Cycle 1
Health 2024-11-14 · Fire 2024-11-14
9 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Rochester, NY
The Brook at High Falls Nursing Home and Rehabilit
3-star overall rating with 2-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
2150 St. Paul Street, Rochester, NY
(585) 342-5540
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
28
Certified beds
Average residents
24
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2001-01-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.76
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.78 · national 0.87
Aide hours / resident day
2.45
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 3.65 · national 3.89
Licensed hours
1.64
RN + LPN hours · state 1.47 · national 1.54
Weekend hours
3.50
Weekend nurse staffing · state 3.16 · national 3.43
Weekend RN hours
0.78
Weekend registered nurse coverage · state 0.47 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.11 · national 0.07
Adjusted RN hours
0.77
CMS adjusted RN staffing hours
Adjusted total hours
4.15
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
71%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,384
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.18
Composite VBP score used to determine payment impact.
Payment multiplier
0.9931
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.24
Performance 19.93% · Measure score 3.24 · Achievement 3.24 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
6.18
Performance 5.99% · Measure score 6.18 · Achievement 6.18 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
2.63
Baseline 76.92% · Performance 60.61% · Measure score 2.63 · Achievement 0.75 · Improvement 2.63
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.44% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 17.14% · Lower 95% interval 7.68% |
| Discharge to community | 55.78% |
50.57%
5.2 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 48.65% · Lower 95% interval 40.86% |
| Medicare spending per beneficiary | 1.27 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 74 · Denominator 74 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 74 |
| Discharge self-care score | 56.41% |
53.69%
2.7 pts better
|
Numerator 22 · Denominator 39 |
| Discharge mobility score | 69.23% |
50.94%
18.3 pts better
|
Numerator 27 · Denominator 39 |
| Pressure ulcers or injuries, new or worsened | 1.35% |
2.29%
0.9 pts better
|
Numerator 1 · Denominator 74 · Adjusted rate 1.44% |
| Healthcare-associated infections requiring hospitalization | 5.99% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 0% · Lower 95% interval 3.18% |
| Staff COVID-19 vaccination coverage | 100% |
8.2%
91.8 pts better
|
Numerator 82 · Denominator 82 |
| Staff flu vaccination coverage | 77.93% |
42%
35.9 pts better
|
Numerator 113 · Denominator 145 |
| Discharge function score | 69.23% |
56.45%
12.8 pts better
|
Numerator 27 · Denominator 39 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 52 · Denominator 52 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 15.79% |
25.2%
9.4 pts worse
|
Numerator 6 · Denominator 38 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
91.2%
4.9 pts better
|
93.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 96.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.0%
3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
18.5%
18.5 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 16.7% |
6.1%
10.6 pts worse
|
5.4%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.9% |
13.5%
9.6 pts better
|
19.6%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.7% |
14.8%
10.1 pts better
|
16.7%
12 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.6% |
15.5%
6.1 pts worse
|
14.9%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.6%
0.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.4%
1.4 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.5% |
20.8%
1.3 pts better
|
19.8%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.5% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
6.9%
4.9 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
76.7%
16.4 pts better
|
81.7%
11.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.3% · Q2 91.2% · Q3 91.2% · Q4 96.2% · 4Q avg 93.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.7% |
9.7%
10 pts worse
|
12.0%
7.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.7% · Observed 25.8% · Expected 14.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.2%
1.2 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.8% |
78.8%
14 pts better
|
79.7%
13.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.8% |
20.6%
6.2 pts worse
|
23.9%
2.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.8% · Observed 32.3% · Expected 28.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-10 · Fire 2023-05-10
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-11-23 · Fire 2021-11-23
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-05
E · Potential for more than minimal harm
2024-11-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-13
B · Minimal harm
2024-11-14
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-13
E · Potential for more than minimal harm
2023-05-10
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-06-23
E · Potential for more than minimal harm
2023-05-10
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-05-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-23
C · Minimal harm
2023-05-10
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-06-23
B · Minimal harm
2023-05-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-06-23
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-14
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-01-13
E · Potential for more than minimal harm
2024-11-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-13
D · Potential for more than minimal harm
2024-11-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-01-13
D · Potential for more than minimal harm
2024-11-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-13
D · Potential for more than minimal harm
2024-11-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-13
D · Potential for more than minimal harm
2024-11-14
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-01-13
D · Potential for more than minimal harm
2024-11-14
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2025-01-13
B · Minimal harm
2024-11-14
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-01-13
B · Minimal harm
2024-11-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-01-13
E · Potential for more than minimal harm
2024-02-16
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-05-07
E · Potential for more than minimal harm
2024-02-16
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-05-07
E · Potential for more than minimal harm
2023-05-10
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-06-23
E · Potential for more than minimal harm
2023-05-10
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-23
E · Potential for more than minimal harm
2023-05-10
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-10
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-06-23
D · Potential for more than minimal harm
2023-05-10
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-06-23
B · Minimal harm
2023-05-10
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2023-06-23
E · Potential for more than minimal harm
2021-11-23
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-01-14
E · Potential for more than minimal harm
2021-11-23
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-01-14
D · Potential for more than minimal harm
2021-11-23
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2022-01-14
D · Potential for more than minimal harm
2021-11-23
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2022-01-14
Penalties and ownership
What sits behind the stars
Ownership
Mayer, Giorgio
5% Or Greater Direct Ownership Interest · Individual
Grinspan, Aryeh
5% Or Greater Direct Ownership Interest · Individual
Mayer, Abraham
5% Or Greater Direct Ownership Interest · Individual
Grinspan, Aryeh
Corporate Officer · Individual
Mayer, Abraham
Corporate Officer · Individual
Mayer, Giorgio
Corporate Officer · Individual
Oropeza, Christina
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
St. Ann's Community
Rochester, NY
4-star overall rating with 4-star inspections with $55,495 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
The Pearl Nursing Center of Rochester
Rochester, NY
1-star overall rating with 1-star inspections with 16 recent health deficiencies with 24 fire-safety deficiencies in the latest cycle
#3
Kirkhaven
Rochester, NY
2-star overall rating with 2-star inspections with 15 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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