NY DOH Inspection Report

The Brook at High Falls Nursing Home and Rehabilitation Center

📍 2150 St. Paul Street, Rochester, NY 14621

Citations Summary

Feb 2022 – Jan 2026
6 Inspections Conducted
2
No citations found
33% of all inspections
4
Resulted in citations
67% of all inspections
15 Total Citations — state avg: 23
Issued across those 4 inspections
11Standard Health
4Life Safety Code
Severity of Citations
How serious were those 15 citations?
0
Minor potential harm
All corrected ✓
0
No actual harm
None in this period

Inspection Details

Surveys with Citations Only
January 16, 2026 Certification Survey 6 Health 5 LSC
▼
Standard Health Citations
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Infection Prevention & Control
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤👤👤👤👤 Widespread Not yet corrected
Label/store Drugs And Biologicals
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated Not yet corrected
Resident Rights/exercise Of Rights
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Standards Of Construction For New Existing Nh
Standard Health Citation — quality of care
Level 0 👤 Scope Not yet corrected
Life Safety Code Citations
Corridor - Doors
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Hazardous Areas - Enclosure
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Sprinkler System - Maintenance And Testing
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Subdivision Of Building Spaces - Smoke Barrie
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern Not yet corrected
Vertical Openings - Enclosure
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤 Isolated Not yet corrected
November 14, 2024 Certification/Complaint Survey 9 Health 3 LSC
▼
Standard Health Citations
ADL Care Provided For Dependent Residents
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated January 13, 2025
Bedrooms Assure Full Visual Privacy
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated January 13, 2025
Care Plan Timing And Revision
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated January 13, 2025
Infection Prevention & Control
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤👤👤 Pattern January 13, 2025
Menus Meet Resident Nds/prep In Adv/followed
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated January 13, 2025
Posted Nurse Staffing Information
Standard Health Citation — quality of care
Level 1 · Potential for minimal harm 👤👤👤 Pattern January 13, 2025
Quality Of Care
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated January 13, 2025
Resident Records - Identifiable Information
Standard Health Citation — quality of care
Level 1 · Potential for minimal harm 👤👤👤 Pattern January 13, 2025
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤👤👤 Pattern January 13, 2025
Life Safety Code Citations
Gas Equipment - Cylinder And Container Storag
Life Safety Code Citation — NFPA requirements
Level 1 · Potential for minimal harm 👤👤👤 Pattern January 13, 2025
Maintenance, Inspection & Testing - Doors
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern January 13, 2025
Sprinkler System - Installation
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern February 5, 2025
February 16, 2024 Complaint Survey 2 Health 0 LSC
▼
Standard Health Citations
Maintains Effective Pest Control Program
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤👤👤 Pattern May 7, 2024
Safe/clean/comfortable/homelike Environment
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤👤👤 Pattern May 7, 2024
May 10, 2023 Certification/Complaint Survey 10 Health 5 LSC
▼
Standard Health Citations
Dialysis
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated June 23, 2023
Food Procurement,store/prepare/serve-sanitary
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤👤👤 Pattern June 23, 2023
Free From Unnec Psychotropic Meds/prn Use
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated June 23, 2023
Free Of Accident Hazards/supervision/devices
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated June 23, 2023
Infection Control
Standard Health Citation — quality of care
Level 1 · Potential for minimal harm 👤👤👤👤👤 Widespread June 23, 2023
Notice Of Bed Hold Policy Before/upon Trnsfr
Standard Health Citation — quality of care
Level 1 · Potential for minimal harm 👤👤👤 Pattern June 23, 2023
Qaa Committee
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤👤👤 Pattern June 23, 2023
Rn 8 Hrs/7 Days/wk, Full Time Don
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤👤👤 Pattern June 23, 2023
Services Provided Meet Professional Standards
Standard Health Citation — quality of care
Level 2 · Minor potential harm 👤 Isolated June 23, 2023
Standards Of Construction For New Existing Nh
Standard Health Citation — quality of care
Level 1 · Potential for minimal harm 👤👤👤 Pattern June 23, 2023
Life Safety Code Citations
Egress Doors
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern June 23, 2023
Electrical Systems - Essential Electric Syste
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern June 23, 2023
Ep Training Program
Life Safety Code Citation — NFPA requirements
Level 1 · Potential for minimal harm 👤👤👤👤👤 Widespread June 23, 2023
Gas Equipment - Cylinder And Container Storag
Life Safety Code Citation — NFPA requirements
Level 1 · Potential for minimal harm 👤👤👤 Pattern June 23, 2023
Subdivision Of Building Spaces - Smoke Barrie
Life Safety Code Citation — NFPA requirements
Level 2 · Minor potential harm 👤👤👤 Pattern June 30, 2023
Severity Scale Reference
Level 0 — No Harm Potential Level 2 — Minor Potential Harm Level 3 — Actual Harm Level 4 — Immediate Jeopardy

Complaints

Feb 2022 – Jan 2026
Above state average. This facility received 151.8 complaints per 100 beds vs. a statewide rate of 55.0. 3 citations resulted from those complaints (11.1 per 100 beds vs. 3.0 statewide).
Total Complaints
41
55,221 statewide
Per 100 Occupied Beds
151.8
55.0 state avg
On-Site Inspections
8
8,103 statewide
Citations Issued
3
11.1 per 100 beds · avg 3.0
Facility-Reported Incidents
20%
55% statewide
Citations by CategoryThis Facility
Administration0
Dietary Services2
Other Services0
Physical Environment11
Quality of Care19
Resident Rights8
Total40

Enforcement & Fines

Feb 2016 – Jan 2026
1 enforcement action totaling $14,000 in fines over the reporting period. Resolved via Stipulation & Order agreements with the NY Department of Health where applicable.
May 21, 2021
$14,000
Stipulation & Order #NH-21-181 · Signed October 15, 2021
Reason: Quality of Care