Inspection Reports for
The Brook at High Falls
2150 St Paul St, Rochester, NY 14621, United States, NY
Back to Facility Profile5 Reports
Inspection Report — Jan 16, 2026
State
Date: Jan 16, 2026
Visit Reason
State-compiled facility profile showing 6 inspections from 2022 to 2026 with deficiency and enforcement history.
Complaint Details
Facility received 46 complaints with 9 on-site inspections resulting in 11 citations related to complaints during the reporting period.
Findings
Across 6 inspections, 4 resulted in citations totaling 56 deficiencies primarily related to standard health and life safety code issues. The facility had 46 complaints with 9 on-site inspections and 1 enforcement action involving fines.
Citations (40)
Free Of Accident Hazards/supervision/devices: Standard Health Citation for quality of care with pattern scope.
Infection Prevention & Control: Standard Health Citation for quality of care with widespread scope.
Label/store Drugs And Biologicals: Standard Health Citation for quality of care with isolated scope.
Resident Rights/exercise Of Rights: Standard Health Citation for quality of care with pattern scope.
Safe/clean/comfortable/homelike Environment: Standard Health Citation for quality of care with pattern scope.
Standards Of Construction For New Existing Nh: Standard Health Citation for quality of care with scope.
Corridor - Doors: Life Safety Code Citation for NFPA requirements with pattern scope.
Hazardous Areas - Enclosure: Life Safety Code Citation for NFPA requirements with pattern scope.
Sprinkler System - Maintenance And Testing: Life Safety Code Citation for NFPA requirements with pattern scope.
Subdivision Of Building Spaces - Smoke Barrie: Life Safety Code Citation for NFPA requirements with pattern scope.
Vertical Openings - Enclosure: Life Safety Code Citation for NFPA requirements with isolated scope.
ADL Care Provided For Dependent Residents: Standard Health Citation for quality of care with isolated scope.
Bedrooms Assure Full Visual Privacy: Standard Health Citation for quality of care with isolated scope.
Care Plan Timing And Revision: Standard Health Citation for quality of care with isolated scope.
Infection Prevention & Control: Standard Health Citation for quality of care with pattern scope.
Menus Meet Resident Nds/prep In Adv/followed: Standard Health Citation for quality of care with isolated scope.
Posted Nurse Staffing Information: Standard Health Citation for quality of care with pattern scope.
Quality Of Care: Standard Health Citation for quality of care with isolated scope.
Resident Records - Identifiable Information: Standard Health Citation for quality of care with pattern scope.
Safe/clean/comfortable/homelike Environment: Standard Health Citation for quality of care with pattern scope.
Gas Equipment - Cylinder And Container Storag: Life Safety Code Citation for NFPA requirements with pattern scope.
Maintenance, Inspection & Testing - Doors: Life Safety Code Citation for NFPA requirements with pattern scope.
Sprinkler System - Installation: Life Safety Code Citation for NFPA requirements with pattern scope.
Dialysis: Standard Health Citation for quality of care with isolated scope.
Food Procurement,store/prepare/serve-sanitary: Standard Health Citation for quality of care with pattern scope.
Free From Unnec Psychotropic Meds/prn Use: Standard Health Citation for quality of care with isolated scope.
Free Of Accident Hazards/supervision/devices: Standard Health Citation for quality of care with isolated scope.
Infection Control: Standard Health Citation for quality of care with widespread scope.
Notice Of Bed Hold Policy Before/upon Trnsfr: Standard Health Citation for quality of care with pattern scope.
Qaa Committee: Standard Health Citation for quality of care with pattern scope.
Rn 8 Hrs/7 Days/wk, Full Time Don: Standard Health Citation for quality of care with pattern scope.
Services Provided Meet Professional Standards: Standard Health Citation for quality of care with isolated scope.
Standards Of Construction For New Existing Nh: Standard Health Citation for quality of care with pattern scope.
Egress Doors: Life Safety Code Citation for NFPA requirements with pattern scope.
Electrical Systems - Essential Electric Syste: Life Safety Code Citation for NFPA requirements with pattern scope.
Ep Training Program: Life Safety Code Citation for NFPA requirements with widespread scope.
Gas Equipment - Cylinder And Container Storag: Life Safety Code Citation for NFPA requirements with pattern scope.
Subdivision Of Building Spaces - Smoke Barrie: Life Safety Code Citation for NFPA requirements with pattern scope.
Maintains Effective Pest Control Program: Standard Health Citation for quality of care with pattern scope.
Safe/clean/comfortable/homelike Environment: Standard Health Citation for quality of care with pattern scope.
Report Facts
Inspections on page: 6
Total violations/deficiencies cited: 56
Inspections with violations: 4
Inspections without violations: 2
Total complaints: 46
On-site complaint inspections: 9
Citations issued from complaints: 11
Enforcement actions: 1
Total fines: 14000
Inspection Report — Nov 7, 2024
Annual Inspection CMS
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.
Citations (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 — Feb 14, 2024
Abbreviated Survey CMS
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.
Citations (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 — May 10, 2023
Annual Inspection CMS
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.
Citations (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 — Nov 23, 2021
Annual Inspection CMS
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.
Citations (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 |
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