SeniorHomeViolations
C+
67/100

The Brook at High Falls Nursing Home and Rehabilit Inspection Report, Violations & Safety Grade (Rochester, New York)

2150 St. Paul Street, Rochester, New York 14621

Phone: 5853425540

CMS Overall:2/5

Overview & Bed Count

Certified Beds
28
Avg Residents/Day
23.9
Ownership
For profit - Individual
Provider Type
Medicare and Medicaid
County
Monroe
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall2/5
Health2/5
Staffing3/5
Quality4/5

Nurse Staffing Check

MetricThis FacilityNew York AvgDifference
RN Hours per Resident per Day0.560.73-0.17
Total Nurse Hours per Resident per Day4.163.69+0.47
CMS Staffing Rating3/52.9/5-
Nursing Staff Turnover66.0%40.3%-

Health Citation History

24 health citations on record

DateCategoryDescriptionSeverity
2026-01-16Infection Control DeficienciesProvide and implement an infection prevention and control program.F – Moderate Harm Potential
2026-01-16Resident Rights DeficienciesHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.E – Moderate Harm Potential
2026-01-16Resident Rights DeficienciesHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.E – Moderate Harm Potential
2026-01-16Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.E – Moderate Harm Potential
2026-01-16Pharmacy Service DeficienciesEnsure 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.D – Moderate Harm Potential
2024-11-14Resident Rights DeficienciesHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.E – Moderate Harm Potential
2024-11-14Infection Control DeficienciesProvide and implement an infection prevention and control program.E – Moderate Harm Potential
2024-11-14Resident Assessment and Care Planning DeficienciesDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.D – Moderate Harm Potential
2024-11-14Quality of Life and Care DeficienciesProvide care and assistance to perform activities of daily living for any resident who is unable.D – Moderate Harm Potential
2024-11-14Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2024-11-14Nutrition and Dietary DeficienciesEnsure 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.D – Moderate Harm Potential
2024-11-14Environmental DeficienciesProvide bedrooms that don't allow residents to see each other when privacy is needed.D – Moderate Harm Potential
2024-11-14Nursing and Physician Services DeficienciesPost nurse staffing information every day.B – Minimal Harm Potential
2024-11-14Resident Assessment and Care Planning DeficienciesSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.B – Minimal Harm Potential
2024-02-16Resident Rights DeficienciesHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.E – Moderate Harm Potential
2024-02-16Environmental DeficienciesMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.E – Moderate Harm Potential
2023-05-10Nursing and Physician Services DeficienciesHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.E – Moderate Harm Potential
2023-05-10Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2023-05-10Administration DeficienciesHave the Quality Assessment and Assurance group have the required members and meet at least quarterlyE – Moderate Harm Potential
2023-05-10Resident Assessment and Care Planning DeficienciesEnsure services provided by the nursing facility meet professional standards of quality.D – Moderate Harm Potential
2023-05-10Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2023-05-10Quality of Life and Care DeficienciesProvide safe, appropriate dialysis care/services for a resident who requires such services.D – Moderate Harm Potential
2023-05-10Pharmacy Service DeficienciesImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.D – Moderate Harm Potential
2023-05-10Resident Rights DeficienciesNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.B – Minimal Harm Potential

Fire Safety Citation History

13 fire safety citations on record

DateCategoryDescriptionSeverity
2026-01-16Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.E – Moderate Harm Potential
2026-01-16Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.E – Moderate Harm Potential
2026-01-16Smoke DeficienciesInstall corridor and hallway doors that block smoke.E – Moderate Harm Potential
2026-01-16Smoke DeficienciesInstall smoke barrier doors that can resist smoke for at least 20 minutes.E – Moderate Harm Potential
2026-01-16Smoke DeficienciesHave an enclosure around a vertical opening shaft.D – Moderate Harm Potential
2024-11-14Smoke DeficienciesInstall an approved automatic sprinkler system.E – Moderate Harm Potential
2024-11-14Miscellaneous DeficienciesTo conduct inspection, testing and maintenance of fire doors by qualified individuals.E – Moderate Harm Potential
2024-11-14Gas, Vacuum, and Electrical Systems DeficienciesHave proper medical gas storage and administration areas.B – Minimal Harm Potential
2023-05-10Egress DeficienciesAdd doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.E – Moderate Harm Potential
2023-05-10Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.E – Moderate Harm Potential
2023-05-10Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.E – Moderate Harm Potential
2023-05-10Emergency Preparedness DeficienciesEstablish staff and initial training requirements.C – Minimal Harm Potential
2023-05-10Gas, Vacuum, and Electrical Systems DeficienciesHave proper medical gas storage and administration areas.B – Minimal Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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