Inspection Reports for The Brook at High Falls
2150 St Paul St, Rochester, NY 14621, United States, NY
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
24.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
384% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 12
Date: Nov 14, 2024
Visit Reason
Multiple standard health and life safety code citations related to quality of care, environment, and safety issues were identified and corrected by January and February 2025.
Findings
Multiple standard health and life safety code citations related to quality of care, environment, and safety issues were identified and corrected by January and February 2025.
Deficiencies (12)
ADL care provided for dependent residents
Bedrooms assure full visual privacy
Care plan timing and revision
Infection prevention & control
Menus meet resident nds/prep in adv/followed
Posted nurse staffing information
Quality of care
Resident records - identifiable information
Safe/clean/comfortable/homelike environment
Gas equipment - cylinder and container storag
Maintenance, inspection & testing - doors
Sprinkler system - installation
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Nov 7, 2024
Visit Reason
The inspection was a Recertification Survey conducted from 11/07/2024 to 11/14/2024 to assess compliance with regulatory requirements for The Brook at High Falls Nursing Home and Rehabilit.
Findings
The facility was found deficient in multiple areas including maintenance of a safe and homelike environment, care planning, activities of daily living assistance, nutrition and hydration, infection control, privacy, and record safeguarding. Specific issues included inoperable equipment, lack of soap and call bells in resident bathrooms, failure to hold care plan meetings, inadequate nail care, insufficient nutritional support, improper infection control practices, missing privacy curtains, and unsecured damaged resident records.
Deficiencies (9)
Maintenance services were inadequate to maintain a sanitary, orderly, and comfortable homelike environment, including inoperable kitchen freezer, unprotected kitchen lighting, inoperable bathrooms exhaust ventilation, lack of soap in resident bathrooms, missing call bell, and unsecured exit sign.
Failure to hold comprehensive person-centered care plan meetings quarterly and invite resident and/or representative for one resident.
Failure to provide necessary assistance for activities of daily living, specifically inadequate nail care for one resident.
Failure to ensure treatment and care according to orders and professional standards for one resident, including inadequate nutrition, hydration, and pressure injury management.
Nurse staffing information was not posted at the beginning of each shift and was not posted on weekends as required.
Failure to ensure menus met nutritional needs and dietary recommendations were followed for one resident, including missing fortified pudding and nutritional supplements.
Failure to safeguard resident medical record information against loss, destruction, or unauthorized use; records stored in damaged boxes in an unlocked basement electrical room.
Failure to establish and maintain an infection prevention and control program, including improper food handling without gloves, laundry staff not wearing gowns when handling soiled linens, and infection control policies not reviewed annually.
Failure to provide privacy curtains in semi-private rooms for two residents, resulting in lack of visual privacy.
Report Facts
Meal opportunities with no fluid intake documented: 18
Meal opportunities with no nutritional supplement documented: 18
Care plan meetings missed: 1
Residents reviewed for care planning: 12
Residents reviewed for nutrition/hydration: 3
Residents reviewed for pressure injury: 1
Residents reviewed for activities of daily living: 1
Residents reviewed for menu compliance: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Stated privacy curtains were not hung due to refurbishment and housekeeping not knowing curtain hooks location; also stated Resident #9's nails were cleaned on shower days and in between. | |
| Certified Nursing Assistant #2 | Observed touching resident food without gloves; stated gloves were not readily available; also stated Resident #178 refused care and breakfast. | |
| Certified Nursing Assistant #3 | Collected Resident #13's meal tray; stated missing fortified pudding and mighty shake were not offered; stated Resident #13 had wandered and should have been encouraged to eat. | |
| Director of Nursing #2 | Director of Nursing | Aware of missing soap dispensers; concerned about hand hygiene; stated care plan meetings should be held quarterly; stated intakes and refusals should be documented; stated laundry staff should wear gowns; stated nurse staffing posting process was unclear. |
| Director of Maintenance | Stated lack of time to fix inoperable staff bathroom and leaking sink; stated vents were being repaired; stated ventilation checks were not regularly performed. | |
| Director of Social Work | Stated care plan meetings should be quarterly; invited Resident #3 and family to meeting but family did not respond. | |
| Kitchen Manager | Stated inoperable freezer needed replacement; stated light fixtures in kitchen were not working. | |
| Licensed Practical Nurse Manager #1 | Licensed Practical Nurse Manager | Stated Certified Nursing Assistants responsible for nail care; unable to show documentation of nail care; stated Resident #178's coccyx wound looked worse. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Stated Resident #178's coccyx wound looked worse possibly due to poor nutrition and immobility. |
| Laundry Attendant #1 | Observed handling soiled linen without gown; stated no education on gown use; unaware of gown location. | |
| Registered Dietician | Stated documentation of resident intakes was sparse; had spoken with Resident #13 about weight loss but resident was non-interactive. | |
| Resident #3 | Reported never being invited to care plan meetings; expressed desire for meetings to discuss care. | |
| Resident #9 | Observed with dirty fingernails; stated desire for privacy curtains to be reinstalled. | |
| Resident #13 | Did not receive all ordered fortified foods and nutritional supplements; refused 100% of meal without staff intervention. | |
| Resident #15 | Reported no privacy curtain in room; preferred privacy and door closed. | |
| Regional Director of Nursing | Verified resident records should not be stored in basement electrical room; stated infection control policies provided were most current but not reviewed annually. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 2
Date: Feb 16, 2024
Visit Reason
Standard health citations related to pest control and environment issues were identified and corrected by May 7, 2024.
Findings
Standard health citations related to pest control and environment issues were identified and corrected by May 7, 2024.
Deficiencies (2)
Maintains effective pest control program
Safe/clean/comfortable/homelike environment
Inspection Report
Abbreviated Survey
Census: 9
Deficiencies: 7
Date: Feb 14, 2024
Visit Reason
The inspection was an abbreviated survey conducted to assess the facility's environment and pest control program, including observations of physical conditions and pest activity.
Findings
The facility was found to have multiple environmental deficiencies including a deteriorated and unsafe exit ramp handrail, missing door threshold transition strips, damaged walls, broken floor tiles, windows without opening handles, and holes in carpets. Additionally, the facility did not maintain an effective pest control program, with evidence of rodent activity and pest harborage areas observed in resident rooms, kitchen, and basement.
Deficiencies (7)
Deteriorated and unsafe railing on an exit ramp with corroded support posts and wobbling handrail.
Missing door threshold transition strip between corridor floor tiles and carpet at resident room entrance.
Damaged walls including large missing sections of horizontal wall protective material near beds.
Broken floor tiles in resident rooms with various sizes of damage.
Resident room windows without handles or mechanisms to open.
Holes in carpet near beds in resident rooms.
Ineffective pest control program with evidence of rodent activity including mouse droppings in multiple areas and unsealed openings allowing pest entry.
Report Facts
Residents able to ambulate independently: 9
Pest vendor service reports reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Manager | Stated number of residents able to ambulate independently. | |
| Director of Environmental Services | Reported ramp handrail issue and unknown reason for missing window handles. | |
| Facilities Director | Discussed plans to replace ramp and pest control issues. | |
| Administrator | Discussed remodeling plans and pest control documentation. | |
| Resident #5 | Reported mouse sightings and named the mouse. | |
| Resident #13 | Reported seeing mice in their room about a month ago. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 15
Date: May 10, 2023
Visit Reason
Multiple standard health and life safety code citations related to dialysis, food safety, medication use, infection control, staffing, and building safety were identified and corrected by June 2023.
Findings
Multiple standard health and life safety code citations related to dialysis, food safety, medication use, infection control, staffing, and building safety were identified and corrected by June 2023.
Deficiencies (15)
Dialysis
Food procurement,store/prepare/serve-sanitary
Free from unnec psychotropic meds/prn use
Free of accident hazards/supervision/devices
Infection control
Notice of bed hold policy before/upon trnsfr
Qaa committee
Rn 8 hrs/7 days/wk, full time don
Services provided meet professional standards
Standards of construction for new existing nh
Egress doors
Electrical systems - essential electric syste
Ep training program
Gas equipment - cylinder and container storag
Subdivision of building spaces - smoke barrie
Inspection Report
Annual Inspection
Deficiencies: 9
Date: May 10, 2023
Visit Reason
The inspection was a Recertification Survey conducted from 5/04/23 to 5/10/23 to assess compliance with regulatory standards for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including failure to provide written notice of bed-hold policy upon resident transfer, inadequate provision of prescribed adult briefs, inconsistent medication administration, unsafe hot water temperatures, inadequate dialysis care and fluid restriction monitoring, insufficient RN coverage, lack of gradual dose reductions for psychotropic medications, food safety violations in the kitchen, and failure to maintain a fully compliant Quality Assessment and Assurance committee.
Deficiencies (9)
Failure to notify resident or representative in writing of bed-hold policy duration upon hospital transfer.
Failure to provide prescribed adult briefs causing skin irritation and blistering.
Medications not consistently administered per physician orders.
Unsafe water temperatures up to 149°F in resident bathrooms and hot water tank, risking resident safety.
Dialysis care deficient due to failure to monitor and enforce resident's fluid restriction.
Facility did not have a Registered Nurse on duty for at least eight consecutive hours per day on 26 days over four months.
Failure to implement gradual dose reductions or psychiatric evaluations for psychotropic medication use.
Food safety violations including improper thawing, improper food temperatures, inoperable sinks and coolers, and inadequate hand-wash sink.
Quality Assessment and Assurance committee lacked Medical Director or designee attendance for past 10 months.
Report Facts
Days without RN coverage: 26
Fluid restriction: 1500
Weight gain: 33
Water temperature: 149
Medication missed doses: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)/ Nurse Manager (NM) | Licensed Practical Nurse / Nurse Manager | Provided information on medication administration and psychotropic medication consults. |
| Administrator | Facility Administrator | Provided information on bed-hold policy, RN coverage, hot water issues, and QAPI meetings. |
| Director of Nursing (DON) | Director of Nursing | Discussed supply and ordering of prescribed adult briefs. |
| Dialysis Registered Nurse (RN) | Dialysis Registered Nurse | Discussed resident's fluid restriction compliance and dialysis care. |
| Dialysis Registered Dietician (RD) | Dialysis Registered Dietician | Discussed monitoring of resident's fluid intake. |
| CNA #3 | Certified Nursing Assistant | Observed providing care and discussed briefs used for Resident #5. |
| CNA #2 | Certified Nursing Assistant | Discussed fluid intake monitoring and resident hydration. |
| Food Service Director | Food Service Director | Discussed kitchen equipment issues and food safety violations. |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: May 10, 2023
Visit Reason
The inspection was a Recertification Survey conducted from 5/04/23 to 5/10/23 to assess compliance with professional standards of quality, safety, and regulatory requirements in the nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide prescribed adult briefs to a resident, inconsistent medication administration, unsafe water temperatures in resident bathrooms, inadequate dialysis care and fluid restriction monitoring, lack of consistent RN coverage, failure to implement gradual dose reductions for psychotropic medications, improper food storage and preparation practices, and lack of Medical Director participation in quality assurance meetings.
Deficiencies (8)
Failure to provide Resident #5 with prescribed adult briefs causing skin irritation and blisters.
No documented evidence that medications were consistently administered per physician orders for Resident #329.
Unsafe water temperatures up to 149°F in multiple resident bathrooms and hot water tank set at 140°F.
Dialysis services for Resident #329 were not consistent with professional standards; fluid restriction not properly monitored.
Facility did not have a Registered Nurse on duty for at least eight consecutive hours per day on 26 days over four months.
Failure to implement gradual dose reductions or psychiatric evaluation for Resident #6 on antidepressant medication.
Food was not thawed properly, foods held at improper temperatures, three-bay sink and milk cooler inoperable, and hand-wash sink not properly maintained.
Quality Assessment and Assurance committee lacked Medical Director or designee attendance for past 10 months.
Report Facts
Missed medication doses: 5
Days without RN coverage: 26
Weight gain: 33
Fluid restriction: 1.5
Water temperatures: 149
Water temperatures: 140
Days with no fluids recorded: 22
Days with blank fluid documentation: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Regular aide for Resident #5, involved in observation and interview regarding briefs. | |
| Licensed Practical Nurse (LPN)/ Nurse Manager (NM) | Interviewed regarding briefs for Resident #5, medication administration, and dialysis care. | |
| Director of Nursing (DON) | Interviewed regarding supply and ordering of briefs for Resident #5. | |
| Dialysis Registered Nurse (RN) | Interviewed regarding Resident #329's blood pressure and medication administration. | |
| Dialysis Registered Dietician (RD) | Interviewed regarding Resident #329's fluid restriction compliance. | |
| CNA #2 | Interviewed regarding fluid intake and water pitcher for Resident #329. | |
| Receptionist | Interviewed regarding nurse staffing reports and RN coverage. | |
| Administrator | Interviewed regarding RN coverage and quality assurance meetings. | |
| Licensed Practical Nurse (LPN)/Nurse Manager (NM) | Interviewed regarding psychiatric consult for Resident #6. | |
| Physician | Interviewed regarding Resident #6's antidepressant medication. | |
| Food Service Director | Interviewed regarding kitchen deficiencies including refrigerator and cooler issues. | |
| Cook/Tray Aide | Interviewed regarding hand-wash sink and thawing of ground beef. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 6
Date: Nov 23, 2021
Visit Reason
Standard health citations related to assessments, dialysis, drug regimen review, physical environment, and construction standards were identified and corrected by January 2022.
Findings
Standard health citations related to assessments, dialysis, drug regimen review, physical environment, and construction standards were identified and corrected by January 2022.
Deficiencies (6)
Comprehensive assessments & timing
Dialysis
Drug regimen review, report irregular, act on
Physical environment
Qrtly assessment at least every 3 months
Standards of construction for new existing nh
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Nov 23, 2021
Visit Reason
The Recertification Survey was conducted to assess compliance with regulatory requirements for The Brook at High Falls Nursing Home and Rehabilitation.
Findings
The facility was found deficient in completing timely Comprehensive Minimum Data Set (MDS) Assessments, updating resident assessments quarterly, providing appropriate dialysis care for a resident requiring such services, and maintaining evidence of monthly pharmacist drug regimen reviews.
Deficiencies (4)
Failure to complete timely Comprehensive Minimum Data Set (MDS) Assessments for three residents.
Failure to update each resident’s assessment at least once every 3 months for three residents.
Failure to provide safe, appropriate dialysis care/services for a resident requiring dialysis, including lack of monitoring of AV fistula, fluid restriction, and communication with dialysis facility.
Failure to maintain evidence that the medication regimen review was completed monthly by the pharmacist and addressed by the physician for one resident.
Report Facts
Residents reviewed: 13
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 1
Fluid restriction: 32
Dialysis frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse MDS Coordinator | Registered Nurse | Named in relation to delayed MDS assessments |
| Administrator | Administrator | Named in relation to delayed MDS assessments |
| Licensed Practical Nurse Nurse Manager | Licensed Practical Nurse/Nurse Manager | Named in relation to dialysis care deficiency |
| Registered Dietitian | Registered Dietitian | Named in relation to dialysis care deficiency |
| Dialysis Center Registered Nurse | Registered Nurse | Named in relation to dialysis care deficiency |
| Director of Nursing | Director of Nursing | Named in relation to dialysis care deficiency |
| Registered Nurse #1 | Registered Nurse | Named in relation to medication regimen review deficiency |
| Physician's Assistant | Physician's Assistant | Named in relation to medication regimen review deficiency |
| Consultant Pharmacist | Pharmacist | Named in relation to medication regimen review deficiency |
| Unit Secretary | Unit Secretary | Named in relation to medication regimen review deficiency |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 22, 2021
Visit Reason
Citation for reporting to national health safety network with widespread scope and level 2 severity; no correction noted.
Findings
Citation for reporting to national health safety network with widespread scope and level 2 severity; no correction noted.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Nov 15, 2021
Visit Reason
Citation for reporting to national health safety network with widespread scope and level 2 severity; no correction noted.
Findings
Citation for reporting to national health safety network with widespread scope and level 2 severity; no correction noted.
Deficiencies (1)
Reporting - national health safety network
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