Kirkhaven

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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 hospital evaluation.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure residents were treated in a dignified manner for two (2) of seven (7) residents reviewed (Residents #97 and #151). Specifically, Resident #97 was observed with fecal matter on their hands, clothing, and assistive device and was later observed eating without hand hygiene while fecal debris remained present under their fingernails. Resident #151 was observed eating meals while wearing feces-soiled clothing and had a strong odor of feces and was observed in an unclean and improperly prepared bed environment.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure its system for developing and implementing individualized meal service (use of meal tickets), including honoring resident preferences and available substitutions, was consistently followed for three (3) of thirteen (13) residents reviewed (Resident #10, Resident #77, and Resident #126). Specifically, residents were served food items which did not match their meal tickets and/or included items identified as dislikes, and substitutions available on the meal tickets were not provided.

Inspectors wroteBased 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. This resulted in actual psychosocial harm that was not Immediate Jeopardy.

Inspectors wroteBased on observations, interviews and record review conducted during an Abbreviated Survey (Incident ID: NY00368335/443768, NY00370316/443765, and NY00372367/443775) completed on 12/08/2025, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs, self-care tasks like bathing and grooming) received the necessary services to maintain good grooming and personal hygiene for eight (8) of eight (8) residents reviewed (Residents #8, #13, #14, #15, #17, #18, #19 and #20). Specifically, Resident #8 was observed on multiple occasions with overgrown facial hair and oily, uncombed hair and stated they had asked staff for assistance but did not receive it. Residents #13, #14 and #20 were observed on multiple occasions with overgrown facial hair and there was no documented evidence staff offered, provided, or the residents refused assistance. [...]

Inspectors wroteBased on observations, interviews and record review conducted during an Abbreviated Survey (NY00368335/443768 and NY00372367/443775) completed on 12/08/2025, the facility failed to ensure all drugs and biologicals used in the facility were stored in locked compartments and permit only authorized personnel to have access for one (1) of four (4) residential units reviewed (Unit Three). Specifically, four (4) bins filled with medication blister packs (a type of packaging that organizes medications into individual, sealed compartments) and medications stored in three (3) plastic bags were observed on an office desk, unsupervised with the door open, and accessible to unlicensed personnel.

Inspectors wroteBased on interviews, and record review conducted during an Abbreviated Survey (Intake ID: NY00368335/443768 and NY00372367/443775) completed on 12/08/2025, the facility failed to provide services that met professional standards of quality for one (1) of three (3) residents reviewed (Resident #4). Specifically, for Resident #4 there was missing administration documentation for several medications, including but not limited to significant medications used to treat hypertension and cardiac related conditions, and no documented evidence the resident received the medications or notifications of missed medications to a medical provider.

Inspectors wroteBased on observations, interviews, and record review conducted during an Abbreviated Survey (Intake ID: 2561610) from 07/15/2025 to 07/16/2025, for one (1) (Resident #1) of one (1) resident reviewed, the facility did not ensure a resident received treatment and care in accordance with professional standards of practice and the person-centered care plan. Specifically, Resident #1 refused several doses of haloperidol (an antipsychotic medication that is used to control severe agitation and aggression) in June 2025 and July 2025 and a medical provider was not notified. Additionally, on 07/11/2025 the resident had increased agitation, wandering behaviors, attempted to exit a bedroom window, and a medical provider was not notified of the incident.

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey conducted from 12/02/2024 to 12/09/2024, the facility did not refer the resident who had an intellectual disability to the appropriate state-designated authority for a Level II Pre-admission Screening and Resident Review (PASARR) for recommendations for one (Resident #115) of two residents reviewed. Specifically, the resident had a letter from the admitting hospital documentation that the resident required a full Level II assessment (referral process for individuals who were known or suspected of having serious mental illness for care planning recommendations) prior to admission or when a significant change occurred. Consequently, Resident #115 received no Level II referrals or services if needed.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, for one (Resident #4) of two residents reviewed, the facility did not provide specialized care needs for the provision of respiratory care in accordance with professional standard of practice, and the resident's care plan, goals, and preferences. Specifically, Resident #4 was observed intermittently wearing oxygen via a tracheostomy (a surgically created opening in the neck and into the windpipe to breathe through) collar (a soft plastic mask used to deliver oxygen to a person with a tracheostomy tube). There was no physician's order in place for supplemental oxygen use or documentation in the resident's medical record that reflected the use and care of the oxygen. [...]

Inspectors wroteBased on observations, record review, and interviews during the Recertification Survey from 12/02/2024 to 12/09/2024, for one of one main kitchen, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there were multiple undated food items not in their original containers and a food item was stored uncovered.

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 12/02/2024 to 12/09/2024, for three (Residents #36, #41, #42) of eight residents reviewed, the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections. Specifically, Resident #41 had their blood sugar checked by a nurse not wearing gloves. [...]

Inspectors wroteBased on observation, interview, and record review conducted during a Recertification Survey from [DATE] to [DATE], for one (Resident #127) of 36 residents reviewed, the facility did not ensure that all residents had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive (a resident's wishes to be or not to be resuscitated in the event of an acute cardiac or pulmonary arrest) that would be honored. Specifically, the facility did not ensure Residents #127's advance directive identifiers were consistent with the resident's wishes. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, for two (Residents #4 and #53) of six residents reviewed, the facility did not develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs including resident goals, desired outcomes and preferences related to their ongoing smoking habits. Specifically, the facility was aware that Residents' #4 and #53 continued to smoke against facility policy and there was no care plan in place to ensure the residents remained safe. This is evidenced by the following: 1. Resident #4 had diagnoses that included chronic respiratory failure, anxiety, and a tracheostomy (surgically created hole in the windpipe that provides alternative airway for breathing). [...]

Inspectors wroteBased on observations, interviews, and record review conducted during a Recertification Survey from 12/02/2024 to 12/09/2024, the facility did not ensure that residents received care in accordance with professional standards of practice, their person-centered care plan, and resident's choice for 2 (Residents #53 and #81) of 29 residents reviewed for quality of care. Specifically, Resident #53 was not wearing a physician ordered compression wrap following a recent amputation of their right lower extremity on multiple observations. Resident #81 had multiple falls, one resulting in a major injury, and there was no documented evidence that the resident had been assessed by a Registered Nurse or that neurological checks had been completed following a fall with a potential head injury. This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, for one (Resident #11) of two residents reviewed for communication, the facility did not ensure the resident received treatment and/or assistive devices to maintain their hearing. Specifically, the facility did not ensure the resident's hearing aids were repaired in a timely manner. This is evidenced by the following: Resident #11 had diagnoses that included auditory hallucinations, high blood pressure, and depression. The Minimum Data Set Resident Assessment documented Resident #11 was cognitively intact, was hard of hearing, and wore hearing aids. During an observation and interview on 12/02/2024 at 10:00 AM, Resident #11 was not wearing either hearing aid. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey and complaint investigation (NY00361034) from 12/02/2024 to 12/09/2024, the facility did not ensure acceptable parameters of nutritional status for one (Residents #127) of five residents reviewed. Specifically, nutritional assessments by a registered dietician were not performed during Resident #127's initial and readmission to the facility and documented weight losses were not identified timely. This is evidenced by the following: The undated facility policy Nutrition Assessment included that a registered dietician would perform a comprehensive nutrition assessment on residents to determine their risk for malnutrition or nutrition-related problems. A nutrition assessment would be completed on all residents on admission, annually, quarterly, and as needed. [...]

Inspectors wroteBased on observation, interviews and record review conducted during the Recertification Survey and complaint investigation the facility did not ensure a resident who displays or is diagnosed with dementia, received the appropriate services to maintain their highest practicable mental and psychosocial well-being for two (Residents #34 and #89) of five residents reviewed for dementia care. Specifically, Resident #34 had a diagnosis of dementia and did not have individualized interventions in place to guide direct care staff in managing behavioral symptoms. Resident #89 who had a history of dementia and behaviors sexual in nature was not appropriately care planned to include interventions to prevent further occurrences.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey from 12/02/2024 to 12/09/2024, for one (Resident #22) of five residents reviewed for nutrition, the facility did not ensure food was prepared in a consistency to meet the residents needs per speech-language pathologist recommendations and physician orders. Specifically, Resident #22 had a history of dysphagia (difficulty swallowing), was on a mechanical soft diet (a diet that consists of easy to chew and swallow foods), and received a food item that was not appropriate on a mechanical soft diet. Additionally, Resident #22 was not care planned for a risk of aspiration (chance of food or liquids accidently inhaled into the lungs requiring close supervision with eating). This is evidenced by the following: [...]

Inspectors wroteBased on observations, interviews and record reviews conducted during the Recertification Survey, completed on 3/16/23, it was determined for four (Resident #49, #75, #303, and #307) of five residents reviewed for dialysis, the facility did not ensure that dialysis services provided were consistent with professional standards of practice, the comprehensive person-centered care plan, physician orders and resident's goals and preferences. Specifically, the issues included: a. That the facility did not have evidence of total fluid intake monitoring for Resident #75 who was on a medically ordered fluid restriction, b. Did not ensure medications were administered as ordered by the physician on dialysis days for Residents #49, #75, #303, and #307. c. [...]

Inspectors wroteBased on observations, interview, and record review conducted during the Standard Recertification Survey completed on 3/16/23, it was determined that for one of one main kitchen, the facility did not store, prepare, distribute, or serve food in accordance with professional standards (U.S. Food and Drug Administration's Model Food Code) for food service safety. Specifically, a low-temperature, mechanical dish washing machine did not maintain an acceptable sanitizer concentration on dishes after the final rinse and had a leak.

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey completed on 3/16/23, it was determined that for one (Resident #303) of one reviewed for choices the facility did not ensure the resident's right to make choices about aspects of life that were significant to them. Specifically, the resident was not given the choice of bathing opportunities. This is evidenced by the following: Resident #303 was admitted to the facility on [DATE] with diagnoses including right femur fracture, diabetes mellitus, depression, and a pressure ulcer. The Minimum Data Set Assessment, dated 2/27/23, documented that the resident was cognitively intact, required extensive assistance with bathing and that type of bathing was very important to them. Review of Resident #303's current medical orders revealed skin observations with weekly shower every Monday. [...]

Inspectors wroteBased on observation, interviews and record review conducted during the Recertification survey and complaint investigation (NY00301678) completed on 3/16/23, it was determined that for one of six residents reviewed for abuse the facility failed to protect the residents right to be free from abuse. Specifically, Resident #353 was held down by multiple staff members and an injection was given against the resident's wishes. The resident was observed with bruising on both legs the following day which was believed to be caused by the incident. Resident #353 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, status post cerebral vascular accident (CVA) with aphasia and right sided monoplegia arm and hand contracture. [...]

Inspectors wroteBased on observation, interviews and record review conducted during the Recertification survey and complaint investigation (#NY00301678) completed on 3/16/23, it was determined that for one of six residents reviewed for abuse the facility did not ensure that an incident of physical abuse was thoroughly investigated to rule out abuse, neglect, or mistreatment. Specifically, Resident #353 was held down by multiple staff and an antibiotic injection administered. The facility did not interview all staff involved and did not put measures in place to prevent further occurrence. Resident #353 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, status post cerebral vascular accident (CVA) with aphasia and right sided monoplegia arm and hand contracture. [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey completed on 3/16/23, it was determined that for one (Resident #49) of 5 residents reviewed for dialysis, the facility did not ensure that each resident was free from significant medication errors. Medication Error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the physician orders or acceptable professional standards of practice (principles which apply to professionals providing services. Accepted professional standards and principles include various practice regulations in each state, and current commonly accepted health standards, established by national organizations, boards, and councils). [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey, it was determined for one of two residents reviewed the facility did not provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice, and the resident's care plan, goals and preferences. Specifically, Resident #77 did not have medical orders or a care plan for the administration and care of oxygen therapy. This is evidence by the following: Review of a facility policy, Oxygen Therapy, dated April 2020, directs oxygen may be administered to a resident in apparent respiratory distress or chest pain at a rate of one to two liters (L) per minute. All other oxygen treatment will require a physician order for amount in liters and frequency. [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey, it was determined for one of one resident reviewed, the facility did not ensure that, for a resident receiving dialysis, the services provided were consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for Resident #12, medical orders to monitor the dialysis catheter access site for complications and to notify the medical team if present were not documented as being done. This is evidenced by the following: Review of a facility policy, Dialysis, dated 3/9/20, directs that all residents who require hemodialysis will have established care standards including: to check the site every shift for bleeding and add to the Treatment Administration Record (TAR). [...]