.2% 2.5% Better
ADL decline (daily activities) 10.3% 14.0% Better
Excessive weight loss 11.7% 7.5% Worse
New/worsened incontinence 15.6% 45.0% Better

How This Grade Was Calculated

This facility's grade of D is based on a score of 46 out of 100, calculated from official CMS Nursing Home Compare data:

  • Overall CMS Rating: 2★ → 16 pts (max 40)
  • Health Inspection Rating: 2★ → 10 pts (max 25)
  • Staffing Rating: 2★ → 8 pts (max 20)
  • Quality Measures Rating: 4★ → 12 pts (max 15)

Grades: A=85+, B=70–84, C=55–69, D=40–54, F=below 40

Facility Details

Ownership
Non profit - Corporation
Certified Beds
147
Provider Type
Medicare and Medicaid
Resident Council
Yes
Family Council
No
Sprinkler System
Yes
Last Inspection
Dec 8, 2024
Deficiencies (Cycle 1)
15