Cycle 1
Health 2024-12-09 · Fire 2024-12-09
16 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Rochester, NY
Kirkhaven
2-star overall rating with 2-star inspections with 15 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
254 Alexander Street, Rochester, NY
(585) 461-1991
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
147
Certified beds
Average residents
133
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1984-02-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.31
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.05
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
1.76
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.12
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.44
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,459
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9896
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.99
Baseline 19.51% · Performance 17.73% · Measure score 7.99 · Achievement 7.99 · Improvement 6.68
Healthcare-associated infections
4.05
Baseline 6.86% · Performance 6.62% · Measure score 4.05 · Achievement 4.05 · Improvement 0.74
Total nurse turnover
0.98
Baseline 44.86% · Performance 59.69% · Measure score 0.98 · Achievement 0.98 · Improvement 0
Adjusted total nurse staffing
1.43
Baseline 4.09 hours · Performance 3.48 hours · Measure score 1.43 · Achievement 1.43 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.49% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 123 · Observed rate 9.76% · Lower 95% interval 7.75% |
| Discharge to community | 50.99% |
50.57%
0.4 pts better
|
No Different than the National Rate · Eligible stays 129 · Observed rate 41.86% · Lower 95% interval 41.45% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 130 · Denominator 130 |
| Falls with major injury | 1.54% |
0.77%
0.8 pts worse
|
Numerator 2 · Denominator 130 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 48 · Denominator 96 |
| Discharge mobility score | 48.96% |
50.94%
2 pts worse
|
Numerator 47 · Denominator 96 |
| Pressure ulcers or injuries, new or worsened | 3.08% |
2.29%
0.8 pts worse
|
Numerator 4 · Denominator 130 · Adjusted rate 3.87% |
| Healthcare-associated infections requiring hospitalization | 6.63% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 6.25% · Lower 95% interval 4.24% |
| Staff COVID-19 vaccination coverage | 2.13% |
8.2%
6.1 pts worse
|
Numerator 4 · Denominator 188 |
| Staff flu vaccination coverage | 54.63% |
42%
12.6 pts better
|
Numerator 118 · Denominator 216 |
| Discharge function score | 55.21% |
56.45%
1.2 pts worse
|
Numerator 53 · Denominator 96 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 48 · Denominator 48 |
| Resident COVID-19 vaccinations up to date | 28.38% |
25.2%
3.2 pts better
|
Numerator 21 · Denominator 74 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.6 |
1.7
0.9 pts worse
|
1.9
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 3.1 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 24.3% |
91.2%
66.9 pts worse
|
93.4%
69.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 56.6% · Q2 20.5% · Q3 11.2% · Q4 7.6% · 4Q avg 24.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.5% |
95.3%
3.8 pts worse
|
95.5%
4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.0%
About the same
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.6% · Q3 2.6% · Q4 3.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.2% |
18.5%
11.3 pts better
|
11.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.3% · Q3 6.7% · Q4 8.6% · 4Q avg 7.2% |
| Percentage of long-stay residents who lose too much weight | 11.7% |
6.1%
5.6 pts worse
|
5.4%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 8.9% · Q3 12.4% · Q4 14.0% · 4Q avg 11.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.8% |
13.5%
4.7 pts better
|
19.6%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 7.9% · Q3 8.8% · Q4 8.5% · 4Q avg 8.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.8% |
14.8%
6 pts worse
|
16.7%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 23.3% · Q3 23.4% · Q4 19.8% · 4Q avg 20.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.7% |
15.1%
8.4 pts better
|
16.3%
9.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 6.8% · Q3 12.1% · Q4 1.4% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.3% |
15.5%
5.2 pts better
|
14.9%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 11.0% · Q3 7.3% · Q4 14.0% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.6%
0.3 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.5% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.4%
1.2 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.6% |
20.8%
5.2 pts better
|
19.8%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 12.0% · Q3 11.5% · Q4 14.8% · 4Q avg 15.6% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
6.9%
1 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 9.1% · Q3 9.5% · Q4 7.6% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 33.2% |
76.7%
43.5 pts worse
|
81.7%
48.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 45.0% · Q2 31.2% · Q3 23.1% · Q4 33.3% · 4Q avg 33.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
9.7%
2.4 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 8.2% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.2%
0.2 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 56.2% |
78.8%
22.6 pts worse
|
79.7%
23.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 56.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
20.6%
2.9 pts worse
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 28.2% · Expected 28.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-16 · Fire 2023-03-16
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2021-04-02 · Fire 2021-04-02
2 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-28
E · Potential for more than minimal harm
2024-12-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-05
E · Potential for more than minimal harm
2024-12-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-19
D · Potential for more than minimal harm
2024-12-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-02-05
D · Potential for more than minimal harm
2024-12-09
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-02-05
F · Potential for more than minimal harm
2023-03-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-15
E · Potential for more than minimal harm
2023-03-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-03-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-15
C · Minimal harm
2023-03-16
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2023-05-15
C · Minimal harm
2023-03-16
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2023-05-15
E · Potential for more than minimal harm
2021-04-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-06-01
D · Potential for more than minimal harm
2021-04-02
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2021-06-01
D · Potential for more than minimal harm
2021-04-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-06-01
C · Minimal harm
2021-04-02
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2021-06-01
Inspection history
Recent health citations
G · Actual harm
2025-12-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Not marked corrected
E · Potential for more than minimal harm
2025-12-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Not marked corrected
E · Potential for more than minimal harm
2025-12-08
F761 · Pharmacy Service Deficiencies
Health
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.
Not marked corrected
D · Potential for more than minimal harm
2025-12-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Not marked corrected
D · Potential for more than minimal harm
2025-07-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-10
E · Potential for more than minimal harm
2024-12-09
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-02-05
E · Potential for more than minimal harm
2024-12-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-05
E · Potential for more than minimal harm
2024-12-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-05
E · Potential for more than minimal harm
2024-12-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-05
D · Potential for more than minimal harm
2024-12-09
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2025-02-05
D · Potential for more than minimal harm
2024-12-09
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-02-05
D · Potential for more than minimal harm
2024-12-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-05
D · Potential for more than minimal harm
2024-12-09
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-02-05
D · Potential for more than minimal harm
2024-12-09
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-05
D · Potential for more than minimal harm
2024-12-09
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-02-05
D · Potential for more than minimal harm
2024-12-09
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-02-05
E · Potential for more than minimal harm
2023-03-16
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-05-15
E · Potential for more than minimal harm
2023-03-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-03-16
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-03-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-03-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-03-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-15
D · Potential for more than minimal harm
2021-04-02
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-06-01
D · Potential for more than minimal harm
2021-04-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-06-01
Penalties and ownership
What sits behind the stars
Ownership
Fornataro, Leticia
Corporate Director · Individual
Maar, Scott
Corporate Officer · Individual
Muthig, Mark
Corporate Director · Individual
Schaller, Christine
Operational/Managerial Control · Individual
Schaller, Christine
Corporate Officer · Individual
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#3
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