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CMS (the Centers for Medicare & Medicaid Services) is the federal agency that rates nursing home quality. Its Overall Rating runs from 1 to 5 stars, combining health inspections, staffing, and quality measures, with inspections weighted most heavily.
CMS (the Centers for Medicare & Medicaid Services) is the federal agency that rates nursing home quality. Its Overall Rating runs from 1 to 5 stars, combining health inspections, staffing, and quality measures, with inspections weighted most heavily.
The Brook at High Falls operates as a 28-bed skilled nursing facility at 2150 St Paul Street in Rochester, Monroe County, New York. Owner Christina Oropeza oversees the facility through AGA Operating LLC, a for-profit operator.
The 3-star CMS rating positions the community slightly below the New York state average.
Where the facility demonstrates strength is staffing intensity: registered nurses and nursing staff combine for 3 hours 57 minutes of care per resident daily; 13% above New York averages. Weekends show particularly robust RN presence at 47 minutes per day, running 68% above benchmark. Physical therapists deliver 11 minutes per resident daily, 57% above state norms.
Six separate state inspections over four years yielded 15 total health and life safety citations.
The November 14, 2024 complaint investigation identified systemic deficiencies in resident care, facility environment, and safety protocols. Inspectors found failures in activities of daily living assistance, visual privacy safeguarding (missing privacy curtains affecting multiple residents), quarterly care planning compliance, and infection control execution. Significant documentation gaps emerged: staff touched food without gloves; laundry personnel handled soiled linens without protective gowns; resident medical records sat in damaged boxes stored in an unlocked basement electrical room. Environmental violations included missing call bells, absent bathroom soap dispensers, inoperable kitchen equipment, unsafe gas storage, and non-functional door mechanisms.
The facility corrected all citations by late January and early February 2025. No federal fines or Medicare/Medicaid payment denials have been assessed over the past three years.
Occupancy has contracted dramatically to 32%; ranked 426th of 433 New York homes against a state average of 88.3%. The facility draws admissions from Medicare short-stays (1-month average), private-pay brief stays (19 days), and Medicaid long-term residents (2 years), with current census skewed heavily toward Medicaid (45.5%).
Clinical quality measures reveal long-stay weight loss impacts 16.4% of residents at 168% worse than state average, yet fall rates remain zero and depression symptoms absent entirely. Short-stay rehospitalization reached 26.8% against a 20.6% state norm, with emergency department utilization at 19.7%; more than double the 9.7% state figure. The facility’s deficiency rate has averaged 24.7 violations per year since 2021, running 384% above New York averages.
The Brook is structured for Medicare and private-pay short-term rehabilitation and skilled nursing stays in a small-scale setting where higher staffing ratios and intensive therapy services support acute clinical recovery.
The Overall CMS Rating combines results from health inspections, staffing levels and quality measures. Health inspections carry the most weight. Staffing and quality scores can increase or decrease the final rating based on performance compared to state and national standards.
Based on the results of the facility's three most recent standard inspections and any complaint investigations. CMS reviews the number, scope, and severity of deficiencies, with more recent findings weighted more heavily.
Measures average nursing staff hours per resident per day, including Registered Nurses (RNs) and total nursing staff. Ratings are adjusted based on the level of care residents require and are compared to state and national benchmarks.
Based on clinical and physical health indicators reported to CMS, such as hospital readmissions, falls, pressure ulcers, and improvements in mobility. These measures reflect how well residents' health needs are being managed.
Daily nursing hours per resident by staff type, reported to CMS. Higher is generally better — compare this facility to state and national averages to see where staffing stands.
This home is ranked 95th out of 387 homes in New York for nurse hours. Total adjusted nursing hours per resident per day, combining RN, LPN, and aide time. CMS adjusts this for case-mix so facilities can be fairly compared.
| Staff type | Hours / Day / Resident | vs state avg |
|---|---|---|
|
Registered Nurse (RN)
RNs hold the highest nursing license and can assess residents, interpret test results, and direct care plans. More RN hours per day often signals stronger clinical oversight and faster response to health changes.
| 38m per day | ▼ 10% State avg: 42m per day · National avg: 41m per day |
|
LPN / LVN
Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs) deliver routine hands-on care — medication administration, wound dressing, and monitoring vital signs. They work under RN supervision and make up a large share of daily bedside care.
| 52m per day | ▲ 13% State avg: 46m per day · National avg: 52m per day |
|
Nurse Aide
Certified Nurse Aides (CNAs) provide the most direct day-to-day assistance: bathing, dressing, feeding, and mobility. Nurse aide hours are typically the largest staffing category and directly affect residents' quality of life.
| 2h 16m per day | ▲ 4% State avg: 2h 11m per day · National avg: 2h 21m per day |
|
Weekend Total Nursing
Combined nursing hours (RN + LPN + Nurse Aide) per resident per day on weekends. Staffing often drops on weekends — this figure reveals whether the facility maintains adequate coverage outside of weekday hours.
| 3h 27m per day | ▲ 9% State avg: 3h 10m per day · National avg: 3h 26m per day |
|
Physical Therapist
Hours per resident per day provided by licensed Physical Therapists (PTs) or PT Assistants. PT services help residents recover mobility after injury or illness and are especially important for post-acute (short-stay) rehabilitation.
| 11m per day | ▲ 63% State avg: 7m per day · National avg: 4m per day |
|
Weekend RN
Registered nurse hours specifically on weekends. Facilities sometimes reduce RN presence on Saturdays and Sundays — a low weekend RN figure compared to weekday hours can indicate reduced clinical oversight when most administrative staff are absent.
| 41m per day | ▲ 45% State avg: 28m per day · National avg: 29m per day |
Lower than the New York average: 88.3%The Brook at High Falls is legally operated by AGA Operating LLC (For Profit).
In New York, the Department of Health, Office of Aging and Long Term Care performs unannounced onsite inspections to monitor compliance with state and federal healthcare regulations.
A composite 0–100 score combining this facility's inspections, citations, complaints, and enforcement actions relative to the New York state average. The score below shows how many points this facility sits above or below the typical New York nursing home score (the benchmark); higher is better.
2 points above the New York average for nursing homes (83/100)
Rank #164 / 344 in New York Inspection Score — State benchmarked This home is ranked 164th out of 344 homes in New York. Shows this facility's inspection score compared to the New York average among 344 comparable communities in the ranking pool. Inspection score: 85 out of 100. Letter grade B. 2 points above the New York average for nursing homes (83/100)
Enforcement actions are formal penalties or interventions imposed by New York regulators when a nursing home fails to meet state or federal care, safety, or regulatory standards. They may include directed plans of correction, civil monetary penalties, denial of payment, or appointment of temporary management.
This facility has 1 enforcement action. 33% of New York nursing homes have zero, and the statewide average is 1.6.
This scorecard compares key inspection, citation, and complaint metrics at this facility against the New York state average. Metrics rated ≥15% worse than average are highlighted in red; those ≥15% better are highlighted in green.
Citations
| This Facility | NY Average | vs. NY Avg |
|---|---|---|---|
|
Total citations
Formal regulatory issues recorded by inspectors across all inspection types.
| 15 | 13 | This facility has 15% more total citations than a typical New York nursing home (15 vs. NY avg 13).↑ 15% worse |
|
Health citations
Violations related to resident care, clinical practices, and day-to-day operations.
| 11 | 20 | This facility has 45% fewer health citations than a typical New York nursing home (11 vs. NY avg 20).↓ 45% better |
|
Life safety citations
Violations related to building safety — fire prevention, emergency egress, and similar.
| 4 | 4 | This facility has life safety citations in line with the New York average (4 vs. NY avg 4).— At avg |
|
Citations per year
Average citations per year since 2021.
| 3 | 2.6 | This facility has 15% more citations per year than a typical New York nursing home (3 vs. NY avg 2.6).↑ 15% worse |
|
Citations per inspection
Average citations per inspection.
| 2.5 | 1.4 | This facility has 79% more citations per inspection than a typical New York nursing home (2.5 vs. NY avg 1.4).↑ 79% worse |
Inspections
| This Facility | NY Average | vs. NY Avg |
|---|---|---|---|
|
Total inspections
Combined count of all routine and focused inspections. Excludes complaint investigations.
| 6 | 9 | This facility has 33% fewer total inspections than a typical New York nursing home (6 vs. NY avg 9).↓ 33% better |
|
Inspections with citations
Inspections that resulted in at least one regulatory citation.
| 4 | 4 | This facility has inspections with citations in line with the New York average (4 vs. NY avg 4).— At avg |
|
Inspection citation rate
Percentage of inspections that resulted in at least one citation.
| 67% | 44% | This facility has 23 percentage points higher inspection citation rate than a typical New York nursing home (67% vs. NY avg 44%).↑ 23% worse |
Complaints & Investigations
| This Facility | NY Average | vs. NY Avg |
|---|---|---|---|
|
Total complaints
Formal expressions of concern made by residents, families, or staff.
| 41 | 79 | This facility has 48% fewer total complaints than a typical New York nursing home (41 vs. NY avg 79).↓ 48% better |
|
Complaints per year
Average complaints per year since 2021.
| 8.2 | 15.8 | This facility has 48% fewer complaints per year than a typical New York nursing home (8.2 vs. NY avg 15.8).↓ 48% better |
|
Complaints per bed
Size-adjusted complaint rate based on occupied beds.
| 1.51 | 0.50 | This facility has 202% more complaints per bed than a typical New York nursing home (1.51 vs. NY avg 0.5).↑ 202% worse |
|
Complaint investigations
On-site investigations triggered by complaints filed with New York regulators.
| 8 | 15 | This facility has 47% fewer complaint investigations than a typical New York nursing home (8 vs. NY avg 15).↓ 47% better |
An editor-reviewed summary of the themes and findings across this facility's recent inspection reports.
New York average 3.6
Last Health inspection on Nov 2024
New York average 18.5
New York average 5.05
Health citations are formal notices following inspections when they fail to comply with safety and care standards.
14 of 23 citations resulted from standard inspections; 2 of 23 resulted from complaint investigations; and 7 of 23 came from combined inspections (standard and complaint).
100% better than New York averageNew York average: 0.2
100% better than New York averageNew York average: 0.2
Corrected
Corrected
Corrected
Corrected
How this facility protects residents through staff vaccination policies and immunization practices.
Percentage of facility employees vaccinated against influenza.
Reporting period: October 1 – December 31, 2025 (Q4 2025). Source: CMS Payroll-Based Journal report.
1586% more staff per resident than New York average
12% worse than New York average
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
Manages medical care and health needs.
All 3 RN Staff are full-time employees. No contractors work on this role.
3
Average shift length. Calculated as total hours divided by days worked and average staff per day.
9.4 hoursAssists with medical care and medications.
All 13 LPN Staff are full-time employees. No contractors work on this role.
13
Average shift length. Calculated as total hours divided by days worked and average staff per day.
6.9 hoursHelps with daily care and mobility.
All 30 CNA Staff are full-time employees. No contractors work on this role.
30
Average shift length. Calculated as total hours divided by days worked and average staff per day.
6.9 hours
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
This data comes from the CMS Payroll-Based Journal report covering October 1 – December 31, 2025.
| Certified Nursing Assistant | 30 | 0 | 30 | 5,458 | 92 | 100% | 6.9 |
| Licensed Practical Nurse | 13 | 0 | 13 | 2,080 | 92 | 100% | 6.9 |
| Registered Nurse | 3 | 0 | 3 | 821 | 68 | 74% | 9.4 |
| Other Dietary Services Staff | 4 | 0 | 4 | 506 | 81 | 88% | 6 |
| Nurse Practitioner | 1 | 0 | 1 | 487 | 62 | 67% | 7.9 |
| Respiratory Therapy Technician | 4 | 0 | 4 | 458 | 62 | 67% | 7 |
| Physical Therapy Assistant | 2 | 0 | 2 | 458 | 55 | 60% | 7.5 |
| Physical Therapy Aide | 1 | 0 | 1 | 385 | 52 | 57% | 7.4 |
| Speech Language Pathologist | 1 | 0 | 1 | 252 | 53 | 58% | 4.8 |
| Qualified Social Worker | 2 | 0 | 2 | 246 | 50 | 54% | 4.8 |
| Clinical Nurse Specialist | 1 | 0 | 1 | 213 | 28 | 30% | 7.6 |
| Dental Services Staff | 1 | 0 | 1 | 208 | 26 | 28% | 8 |
| Administrator | 1 | 0 | 1 | 192 | 24 | 26% | 8 |
| Dietitian | 1 | 0 | 1 | 112 | 15 | 16% | 7.5 |
Federal penalties imposed by CMS for regulatory violations, including civil money penalties (fines) and denials of payment for new Medicare/Medicaid admissions.
Source: CMS Penalties Database
No penalties in the past 3 years
No civil money penalties or payment denials were reported in the last 3 years.
These measures show how residents usually do over time at this home, based on health outcomes and preventive care.
A composite score based on pressure ulcers, falls with injury, weight loss, walking ability decline, and activities of daily living decline.
10.7
9% worse than New York averageNew York average: 9.8
A composite score based on activities of daily living decline, walking ability decline, and incontinence.
21.4
18% worse than New York averageNew York average: 18.1
CMS star rating based on long-stay quality measure performance. 5 stars = significantly above average, 1 star = significantly below average.
Percent of long-stay residents whose need for help with daily activities has increased
23.2%
41% worse than New York averageNew York average: 16.4%
Percent of low risk long-stay residents who lose control of their bowels or bladder
19.5%
9% better than New York averageNew York average: 21.4%
Percent of long-stay residents experiencing one or more falls with major injury
0.0%
100% better than New York averageNew York average: 3.0%
Percent of long-stay high risk residents with pressure ulcers
3.1%
57% better than New York averageNew York average: 7.2%
Percent of long-stay residents with a urinary tract infection
1.8%
30% worse than New York averageNew York average: 1.4%
Percent of long-stay residents who lose too much weight
16.4%
168% worse than New York averageNew York average: 6.1%
Percent of long-stay residents who have depressive symptoms
1.9%
90% better than New York averageNew York average: 18.1%
Percent of long-stay residents who received an antipsychotic medication
0.0%
100% better than New York averageNew York average: 12.6%
Percent of long-stay residents assessed and appropriately given the pneumococcal vaccine
93.0%
In line with New York averageNew York average: 91.4%
CMS star rating based on short-stay quality measure performance. 5 stars = much above average, 1 star = much below average.
Percent of short-stay residents assessed and appropriately given the pneumococcal vaccine
92.1%
20% better than New York averageNew York average: 76.6%
Percent of short-stay residents who newly received an antipsychotic medication
0.6%
56% better than New York averageNew York average: 1.3%
Percent of short-stay residents assessed and appropriately given the seasonal influenza vaccine
92.8%
18% better than New York averageNew York average: 78.8%
Percentage of short-stay residents who were re-hospitalized after their nursing home admission.
26.8%
30% worse than New York averageNew York average: 20.6%
Percentage of short-stay residents who had an outpatient emergency department visit.
19.7%
103% worse than New York averageNew York average: 9.7%
Percentage of SNF residents who experience falls with major injury during their stay.
0.0%
100% better than New York averageNew York average: 0.8%
Percentage of residents at or above expected ability to care for themselves at discharge.
56.4%
5% better than New York averageNew York average: 53.7%
Rate of successful return to home or community from a skilled nursing facility.
55.8%
10% better than New York averageNew York average: 50.6%
Quality measures are calculated from Minimum Data Set (MDS) assessments. For most measures, lower percentages indicate better care quality.
34% of new residents, usually for short-term rehab.
62% of new residents, often for short stays.
4% of new residents, often for long-term daily care.
Source: CMS Long-Term Care Facility Characteristics (Data as of Jan 2026)
Total residents
22Residents meet regularly to discuss policies, care quality, and activities
Organized group of residents that meets regularly to discuss facility policies, quality of life, and activities.
Data sourced from CMS Long-Term Care Facility Characteristics quarterly report. Payer mix reflects the current resident census by primary payment source.
Historical financial and operational data for The Brook at High Falls based on CMS SNF Cost Reports.
The portion of the home's budget spent on staff, including nurses, caregivers, and other employees who support care and operations.
Rank #381 / 382Payroll — State benchmarkedThis home is ranked 381st out of 382 homes in New York. Shows total annual staff payroll benchmarked to the New York average. Higher payroll investment relative to peers often signals better staffing and less reliance on cheaper contract labor.Click the rank badge to see the full State ranking.Click here to see the full State ranking.
All remaining costs needed to run the home, such as food, utilities, building maintenance, supplies and administrative expenses.
Residents typically stay for brief periods, with frequent admissions and discharges throughout the year.
3.1 miles from city center
Estimated distance in miles from Rochester's city center to The Brook at High Falls's address, calculated via Google Maps.
— 1.57 miles to nearest hospital (Lipson Cancer And Blood Center)
Add your location
The Brook at High Falls is located in Rochester, New York.
Here are the financial assistance programs available to residents in New York.
The information below is reported by the New York State Department of Health.
| Edna Tina Wilson Living Center |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care). | Rochester (Island Cottage Road) | 120
Facility
120
NY AVG
160
Rank
#412 / 748 |
98.3%
Facility
98.3%
NY AVG
88.3%
Rank
#16 / 432 | +11% | 4.83
Facility
4.83
NY AVG
3.58
Rank
#21 / 387 | -56% | +35% | $0
Facility
$0
NY AVG
$67.6k
Rank
#1 / 394 | 86
Facility
86
NY AVG
83
Rank
#157 / 344 | 5
Facility
5
NY AVG
18.5
Rank
#14 / 393 | 1.7
Facility
1.7
NY AVG
5.1
Rank
#10 / 393 | - | 118 |
2
Facility
2
NY AVG
63
Rank
#1144 / 1173 | Sandra Loan | $17.7M
Facility
$17.7M
NY AVG
$32.0M
Rank
#297 / 382 | $11.3M
Facility
$11.3M
NY AVG
$10.7M
Rank
#242 / 382 | 64.1%
Facility
64.1%
NY AVG
37%
Rank
#44 / 382 | 335769 | ||||
| Jewish Home of Rochester |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care). | Rochester (South Winton Road) | 328
Facility
328
NY AVG
160
Rank
#44 / 748 |
96.0%
Facility
96.0%
NY AVG
88.3%
Rank
#198 / 432 | +9% | 5.25
Facility
5.25
NY AVG
3.58
Rank
#12 / 387 | -84% | +47% | $0
Facility
$0
NY AVG
$67.6k
Rank
#1 / 394 | 85
Facility
85
NY AVG
83
Rank
#164 / 344 | 3
Facility
3
NY AVG
18.5
Rank
#6 / 393 | 1.5
Facility
1.5
NY AVG
5.1
Rank
#5 / 393 | - | 304 |
8
Facility
8
NY AVG
63
Rank
#1097 / 1173 | Robert Baker | $59.5M
Facility
$59.5M
NY AVG
$32.0M
Rank
#52 / 382 | $41.6M
Facility
$41.6M
NY AVG
$10.7M
Rank
#22 / 382 | 69.9%
Facility
69.9%
NY AVG
37%
Rank
#21 / 382 | 335105 | ||||
| Friendly Home |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care).
HC Home Care Professional care delivered in the person's own home — from companionship and errands to skilled nursing and therapy. Allows seniors to age in place. Medicare covers skilled home health when medically necessary.
MC Memory Care Secured, specialized care for people living with Alzheimer's or dementia. Staff trained in cognitive impairment, with higher staff-to-resident ratios and an environment designed to reduce confusion and wandering risk. | Rochester (City Of Rochester) | 200
Facility
200
NY AVG
160
Rank
#169 / 748 |
89.0%
Facility
89.0%
NY AVG
88.3%
Rank
#303 / 432 | +1% | 4.71
Facility
4.71
NY AVG
3.58
Rank
#25 / 387 | -89% | +32% | $0
Facility
$0
NY AVG
$67.6k
Rank
#1 / 394 | 87 | 14
Facility
14
NY AVG
18.5
Rank
#148 / 393 | 4.7
Facility
4.7
NY AVG
5.1
Rank
#193 / 393 | - | 171 |
17
Facility
17
NY AVG
63
Rank
#1046 / 1173 | Christine Johnson | $34.2M
Facility
$34.2M
NY AVG
$32.0M
Rank
#165 / 382 | $19.1M
Facility
$19.1M
NY AVG
$10.7M
Rank
#123 / 382 | 55.9%
Facility
55.9%
NY AVG
37%
Rank
#97 / 382 | 335476 | ||||
| Park Place Southwest |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care). | Rochester (Genesee Street) | 120
Facility
120
NY AVG
160
Rank
#412 / 748 | - | - | 3.85
Facility
3.85
NY AVG
3.58
Rank
#95 / 387 | -38% | +8% | $12.9k
Facility
$12.9k
NY AVG
$67.6k
Rank
#319 / 394 | - | 11
Facility
11
NY AVG
18.5
Rank
#92 / 393 | 2.8
Facility
2.8
NY AVG
5.1
Rank
#52 / 393 | 1 | 116 |
75
Facility
75
NY AVG
63
Rank
#530 / 1173 | Rachel Adonis | $15.9M
Facility
$15.9M
NY AVG
$32.0M
Rank
#318 / 382 | $11.9M
Facility
$11.9M
NY AVG
$10.7M
Rank
#227 / 382 | 74.8%
Facility
74.8%
NY AVG
37%
Rank
#11 / 382 | 335620 | ||||
| The Brook at High Falls |
NH Nursing Home Licensed facility providing 24/7 skilled nursing care for residents with complex, ongoing medical needs. Staffed by RNs, LPNs, and CNAs. Inspected and star-rated annually by CMS. Accepts Medicare (short-term rehab) and Medicaid (long-term care). | Rochester (Group 14621) | 28
Facility
28
NY AVG
160
Rank
#737 / 748 |
32.1%
Facility
32.1%
NY AVG
88.3%
Rank
#414 / 432 | -64% | 3.95
Facility
3.95
NY AVG
3.58
Rank
#95 / 387 | -64% | +10% | $0
Facility
$0
NY AVG
$67.6k
Rank
#1 / 394 | 85
Facility
85
NY AVG
83
Rank
#164 / 344 | 23
Facility
23
NY AVG
18.5
Rank
#287 / 393 | 5.8
Facility
5.8
NY AVG
5.1
Rank
#272 / 393 | - | 9 |
58
Facility
58
NY AVG
63
Rank
#719 / 1173 | Christina Oropeza | $4.4M
Facility
$4.4M
NY AVG
$32.0M
Rank
#381 / 382 | $2.6M
Facility
$2.6M
NY AVG
$10.7M
Rank
#381 / 382 | 58.9%
Facility
58.9%
NY AVG
37%
Rank
#72 / 382 | 335825 |
The Brook at High Falls is in the Group 14621 neighborhood of Rochester.
The legal owner and operator of The Brook at High Falls is AGA Operating LLC (For Profit).
The Brook at High Falls has a walk score of 58. Moderately walkable. Some errands can be accomplished on foot, with a mix of nearby amenities.
The Brook at High Falls's occupancy is 32%.
The Brook at High Falls has 28 beds.
The Brook at High Falls has had 15 recently reported deficiencies.
The Brook at High Falls is located at 2150 St Paul St, Rochester, NY 14621, United States.
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