Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Highlands At Brighton during CMS and state inspections, most recent first.
Failure to timely report resident-to-resident physical aggression: two residents were involved in a verbal altercation that escalated when one resident threw a cup of ice and struck the other resident. The incident was classified as physical aggression, but the DON and NYSDOH were not notified within the required timeframe. Both residents were cognitively intact; one had anxiety, bipolar disorder, and failure to thrive, and the other had psychosis, CVA, and adjustment disorder.
Inconsistent monitoring and documentation of a resident’s self-administered medications led to a medication accountability failure. A resident with diabetes, obesity, and psychotic disorder was care planned to use a medi-set with nursing checks each shift and weekly refills, but the record lacked evidence of provider notification for noncompliance, lacked refill documentation, and contained inconsistent MAR entries. The resident later stated they took all of their medications for the week with intent to self-harm, and staff found the medi-set empty with multiple days’ worth of medications missing; the resident was sent to the hospital after ingesting extra pills.
Medication carts were left unlocked and unattended on multiple units, and loose pills were found in carts. On one unit, 16 resident-labeled cups contained pre-poured meds for an entire medication pass, and the LPN could not identify all of the meds in the cups. The RN manager and DON stated that pre-pouring meds before administration was not a safe practice and that carts should be secured.
Open Computer Screen Exposed Resident Medical Information: A hallway computer on a unit was left open and displayed a resident's picture, name, DOB, vital signs, code status, and diagnoses including ESBL, CRE, and MDRO while no staff were present for several minutes. The resident had chronic respiratory failure, diabetes, MRSA, and was documented as being in a persistent vegetative state. The RT said they had been busy but usually closed the screen, and the DIR of Respiratory and DON stated that leaving the screen open was a HIPAA breach.
A resident reported that a CNA touched their leg and foot on multiple occasions and made them feel uncomfortable. Nursing notes documented the resident’s concerns, but the facility’s file lacked a thorough investigation, witness statements, and a documented determination of whether abuse was ruled out. The DON later stated the investigation was unofficial and incomplete, while the Administrator said the behavior did not rise to abuse because staff must check on residents overnight.
Failure to Provide Needed Grooming and Personal Hygiene Assistance: Two residents who were dependent on staff for personal hygiene did not receive needed help with shaving, showering, and hair washing. One resident had a significant amount of facial hair and uncombed, oily hair, while the other had long, oily hair, a dry, flaky scalp, and facial hair over multiple observations. The care plans and personal care profiles lacked grooming interventions, and staff interviews confirmed the residents needed hands-on assistance and that their needs were not consistently anticipated.
Failure to Apply Ordered Compression Sleeve: A resident with left hemiparesis, limited ROM, and left arm pain was observed multiple times without the ordered compression sleeve in place, despite care plan, PCCP, and MD orders directing it be worn during the day and removed at night. An LPN noted there was no progress note showing refusal, while the SW, CNA, and DON stated the resident did not advocate for themself and staff were expected to apply the sleeve as ordered.
A resident care aide handled ready-to-eat graham crackers with bare hands and gave them to two residents, including one with cerebral palsy, muscular dystrophy, and severely impaired cognition and another with Parkinsonism, dementia, protein-calorie malnutrition, and severely impaired cognition. The aide did not perform hand hygiene or use gloves between residents, and an LPN manager stated staff should sanitize hands after resident contact and should not touch ready-to-eat food with bare hands.
Daily nurse staffing postings did not show the required staffing details for each shift. Observations found numbers listed next to RN, LPN, and CNA titles, but the postings did not clearly identify the actual number of staff directly responsible for resident care versus the hours worked. Interviews with the Staffing Coordinator, DON, and Administrator showed they believed the postings reflected hours worked and census information, and they were not aware both the total number of staff and the actual hours worked had to be listed.
Failure to Timely Report Resident-to-Resident Physical Aggression
Penalty
Summary
The facility did not ensure alleged resident-to-resident physical aggression was reported immediately to the Administrator and the New York State Department of Health for two residents involved in an incident on 11/24/2025 at 6:00 PM. During a verbal altercation in the dining room, Resident #4 threw a cup containing ice at Resident #5 and struck Resident #5 on the arm. The incident was classified as Physical Aggression, and staff became aware of it at the time it occurred, but the Administrator was not notified until 11/28/2025 at 3:00 PM and the incident was not reported to the New York State Department of Health until 12/02/2025 at 3:45 PM. The investigation report was submitted the next day. The facility policy required staff to report potential or actual abuse, mistreatment, or neglect to the DON, Administrator, or the New York State Department of Health, and the report stated the incident should have been reported within 24 hours because no serious bodily injury occurred. Resident #4 had diagnoses including anxiety, bipolar disorder, and failure to thrive, and was documented as cognitively intact. Resident #5 had diagnoses including psychosis, cerebrovascular accident, and adjustment disorder, and was also documented as cognitively intact. Witness statements were obtained immediately after the incident, and Resident #5 was assessed with no observed injuries or signs of emotional distress. The record documented that Resident #4 stated, "I do not care, I do not feel bad, I do not like Resident #5 and I will do it again." The residents were separated for safety, monitored for the remainder of the shift, and later placed in rooms away from each other and not seated near each other in the dining room.
Inconsistent Monitoring and Documentation of Self-Administered Medications
Penalty
Summary
The facility failed to ensure Resident #6’s environment remained as free from accident hazards as possible by not consistently monitoring and documenting the resident’s self-administration of medications as ordered. Resident #6 had diagnoses including diabetes, obesity, and psychotic disorder with delusions, and was documented as cognitively intact. The care plan stated the resident could self-administer medications using a medi-set, with nursing staff to check the medi-set every shift, refill it weekly per provider orders, and notify the medical team if the resident was noncompliant. The physician order for medi-set training required nursing staff to check the medi-set after each scheduled medication administration, document in the MAR that the resident self-administered medications, document every shift whether compliance and prompting were needed, and refill the medi-set every Thursday on day shift. Review of progress notes showed the resident was noncompliant with medications on multiple occasions, but the record did not show that a medical provider was notified. The record also lacked documentation identifying when the medi-set was refilled, and the historical MAR contained inconsistent nursing documentation, with some nurses documenting medications as given and others documenting them as given by other. On 08/19/2025, the resident stated they had taken all medications for the week with the intention to harm themselves because they felt lonely and had no one to talk to. Staff found the resident on the floor, and the medi-set was checked and found to be empty, with six days’ worth of medications missing. The resident told staff they had taken extra pills and became dizzy. The emergency department note documented the resident intentionally ingested four days’ worth of medications, including Biktarvy and Depakote, and the resident remained hospitalized and was followed by toxicology services. A psychiatric evaluation documented chronically elevated suicide risk and elevated acute risk after the intentional ingestion, with a safety plan that included facility staff assisting with medications.
Medication carts left unsecured and medications pre-poured and loose
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles on four of five medication carts reviewed. On the Residential B Unit, a medication cart was observed unlocked and unattended. On the Residential D Unit, a medication cart was observed unlocked and unattended with three bottles of omeprazole sitting on top of the cart. On the Residential A Unit, a medication cart was observed unlocked and unattended, and multiple loose pills were found in the cart. On the Residential E Unit, there were 16 resident-labeled cups on top of the medication cart containing multiple pre-poured medications prepared before the scheduled medication pass, along with multiple loose pills in the drawers. During interview, an LPN stated the entire 5:00 PM and 8:00 PM medication pass for the Residential E Unit was already in the cups on the cart and could not identify all of the medications in the cups, including levetiracetam, ziprasidone, buspirone, and lisinopril. The LPN stated they did not know the policy or procedure for inspecting medication carts for expired medications or loose pills and stated it was unsafe to have loose medications in the cart and to administer medications to a resident they could not identify. The RN manager stated medication carts should be checked weekly for expired medications or loose pills and that it was not a safe practice to pre-pour medications. The DON stated it was never appropriate to pull medications prior to the scheduled administration time and that it was an unsafe practice.
Open Computer Screen Exposed Resident Medical Information
Penalty
Summary
The facility did not ensure the resident's right to privacy and confidentiality of personal and medical records was maintained when a computer stationed in a hallway on Residential Unit D was left open and exposed Resident #1's information. During observation, the screen displayed the resident's picture, name, date of birth, vital signs, code status, and a banner listing diagnoses including ESBL, CRE, and MDRO, while no staff were present in the area to secure the information for nine minutes. Resident #1 had diagnoses including chronic respiratory failure, diabetes, and MRSA infection. The resident's MDS dated 05/30/2025 documented a persistent vegetative state and cognition as undetermined. During interview, the Respiratory Therapist stated they had been busy on the unit but usually closed the computer screen before walking away and had received HIPAA training about maintaining privacy and protecting medical records. The Director of Respiratory and the DON both stated that an open computer screen exposing a resident's medical record was a breach of confidentiality and that staff should secure their computers when not present.
Incomplete Investigation of Alleged Resident Touching
Penalty
Summary
The facility did not ensure an alleged incident involving Resident #90 was thoroughly investigated to rule out abuse, neglect, or mistreatment. Resident #90 had diagnoses including Wernicke's encephalopathy, transverse myelitis, and muscle weakness, and the Minimum Data Set dated 06/20/2025 identified the resident as cognitively intact. The resident’s care plan also noted personality disorder, schizoaffective disorder, and persecutory delusions, with interventions focused on assessing coping skills, support systems, and triggers. Resident #90 reported that Certified Nursing Assistant #3 touched their leg and foot on multiple occasions, including wiggling the resident’s big toe and touching the back of the calf while on the overnight shift. On 01/25/2025, an LPN documented that the resident said the aide had touched their foot or leg on three occasions, made them feel uncomfortable, and felt weird. On 01/28/2025, another LPN documented speaking with the resident, who stated the aide touched their leg and grabbed their toes on two occasions to check whether the resident was breathing, and that the resident did not feel unsafe or that the behavior was sexual, but felt it was inappropriate. The facility’s investigation file contained only the two nursing progress notes and a typed, unsigned statement with the CNA’s typed name. It did not include additional investigative findings, a statement from the first LPN, other staff or witness statements, or a documented determination of whether abuse was ruled out. During interviews, the DON stated the facility had done an “unofficial” investigation and acknowledged it was not complete or thorough, while the Administrator stated they did not believe the allegation rose to abuse because staff must check on residents during the night shift.
Failure to Provide Needed Grooming and Personal Hygiene Assistance
Penalty
Summary
The facility did not ensure that residents who were unable to complete activities of daily living received the necessary assistance to maintain good grooming and personal hygiene. During the survey, two residents were identified as not receiving needed help with shaving, showering, hair washing, and general grooming, despite being dependent on staff for these tasks. Resident #5 had diagnoses including end stage renal disease, low back pain, and depression. The resident’s MDS documented cognitive intactness and a need for supervision and hands-on assistance with personal hygiene. However, the care plan and Personal Care Profile did not include measurable grooming goals or instructions for personal grooming. On observation, the resident had a significant amount of facial hair and uncombed, oily hair. The resident stated they did not like having facial hair, avoided looking in the mirror, and could not remember the last time facial hair removal or hair washing had been done. A LPN later stated the resident required hands-on assistance with personal grooming and facial hair removal, and the DON stated someone should have assisted the resident daily. Resident #57 had diagnoses including hemiplegia/hemiparesis, dysphagia, and muscle weakness. The resident’s MDS documented cognitive intactness and dependence with showering and personal hygiene. The care plan and Personal Care Profile did not include interventions related to personal hygiene and grooming. A nursing progress note documented the resident’s last shower and hair wash, and subsequent observations showed long, oily hair, a dry, flaky scalp, and a significant amount of facial hair over multiple days. The resident stated they wanted a haircut and shave, had not received a shower because the unit was short-staffed, and had not had their hair washed for a couple of weeks. A CNA stated the resident would not advocate for themself and staff needed to anticipate their needs, and the DON stated staff should assist when the resident’s hair was soiled and disheveled.
Failure to Apply Ordered Compression Sleeve
Penalty
Summary
Resident #57 did not receive treatment and care in accordance with orders and the comprehensive care plan when the ordered compression sleeve for the left arm was not in place on multiple observations. The resident had diagnoses including left hemiplegia/hemiparesis, dysphagia, and muscle weakness, and the MDS documented the resident was cognitively intact with limited range of motion in the left upper extremity. The care plan directed staff to ensure the compression sleeve was applied in the morning and removed at bedtime, and the personal care profile and medical order also directed that the sleeve be worn during the day and removed at night. During observations on 08/11/2025, the resident was lying in bed without the compression sleeve at 10:10 AM and again at 4:53 PM, and stated they had pain in the left arm at both times. On 08/12/2025 at 9:18 AM, the resident was sitting up in bed with the left arm resting on a pillow and still was not wearing the sleeve, and again stated they had pain in the arm. An LPN stated the sleeve should have been applied every morning and removed at night, and that there was no progress note indicating the resident refused the sleeve despite a documented pain score of 5 out of 10 in the left arm. The SW and CNA stated the resident did not advocate for themself and staff needed to check on them and anticipate their needs, and the DON stated staff would be expected to apply the sleeve as ordered and when the resident reported pain.
Bare-Hand Contact With Ready-to-Eat Snacks
Penalty
Summary
Food was not served in accordance with professional standards for food safety when Resident Care Aide #1 handled ready-to-eat graham crackers with bare hands and then gave them to two residents. During an observation on 08/06/2025 at 9:59 AM, the aide opened a package of two graham crackers, touched portions of the crackers with an ungloved hand, and handed them to Resident #81. The aide then went to an unknown resident, removed an empty Ensure bottle for disposal, and did not perform hand hygiene or put on gloves before returning to open another package of graham crackers and touching them with a bare hand before giving them to Resident #69, who consumed them. Resident #69 had diagnoses including cerebral palsy, muscular dystrophy, and left hand contracture, and the MDS dated 07/10/2025 showed severely impaired cognition. Resident #81 had diagnoses including Parkinsonism, dementia, and protein-calorie malnutrition, and the MDS showed severely impaired cognition. During interviews, Resident Care Aide #1 stated they usually wear gloves when assisting residents during meals and should have worn gloves when touching the graham crackers. An LPN Manager stated staff should perform hand hygiene anytime they come in contact with residents and should not touch ready-to-eat food items with bare hands. The Administrator and DON stated they were not aware staff were touching food with bare hands and noted the aide had worked in the kitchen and should have known better.
Daily nurse staffing postings lacked required staffing details
Penalty
Summary
Post nurse staffing information did not include the required daily details showing the actual number of licensed nursing staff (RNs and LPNs) and unlicensed nursing staff (CNAs) directly responsible for resident care during each shift. During observations, the posted staffing information listed numbers next to nursing titles, ranging from 8 to 56, but did not specify whether those numbers represented actual hours worked or the total number of staff assigned to each shift. Review of the daily nurse staffing information from 06/01/2025 through 08/11/2025 showed that the postings did not include the total number of RNs, LPNs, and CNAs for each shift. During interviews, Staffing Coordinator #1 stated the postings reflected the number of residents and how many nurses and CNAs were scheduled for each unit, and explained that a number such as 8 next to RN meant one RN worked 8 hours, while 16 next to CNA meant two CNAs worked 8 hours each. The Staffing Coordinator stated they had been taught to document only the actual hours worked. The DON stated the postings included resident census and the actual hours for RNs, LPNs, and CNAs scheduled each shift, and that the total number of nursing staff was reflected in the actual hours worked. The DON and Administrator stated they were not aware the daily postings had to include both the total number of staff and the actual hours worked.
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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) |
|---|---|---|---|---|
| Woodside Manor Nursing Home Inc | 0.3 mi | ★★★★★ | 7 | 0 |
| Jewish Home Of Rochester | 0.9 mi | ★★★★★ | 10 | 0 |
| The Brightonian, Inc | 1 mi | ★★★★★ | 0 | 0 |
| Monroe Community Hospital | 1.2 mi | ★★★★★ | 3 | 2 |
| The Hurlbut | 1.4 mi | ★★★★★ | 0 | 0 |
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