KIRKHAVEN - ROCHESTER, NY

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Addresss:

254 ALEXANDER STREET
ROCHESTER, NY, 14607

Phone (make sure to verify first before calling): (585) 461-1991

Number of Certified Beds: 147
Total Number of Residents: 135
Percent of Occupied Beds: 92%
Sprinkler Status: Partially Sprinklered
Program Participation: Medicare and Medicaid
Type of Ownership: Non profit - Church related
Located Within a Hospital?: No
Multi Nursing Home Ownership?: No
Resident and Family Councils: Both
Continuing Care Retirement Community?: No
Quality Indicator Survey?: No
Special Focus Facility?: No
Type: Skilled Nursing Facilities

Overall Star Rating: 3 Stars
Health Inspections Star Rating: 3 Stars
Nurse Staffing Star Rating: 3 Stars
Quality Measures Star Rating: 4 Stars
RN Only Star Rating: 2 Stars

Other nearby hospitals and nursing homes

BLOSSOM SOUTH NURSING AND REHABILITATION CENTER (1.28 miles)
GENESEE HOSPITAL (0.03 miles)
GOODMAN GARDENS HRF (0.43 miles)
HIGHLAND HOSPITAL (1.25 miles)
ST JOHNS HOME FOR THE AGING (1.67 miles)
THE GENESEE HOSPITAL ECF CLSD (0.10 miles)
WESLEY GARDENS CORPORATION (0.52 miles)

Employment Full-Time Equivalent

Administrative Staff - Full Time: 10.19

Administrative Staff - Part Time: 1.29

Certified Nurse Aides - Full Time: 36.06

Certified Nurse Aides - Part Time: 31.71

Food Service Personnel - Full Time: 9.37

Food Service Personnel - Part Time: 7.83

Housekeeping Personnel - Full Time: 20.44

Licensed Practical/ Vocational Nurses - Full Time: 14.51

Licensed Practical/ Vocational Nurses - Part Time: 11.31

Medical Directors - Under Contract: 0.06

Mental Health Services Personnel - Under Contract: 0.03

Nurses With Administrative Duties - Full Time: 3.43

Occupational Therapy Aides - Full Time: 0.51

Physical Therapists - Under Contract: 1.34

Registered Nurses - Full Time: 9.87

Rn Director Of Nursing - Full Time: 1.03

Social Workers - Full Time: 2.29

Activities Professionals - Full Time: 1.14

Activities Professionals - Part Time: 1.37

Dentists - Under Contract: 0.06

Dietitians - Part Time: 0.51

Nurses With Administrative Duties - Part Time: 2.60

Occupational Therapists - Under Contract: 1.30

Administrative Staff - Under Contract: 0.46

Podiatrists - Under Contract: 0.03

Speech Pathologists - Under Contract: 0.49

Other Physicians - Under Contract: 0.54

Physician Extenders - Under Contract: 0.23

Dietitians - Full Time: 1.10

Registered Nurses - Part Time: 4.21

Occupational Therapy Assistants - Under Contract: 1.14

Social Workers - Part Time: 0.46

Housekeeping Personnel - Part Time: 5.10

Physical Therapy Aide - Full Time: 0.51

Licensed Practical/ Vocational Nurses - Under Contract: 0.36

Number Of Beds

Total: 147

Total Certified: 147

For Residents With Alzeheimers: 34

For Residents With Specialized Rehab Needs: 10

Provided Services

Activities Services Are Provided Onsite To Residents

Clinical Laboratory Services Are Provided Offsite To Residents

Dental Services Are Provided Offsite To Residents

Dental Services Are Provided Onsite To Residents

Diagnostic Xray Services Are Provided Onsite To Residents

Dietary Services Are Provided Onsite To Residents

Housekeeping Services Are Provided Onsite To Residents

Mental Health Services Are Provided Onsite To Residents

Nursing Services Are Provided Onsite To Residents

Occupational Therapy Services Are Provided Onsite To Residents

Pharmacy Services Are Provided Onsite To Residents

Physical Therapy Services Are Provided Onsite To Residents

Physician Extender Services Are Provided Onsite To Residents

Physician Services Are Provided Onsite To Residents

Podiatry Services Are Provided Onsite To Residents

Social Work Services Are Provided Onsite To Residents

Speech/Language Pathology Services Are Provided Onsite To Residents

Therapeutic Recreation Specialist Services Are Provided Onsite To Residents

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

This Nursing Home:	18.3%
New York:	15.6%

Percent of long-stay residents who self-report moderate to severe pain

This Nursing Home:	13.4%
New York:	7.6%

Percent of long-stay high-risk residents with pressure ulcers

Here:	2.4%
State:	8.4%

Percent of long-stay residents who lose too much weight

Here:	3.1%
New York:	6.4%

Percent of long-stay low-risk residents who lose control of their bowels or bladder

This Nursing Home:	43.2%
State:	41.1%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

Here:	0.9%
New York:	3.1%

Percent of long-stay residents with a urinary tract infection

Here:	7.1%
State:	6.8%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	8.7%
State:	12.6%

Percent of long-stay residents experiencing one or more falls with major injury

This Nursing Home:	6.3%
State:	2.9%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	97.6%
New York:	96.7%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	94.5%
New York:	97.3%

Percent of short-stay residents who self-report moderate to severe pain

Here:	3.4%
State:	16.9%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Nursing Home:	65.9%
New York:	86.9%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	42.3%
State:	85.0%

Percent of short-stay residents who newly received an antipsychotic medication

This Nursing Home:	2.9%
New York:	3.1%

Percent of long-stay residents who received an antipsychotic medication

Here:	27.5%
State:	20.8%

Complaint Deficiency

Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Put firmly secured handrails on each side of hallways
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
- Harm: Potential for minimal harm
- Scope: Many
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Allow the resident the right to participate in the planning or revision of the resident's care plan
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Give the right treatment and services to residents who have mental or psychosocial problems adjusting
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that residents are safe from serious medication errors
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Potential for minimal harm
- Scope: Some

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.440
State:	0.637

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

Here:	1.130
New York:	0.790

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	1.560
New York:	1.425

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.070
State:	0.080

Number Therapy Hours Per Resident Per Day

Here:	0.070
New York:	0.081

KIRKHAVEN - ROCHESTER, NY

Quality Measures

Complaint Deficiency

Staff Information

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