Kirkhaven

In the surveyor’s words

From the most serious findings on record at Kirkhaven, in the surveyor’s own words.

• Actual harm, isolatedF550Dec 8, 2025

  Based on observations, interviews, and record review conducted during an Abbreviated Survey (NY00370316/443765, NY00372543/443769) completed on 12/08/2025, the facility failed to ensure one (1) of seven (7) residents reviewed (Resident #8) was treated with respect and dignity and cared for in a manner that promoted quality of life. Specifically, the facility failed to honor Resident #8's expressed preferences and repeated requests for assistance with grooming and hygiene and the resident stated it made them feel dirty and grubby. […]

• No harm, potential for more than minimal, patternF610Mar 18, 2026

  Based on observations, interviews, and record review, the facility did not ensure allegations of abuse were responded to timely, thoroughly investigated, and residents were protected from potential abuse for two (2) of three (3) residents reviewed (Resident #1 and Resident #2). Specifically, staff failed to initiate a timely response following allegations or observations of potential abuse, failed to immediately remove involved staff from resident care, and failed to conduct a thorough investigation, as available video surveillance was not reviewed as part of the initial investigation and was only reviewed after surveyor inquiry.The findings include:The facility policy, Abuse Policy, last reviewed 09/05/2024, defined an alleged abuse violation as a situation or occurrence observed or… […]

• No harm, potential for more than minimal, patternF677Mar 18, 2026

  Based on observations, interviews, and record review, the facility did not ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (1) of eight (8) residents reviewed (Resident #112). Specifically, Resident #112 did not receive scheduled hygiene care, including shaving and showering, on multiple occasions, and the facility did not ensure care was completed, documented, or reattempted when missed.The findings include: The facility policy Standards of Care at Kirkhaven, updated 08/20/2020, included baths or showers are given per resident preference and the Certified Nursing Assistant is responsible for informing the nurse the resident is receiving a bath or shower per the schedule. […]

• No harm, potential for more than minimal, patternF689Mar 18, 2026

  Based on observations, interviews, and record review, the facility did not ensure the resident environment remained as free of accident hazards as possible and did not ensure adequate supervision and implementation of individualized interventions to prevent accidents for one (1) of eight (8) residents reviewed for accidents (Resident #149) and across three (3) of five (5) resident use floors (third (3rd), fourth (4th), and fifth (5th) floors). Specifically, (1) hot liquids at temperatures capable of causing burns were accessible to residents, including residents with cognitive impairment requiring supervision, and (2) Resident #149, who had severely impaired cognition and was identified as high risk for falls, was not provided supervision and sustained a fall with a head injury requiring… […]

• No harm, potential for more than minimal, patternF725Mar 18, 2026

  Based on observations, interviews, and record review, the facility did not ensure sufficient staffing to provide nursing services to attain or maintain the highest practical physical, mental, and psychosocial well-being of residents for four (4) of four (4) resident units reviewed. Specifically, staffing levels were insufficient to meet resident needs, resulting in delayed toileting assistance, missed or delayed bathing and grooming, failure to provide timely incontinence care, delayed response to resident call systems, and inability to complete required nursing tasks.The findings include: For additional information, see the Centers for Medicare/Medicaid Services Form 2567: F550 - Resident Rights/Exercise of Rights, F561 - Self-determination, F677 - Activities of Daily Living Care for… […]