01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-12-09 | 21 | 2024-12-09 | 5 |
| Cycle 2 | 2023-03-16 | 7 | 2023-03-16 | 5 |
| Cycle 3 | 2021-04-02 | 2 | 2021-04-02 | 4 |
CMS CCN 3356682026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Kirkhaven
254 Alexander Street · Rochester, NY 14607 · Monroe County
Certified beds147CMS provider file
Recent citation rows44current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
44 rows in the current release
1 rows carry G–L scope/severity codes; 0 carry J–L. 10 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-03-18 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2026-05-15 · complaint2026-03-18 · HEALTHF0610Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2026-05-15 · complaint2026-03-18 · HEALTHF0677Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2026-05-15 · complaint2026-03-18 · HEALTHF0689Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2026-05-15 · complaint2026-03-18 · HEALTHF0725Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-05-15 · complaint2026-03-18 · HEALTHF0803Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-05-15 · complaint2025-12-08 · HEALTHF0550Severity G · isolated actual harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2026-02-06 · complaint2025-12-08 · HEALTHF0658Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2026-02-06 · complaint2025-12-08 · HEALTHF0677Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2026-02-06 · complaint2025-12-08 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-06 · complaint2025-07-16 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-09-10 · complaint2024-12-09 · HEALTHF0578Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-02-052024-12-09 · HEALTHF0644Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2025-02-052024-12-09 · HEALTHF0656Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2025-02-052024-12-09 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-02-052024-12-09 · HEALTHF0685Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Correction field: Deficient, Provider has date of correction · 2025-02-052024-12-09 · HEALTHF0692Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Correction field: Deficient, Provider has date of correction · 2025-02-05 · complaint2024-12-09 · HEALTHF0695Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-02-052024-12-09 · HEALTHF0744Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Correction field: Deficient, Provider has date of correction · 2025-02-05 · complaint2024-12-09 · HEALTHF0805Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Correction field: Deficient, Provider has date of correction · 2025-02-052024-12-09 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-02-052024-12-09 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-02-052024-12-09 · FIREK0341Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Correction field: Deficient, Provider has date of correction · 2025-02-052024-12-09 · FIREK0345Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-02-0503 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-12-08 | Fine | $8,278 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- FORNATARO, LETICIAIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2019
- MUTHIG, MARKIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 01/01/2021
- MAAR, SCOTTIndividual · CORPORATE OFFICERNOT APPLICABLE · since 05/04/2005
- SCHALLER, CHRISTINEIndividual · CORPORATE OFFICERNOT APPLICABLE · since 12/19/2022
- SCHALLER, CHRISTINEIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/19/2022
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours—per resident day
RN hours—per resident day
Weekend nurse hours—per resident day
Staff turnover—%CMS reported field
06 / LOCAL RECORDS
Open the Rochester ledger →Other published facilities nearby
Blossom Health Care Center Inc.80 beds · CMS overall 1/561 citation rowsChurch Home Of The Protestant Episcopal Church182 beds · CMS overall 3/520 citation rowsEdna Tina Wilson Living Center120 beds · CMS overall 5/513 citation rowsHamilton Manor Nursing Home40 beds · CMS overall 4/514 citation rowsJewish Home Of Rochester362 beds · CMS overall 5/524 citation rowsLatta Road Nursing Home East40 beds · CMS overall 3/520 citation rowsLatta Road Nursing Home West40 beds · CMS overall 5/59 citation rowsLilac Manor Rehabilitation And Nursing Center200 beds · CMS overall 1/542 citation rows