Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Brook At High Falls Nursing Home And Rehabilit during CMS and state inspections, most recent first.
Infection control lapses were observed across resident care activities. An LPN handled meds with bare hands and long fingernails, returned unused tablets to stock bottles, and used the same blood pressure device for multiple residents without cleaning it between uses, including for a resident on EBP. The DON performed wound care with the same gloves across tasks and touched environmental surfaces before removing them. Hand hygiene supplies were not readily available, and dirty linen bins were repeatedly left uncovered.
Improper Medicare Coverage Change Process: A resident with CVA, hemiparesis, DM, CKD, and moderate cognitive impairment had a Medicare coverage change discussed by facility staff with the responsible party. Staff explained that switching from a Managed Medicare plan to Original Medicare could provide more skilled days, but the responsible party was not given oral or written details about deductibles, co-pays, or reenrollment rights. The BOM confirmed the facility routinely approaches residents or representatives enrolled in Managed Medicare plans and does not provide written information about the impact of the change.
Hot water accessible at resident-use sinks and a shower room exceeded the facility’s safe range, with multiple readings above 120 degrees F. The facility policy required water temperatures to be maintained between 90 and 120 degrees F to prevent scalding, but logs showed a gap in monitoring when maintenance staff were assigned elsewhere. The DNM stated no temperatures were taken during that period.
Medications were stored unsecured in an open, unlocked soiled linen room being used as a temporary med room during renovations, making them accessible to residents, visitors, and non-authorized staff. Surveyors also found two loose, unlabeled pills in a med cart, an expired bottle of Vitamin B, and 14 missing signatures on narcotic count sheets, with no additional evidence of accurate controlled substance accountability.
The facility was found to have multiple maintenance and hygiene deficiencies, including inoperable kitchen lighting and freezer, non-functional staff bathroom, and inadequate ventilation in several areas. Additionally, there was a lack of soap or hand sanitizer in many resident rooms, and a missing nurse call button in a bathroom. Staff were aware of these issues but cited ongoing renovations and prioritization of resident needs as reasons for delays in addressing them.
The facility failed to maintain an effective infection prevention and control program. A CNA was observed handling a resident's food with bare hands and not performing hand hygiene after touching used meal trays. In the laundry room, a staff member handled soiled linens without wearing a protective gown. The facility's infection control policies were outdated and not reviewed annually as required.
A resident in an LTC facility was not invited to any care plan meetings for approximately 22 months, despite being cognitively intact and having significant medical conditions. The facility's policy required quarterly reviews, but it did not specify inviting residents or their representatives. Interviews revealed a lack of systematic scheduling for care plan meetings, and the resident expressed a desire for a meeting to discuss their care.
A resident with cognitive impairment and physical health issues was observed with dirty fingernails over several days, indicating a failure by the LTC facility to provide necessary personal hygiene care. Despite care plans requiring regular nail checks and cleaning, there was no documentation of such care being provided, nor any record of the resident refusing care. Staff interviews confirmed the responsibility for nail care, but documentation was lacking.
A resident with a history of stroke and hemiparesis, at risk for malnutrition and with a stage 3 pressure injury, did not receive adequate care as per their care plan. The resident was not consistently repositioned to off-load pressure from the coccyx wound, and there were significant gaps in documenting fluid intake and nourishment. Staff interviews revealed a lack of documentation and communication regarding the resident's refusals of care and meals, contributing to the worsening of the resident's condition.
A resident with cognitive impairment and nutritional risks did not receive prescribed dietary items, including fortified pudding and a second mighty shake, during a meal. Staff failed to encourage or assist the resident in eating, and the oversight was acknowledged by the kitchen staff and CNA. The RD had not informed the resident's family about weight loss, and the DON stressed the need for adherence to dietary orders.
The facility failed to provide privacy curtains in two semi-private rooms, affecting two residents with cognitive impairments. The absence of curtains, removed for washing, left residents exposed to view from the hallway. Despite requests, staff were unaware of the curtains' location, indicating poor communication and coordination.
The facility did not post nurse staffing information daily as required, with observations showing outdated sheets and no weekend postings. The receptionist responsible for posting was not properly trained by nursing leadership, and the DON was unaware of the correct process. Staffing sheets for weekends were completed retrospectively on Mondays.
The facility did not protect resident medical records from loss, destruction, or unauthorized use. Surveyors found damaged boxes of records, including medical, billing, and discharge information, stored in an unlocked basement electrical room. The boxes were stacked precariously, with files protruding and some showing water damage. The Regional DON confirmed the records should not be stored there.
The facility failed to provide a safe, clean, and homelike environment for residents, with deficiencies including a deteriorated exit ramp railing, missing door threshold transition strip, damaged walls, broken floor tiles, and windows without handles. Interviews revealed that while the issues were known and discussed in safety meetings, concrete plans or timelines for remediation were not provided.
The facility failed to maintain an effective pest control program, with multiple residents reporting frequent mouse sightings and observations confirming numerous droppings and unsealed entry points. Pest vendor reports indicated ongoing issues with rodent-proofing doors and sightings of mice in the basement office area.
Infection Control Lapses During Hand Hygiene, Medication Handling, Wound Care, and Linen Storage
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Multiple residents were involved, including residents with wound care needs, residents receiving medications, and a resident on enhanced barrier precautions. Observations and interviews showed that hand hygiene supplies were not consistently available on the unit, with no soap dispenser in some resident bathrooms and no alcohol-based hand sanitizer dispensers available on the unit during intermittent observations. Staff also reported carrying hand sanitizer in their pockets or using the medication cart or a bathroom sink because hand hygiene supplies were not readily accessible, and the Infection Preventionist stated staff should not keep hand sanitizer in their pockets due to the risk of cross contamination. During medication administration, an LPN prepared medications for several residents by pouring tablets into a bare hand, returning unused tablets to stock bottles, and removing blister-pack medications with fingernails before placing them into medication cups. The same hand-held blood pressure device was used for multiple residents and returned to the medication cart without cleaning between residents. This occurred for residents including one on enhanced barrier precautions. The LPN stated the facility did not have a mobile vital sign machine, that personal vital sign equipment was being used, and that the blood pressure cuff and machine were not cleaned between residents. The LPN also stated handling medications with their hands was how medications were usually prepared. At the time of observation, the LPN had fingernails approximately two inches long with visible dark debris underneath. During wound care for one resident with wounds on the right heel and right ankle, the DON sprayed wound cleanser onto adhered dressings, removed both dressings with the same gloves, left the room to gather supplies, returned with gloves on, and cleansed both wounds using the same pair of gloves. The DON then changed gloves, applied betadine to one wound, and applied Medi-honey by touching the inside of the dressing with a gloved hand. Without changing gloves or performing hand hygiene, the DON touched the resident's blankets, items on the over-bed table, window blinds, the door handle, and placed resident-care supplies on the treatment cart. In addition, dirty linen bins in the hallway were repeatedly observed uncovered while containing soiled linens. The Infection Preventionist stated that touching environmental surfaces with gloves used for wound care increases the risk of cross contamination and that dirty linen bin lids should remain closed to control odors and germs.
Improper Medicare Coverage Change Process
Penalty
Summary
The facility did not ensure that Resident #4 exercised rights regarding Medicare health coverage changes without interference or improper influence, and did not ensure the resident and/or responsible party received the required oral and written explanations about the impact of changing coverage. Resident #4 had diagnoses including cerebral infarction with hemiparesis, diabetes mellitus, and chronic kidney disease. The resident's MDS dated 11/24/2025 documented moderate cognitive impairment and that the resident did not have a Medicare-covered stay since the most recent entry. Addendum VII, Authorization for Legal Representation for Medicare Part D, dated 11/13/2025, documented that the sister facility's BOM recorded verbal authorization from the responsible party for the facility Administrator to act as a limited legal representative for Medicare Part D. The authorization applied only to Medicare Part D, was valid only during the resident's stay, and included enrollment and plan changes, insurance transactions, and claims and litigation. During interview, the responsible party stated they received a phone call from facility staff saying it was important to allow the facility to change the resident's insurance coverage because more services would be covered. The responsible party stated they were not advised of deductibles, co-payments, or reenrollment rights and did not receive written information about the impact of the coverage change. BOM #2 stated the facility contacted the responsible party to discuss changing insurance coverage to Original Medicare, explaining that Managed Medicare Plans typically cover skilled services for 10-14 days while Original Medicare provides additional benefit days, and stated the facility does not want the payor source to change to Medicaid because Medicaid is a lower reimbursement source. BOM #1 confirmed the facility approaches residents and/or responsible parties enrolled in Managed Medicare Plans to discuss disenrollment and that written information about the impact of coverage changes is not provided. The Administrator stated the facility offers residents and/or responsible parties the option to disenroll from current insurance coverage and enroll in Original Medicare when it becomes aware a longer stay may be needed than the insurance will cover.
Hot Water Temperatures Exceeded Safe Limits
Penalty
Summary
The facility did not ensure the resident environment remained free of accident hazards because hot water accessible to residents at point of use exceeded the facility’s stated safe range of 90 to 120 degrees Fahrenheit. The undated facility policy on Water Temperatures, Safety of specified that tap water in the facility must be maintained within a temperature range to prevent scalding, and that water heaters serving resident rooms, bathrooms, common areas, and tub/shower areas must be set to maintain temperatures between 90 and 120 degrees Fahrenheit. During observation, hot water temperatures from resident-accessible bathroom and shower room sinks were measured above 120 degrees Fahrenheit in multiple locations, including 124.0, 125.1, 122.8, 124.5, and 122.2 degrees Fahrenheit. Record review showed hot water temperature logs were documented every three to seven days through 12/18/2025, but there was no documented monitoring until 01/13/2026. The Director of Maintenance stated no hot water temperatures were taken during that period because maintenance staff were assigned to assist at an affiliated facility.
Unsecured Medication Storage and Incomplete Controlled Substance Counts
Penalty
Summary
Medications were not stored securely and were accessible to residents, visitors, and non-authorized staff while the facility was using an unsecured soiled linen room as a temporary medication room during renovations. During observation, a medication cart contained two loose, unlabeled pills in the bottom drawer, preventing verification of the medication integrity, dose, or intended recipient. The room used for medication storage was observed open and unlocked, and multiple medications were stored on a three-tier cart in that room, including an unopened bottle of Vitamin B with an expiration date of February 2024. The facility also had missing signatures on narcotic count sheets for 14 shift changes across multiple shifts, and there was no additional evidence provided to verify accurate narcotic counts or controlled substance accountability for those shifts. The DON stated nurses on shift were primarily responsible for the medication carts they worked on and that the DON checked carts weekly, while the DON also stated the facility was awaiting DEA approval to relocate the medication cabinet during renovations. The DON and LPN stated loose pills were discarded in a sharps container and expired or discontinued medications were returned to the pharmacy, but the observations showed the medication room door was open and unlocked while staff passed by without securing it.
Facility Maintenance and Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment as evidenced by several maintenance issues observed during the recertification survey. The kitchen lighting was not protected or operable, with uncovered fluorescent light fixtures and a non-functional fixture near the back kitchen door. A residential kitchen freezer was found to be inoperable, and a staff bathroom had its water shut off, rendering it unusable. Additionally, the Dirty Utility room hand wash sink was marked as unusable due to a leaking drainpipe. Exhaust ventilation issues were prevalent, with inoperable vents in the housekeeping closet, staff restroom, and several resident bathrooms. The absence of soap or hand sanitizer in numerous resident rooms further compromised hygiene standards. Interviews with staff revealed awareness of these issues, but a lack of timely resolution. The Director of Maintenance acknowledged the inoperable staff bathroom and leaking sink but cited prioritization of resident needs as a reason for delays. The Administrator and Director of Maintenance were aware of the missing ventilation in newly constructed bathrooms, attributing it to ongoing renovations. The absence of a nurse call button in a resident bathroom and an unsecured exit sign in a corridor were also noted. Staff expressed concerns about the limited hand sanitization facilities, impacting their ability to maintain hygiene after resident care.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations during a recertification survey. In the dining room, a Certified Nursing Assistant (CNA) was observed handling a resident's food with bare hands and did not perform hand hygiene after touching used meal trays before handling unused ones. This action was contrary to the facility's hand hygiene policy, which emphasizes the importance of handwashing or using an alcohol-based hand rub before and after handling food. The CNA admitted to not having gloves readily available, and the Director of Nursing confirmed that staff should not touch food directly with bare hands and should perform hand hygiene between assisting residents. In the laundry room, a staff member was seen handling soiled linens without wearing a protective gown, only using gloves. The facility's infection control policy did not specify requirements for handling soiled linens, and the laundry attendant was unaware of the need for gowns. The Infection Preventionist and Director of Nursing were also unaware of the lack of gowns in the laundry room. Additionally, a review of the facility's infection control policies revealed that they had not been reviewed or updated annually as required, with some policies last revised in 2008, 2016, and 2022. The Director of Nursing and Regional Director of Nursing acknowledged that the policies were not up-to-date.
Failure to Conduct Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a comprehensive person-centered care plan meeting was held at least quarterly for a resident who had been in the facility for approximately 22 months. There was no evidence that the resident or their representative had been invited to any care plan meetings during this time. The facility's policy, revised in December 2010, required the interdisciplinary team to develop and maintain a comprehensive care plan for each resident, with reviews and updates at least quarterly. However, the policy did not specify if the resident or their representative should be invited to attend these meetings. The resident, who was cognitively intact and had diagnoses including unintentional poisoning by unspecified drugs, diabetes, and chronic pain, expressed that they had never been invited to a care plan meeting and had questions about their care. Interviews with facility staff revealed a lack of a systematic approach to scheduling and conducting care plan meetings. The Director of Social Work admitted that although they attempted to contact the resident's family for a meeting in April, no follow-up was conducted when the family did not respond. The Director of Nursing, who was new to the facility, was unaware that care plan meetings were not being held for all residents. The resident expressed a desire for a care plan meeting to discuss various aspects of their care, including pain management and dietary concerns, and stated that their family, who visited often, would want to be included in such meetings.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, the resident, who had diagnoses including chronic obstructive pulmonary disease, arthritis, and dementia, was observed over several days with debris underneath their fingernails, including while eating with their hands. The resident's care plan required supervision and assistance with personal hygiene, including checking and cleaning nails on bath days and as necessary. However, there was no documentation in the nursing progress notes that the resident's fingernails had been checked, cleaned, or trimmed, nor was there any record of the resident refusing nail care. Observations during the survey revealed that the resident had dirty fingernails with a dark brown substance underneath on multiple occasions. Interviews with staff indicated that the Certified Nursing Assistants were responsible for cleaning the resident's nails, but there was no documented evidence of this care being provided. The Director of Nursing and a Certified Nursing Assistant acknowledged that the resident's nails should be cleaned as needed, but the Licensed Practical Nurse Manager was unable to provide documentation of nail care in the electronic health record. The facility's failure to document and provide necessary nail care for the resident led to the deficiency noted in the survey.
Failure to Provide Adequate Care for Resident with Pressure Injury and Nutritional Needs
Penalty
Summary
The facility failed to provide appropriate treatment and care for Resident #178, who was at risk for malnutrition and had a stage 3 pressure injury. The resident, who had a history of stroke, hemiparesis, and falls, was documented to have moderately impaired cognition and required assistance with bed mobility and eating. Despite interventions in the care plan to monitor fluid intake and reposition the resident every two hours to off-load pressure from the coccyx wound, these measures were not consistently implemented or documented. Observations revealed that Resident #178 often remained in bed on their back without the required off-loading of the coccyx wound, and there were significant gaps in the documentation of fluid intake and nourishment. The resident expressed difficulty swallowing and nausea, leading to minimal food and fluid consumption. The electronic medical record showed that out of 32 meal opportunities, 18 had no fluid intake documented, and the nutritional supplement Glucerna was not consistently recorded as given. Interviews with staff, including the Registered Dietician, Certified Nursing Assistant, and Licensed Practical Nurses, highlighted a lack of documentation and communication regarding the resident's refusals of care and meals. The Director of Nursing noted that the resident's pressure injury had worsened, with the appearance of eschar, indicating a lack of adequate repositioning and nutritional intake. The facility's failure to adhere to the care plan and physician orders contributed to the resident's declining condition.
Failure to Follow Dietary Recommendations for Resident
Penalty
Summary
During a recertification survey, it was observed that the facility failed to adhere to the dietary recommendations for a resident with vascular dementia, depression, and anxiety. The resident, who was severely cognitively impaired and required assistance with eating, did not receive the prescribed fortified pudding and only received one of the two mighty shakes indicated on their tray card. The resident consumed none of their meal except for the one mighty shake, and staff did not intervene to encourage or assist the resident in eating. Interviews with staff revealed that the kitchen staff were aware of the oversight in providing fortified pudding but did not know which residents were affected. The Certified Nurse Assistant acknowledged the failure to offer the missing items and to encourage the resident to eat. The Registered Dietician admitted not contacting the resident's family about the weight loss and confirmed responsibility for the resident's therapeutic diets. The Director of Nursing emphasized the importance of providing ordered fortified foods and encouraging residents who decline meals.
Lack of Privacy Curtains in Resident Rooms
Penalty
Summary
The facility failed to ensure that all resident rooms were equipped with privacy curtains to provide total visual privacy for residents. This deficiency was observed during a recertification survey, where it was noted that two semi-private rooms, each occupied by two residents, lacked privacy curtains. Resident #15, who has diagnoses including congestive heart failure, depression, and diabetes, expressed dissatisfaction with the lack of privacy, stating that the absence of curtains made them uncomfortable as they did not want their roommate or others to see them receiving care or without clothes. The resident mentioned that the curtain had been down for weeks and was told it was being washed. Similarly, Resident #9, with diagnoses including depression, schizophrenia, and anxiety, was also affected by the absence of privacy curtains. Observations showed that their room was visible from the hallway due to the open door and lack of curtains. Interviews revealed that the curtains were removed for washing, and staff were unaware of their location. A CNA mentioned that the curtains were in a garbage bag in an alcove, while the LPN Manager and the Director of Nursing were unaware of the situation, indicating a lack of communication and coordination among staff regarding the reinstallation of the curtains.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily as required by regulations. Observations on multiple occasions revealed that the nurse staffing information sheet was not updated at the beginning of each shift and was not posted on weekends. Specifically, on 11/08/2024, the staffing sheet displayed information from the previous day, 11/07/2024. Interviews with the receptionist responsible for posting the staffing sheets revealed that they completed the weekend staffing sheets on the following Monday by retrospectively checking who worked. The receptionist was trained by a previous staff member, not by nursing leadership or administration, and was unaware of the correct process for weekend postings. The Director of Nursing was also unaware of the weekend posting process, although they acknowledged that staffing information should be updated at the beginning of each shift, including weekends.
Failure to Safeguard Resident Medical Records
Penalty
Summary
The facility failed to safeguard resident medical record information against loss, destruction, or unauthorized use. During a Recertification Survey conducted from November 7 to November 14, 2024, surveyors observed pallets of damaged boxes containing resident medical records stored in an unlocked basement electrical room. On November 7, 2024, at 11:50 AM, surveyors noted these records in damaged boxes. Further observations on November 13, 2024, at 10:55 AM revealed multiple damaged boxes of records, including resident medical, billing, and discharge records, stacked precariously and falling over, with files protruding. Some boxes showed signs of water damage, and loose resident files were stacked on other boxes. The room's door was not locked, compromising the security of the records. During an interview on November 13, 2024, at 11:08 AM, the Regional Director of Nursing confirmed that these were resident records and acknowledged they should not be stored in that location.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility did not provide a safe, clean, comfortable, and homelike environment for its residents. Observations revealed several deficiencies, including a deteriorated and unsafe railing on an exit ramp, a missing door threshold transition strip, damaged walls, broken floor tiles, and windows in multiple resident rooms that could not be opened due to missing handles. Specifically, the concrete ramp on the northeast side of the building had a metal handrail with seven support posts, of which only two were attached to the ramp. The remaining five support posts were heavily corroded and had gaps between the base and the ramp surface, causing the handrail to wobble. Additionally, the door threshold transition strip was missing at the entrance to a resident room, and there was a large missing section of horizontal wall protective material near the head of the two beds in the same room. Broken floor tiles were also observed in another resident room, with sections of the tiles missing or damaged. Further observations included windows in several resident rooms that were not equipped with handles, preventing them from being opened. The Director of Environmental Services was unaware of why the handles were missing. Additionally, there were two sections of wall damage behind the bed closest to the door in another resident room, along with a hole in the carpet near the bottom of the bed. Interviews with the Nurse Manager, Director of Environmental Services, Facilities Director, and Administrator revealed that the issues had been brought up in safety meetings, and there were plans to remodel and fix the problems, but no concrete plans or timelines were provided. The Administrator mentioned that they were still in the planning stage and had not entered their information into the New York State Electronic Certificate of Need website.
Ineffective Pest Control Program
Penalty
Summary
The facility did not maintain an effective pest control program, as evidenced by observations, interviews, and record reviews during an Abbreviated Survey. The Facilities Director acknowledged a long-standing mouse problem, with the pest vendor visiting once a month. Resident interviews revealed frequent sightings of mice, with one resident naming a mouse that periodically appeared from under the sink. Observations confirmed numerous mouse droppings in resident rooms, the kitchen pantry, and the basement kitchen supply room. Unsealed openings around pipes and doors provided entry points for rodents, and service reports from the pest vendor indicated ongoing issues with rodent-proofing doors and sightings of mice in the basement office area. The Administrator admitted the absence of a pest sighting log, relying instead on a maintenance log for such entries. Pest vendor service reports from August 2023 to January 2024 consistently noted that the kitchen and basement doors were not rodent-proof, and snap traps were set in the basement office where mice were spotted. Observations in the kitchen dish room revealed unsealed openings around pipes, further allowing rodent movement. Residents reported multiple sightings of mice in their rooms and hallways, with droppings found in various locations, indicating a pervasive rodent issue within the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rochester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Ann's Community | 1.7 mi | ★★★★★ | 0 | 0 |
| The Pearl Nursing Center Of Rochester | 1.7 mi | ★★★★★ | 6 | 0 |
| Kirkhaven | 3.2 mi | ★★★★★ | 10 | 0 |
| Lilac Manor Rehabilitation And Nursing Center | 3.3 mi | ★★★★★ | 3 | 0 |
| Unity Living Center | 3.4 mi | ★★★★★ | 0 | 0 |
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