Deficiency Index

The Highlands at Brighton

Rochester, New York · CCN 335778

23 surveys since 2011, and no finding has been recorded at harm level.

Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.

Citations on record
115
Surveys
23
Harm or worse
0
Immediate jeopardy
0
The record, 2011–2026
’11’15’20’25’26
No harm recordedHarm or worseNot surveyed
Harm or worseNone

No finding on record has been cited at harm level or above.

Beyond CMS’s monthly file19/23

Older surveys no longer in CMS’s monthly file or on Care Compare. They are shown here.

The facility

Certified beds
145
Ownership
Non profit - Corporation
Chain
Independent
County
Monroe
Medicare-certified since
1995

CMS ratings

Overall
3
Health inspection
3
Staffing
4
Quality measures
3

CMS’s own Five-Star ratings.

Compared with similar facilities

Since 2021, this facility recorded somewhat fewer weighted findings than its peer group.

Weighted by harm level, against 82 not-for-profit facilities with 128 or more beds in New York.

Last survey on record

May 7, 2026

186 days ago.

Counts surveys with at least one finding. A clean survey leaves no record here, so the real gap may be shorter.

Staffing

MeasureThis facilityPeer median
Nurse hours per resident day5.153.67
Registered-nurse hours per resident day0.61—
Annual nurse turnover47.3%37.8%

As reported by the facility to CMS, beside the peer-group median.

Enforcement

No fines, payment denials or special-focus designation on the current CMS record.

Severity of recent findings

Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
SeverityIsolatedPatternWidespread
Immediate jeopardyJ—K—L—
Actual harmG—H—I—
No harm, potential for more than minimalD1976.0%E28.0%F—
No harm, potential for minimalA—B416.0%C—
CMS’s current file: 25 of the 115 citations on record.

Most frequently cited here

In CMS’s current monthly file.

  • F6773×

    Provide care and assistance to perform activities of daily living for any resident who is unable.

  • F6893×

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  • F6102×

    Respond appropriately to all alleged violations.

  • F7322×

    Post nurse staffing information every day.

  • F8802×

    Provide and implement an infection prevention and control program.

In the surveyor’s words

From the most serious findings on record at The Highlands at Brighton, in the surveyor’s own words.

  • No harm, potential for more than minimal, patternF761Aug 13, 2025

    Based on observations, interviews, and record review conducted during the Recertification Survey from 08/6/2025 to 08/13/2025, for four (4) (Medication Carts on Residential Units A, B, D, and E) of five (5) medication carts reviewed, the facility did not ensure that all drugs and biologicals were stored and/or labeled in accordance with currently accepted professional principles and regulations. Specifically, on the Residential E Unit, there were pre-poured medications for multiple residents and multiple loose medications in the medication cart. On the Residential A Unit, there were multiple loose pills in a medication cart, and an unlocked, unattended medication cart was observed. […]

  • No harm, potential for more than minimal, patternF908Dec 6, 2021

    Based on observations, interviews and record reviews conducted during the Recertification Survey, completed on 12/6/21, it was determined that for one of one main kitchen, the facility did not maintain equipment in safe operating condition. Specifically, the low temperature dishwashing machine and five of six bimetallic food thermometers were not working properly. This is evidenced by the following: Review of a facility policy, Thermostat Calibration, dated 4/16/15, included that the thermometer may be the single most important tool you have to protect food. To calibrate a thermometer, fill a container with ice. Add clean tap water until the container is full. Put thermometer stem into the ice water so that the sensing area is completely submerged. Wait until the indicator stops moving. […]

  • No harm, potential for more than minimal, isolatedF609May 7, 2026

    Based on interviews and record review, the facility did not ensure alleged violations involving resident-to-resident physical aggression were reported immediately to the Administrator and the New York State Department of Health for two (2) of four (4) residents reviewed (Resident #4 and Resident #5). Specifically, on 11/24/2025 at 6:00 PM, Resident #4 threw a cup containing ice at Resident #5 during a verbal altercation, striking Resident #5. The facility did not notify the Administrator until 11/28/2025 at 3:00 PM and did not report the incident to the New York State Department of Health until 12/02/2025 at 3:45 PM.The findings include:The facility policy Abuse, Neglect and Mistreatment, last reviewed in October 2024, included all staff were required to report any potential or actual… […]

  • No harm, potential for more than minimal, isolatedF689May 7, 2026

    Based on observations, interviews, and record review, the facility failed to ensure a resident's environment remained as free from accident hazards as possible for one (1) of five (5) residents reviewed (Resident #6). Specifically, the facility did not ensure consistent monitoring and documentation of Resident #6's self-administration of medications as ordered by the medical provider. The facility also did not ensure accurate accountability of medications available to Resident #6 after the resident reported ingesting multiple days' worth of medications.The findings include:The facility policy Medication Administration: Self-Administration of Medication, last reviewed on 10/04/2018, included if the attending physician and interdisciplinary team approved self-administration of medications,… […]

  • No harm, potential for more than minimal, isolatedF583Aug 13, 2025

    Based on observation, interviews, and record review conducted during a Recertification Survey from 08/06/2025 to 08/13/2025, for one (1) (Resident #1) of one (1) resident reviewed, the facility did not ensure the resident's right to privacy and confidentiality of their personal and medical records was maintained. Specifically, a computer stationed in a hallway on Residential Unit D was observed open, exposing Resident #1's personal and medical information; there were no staff members present to secure the information for nine (9) minutes. This is evidenced by the following:Resident #1 had diagnoses including chronic respiratory failure, diabetes, and methicillin resistant staphylococcus aureus infection (a bacteria that is resistant to a wide range of antibiotics). […]

Read 20 findings in full →The most serious and the most recent: 20 of 115 on record.

Every survey on record

FindingsAt actual harm or above

  • May 7, 2026Complaint2 findings
  • Aug 13, 2025Standard7 findings
  • Oct 4, 2023Standard and complaint8 findings
  • Feb 2, 2023Complaint1 finding
  • Dec 6, 2021Standard8 findings
  • Mar 2, 2021Complaint1 finding
  • Feb 10, 2021Complaint1 finding
  • Jun 10, 2019Standard7 findings
Show the 15 earlier surveys
  • Feb 1, 2018Standard13 findings
  • May 25, 2017Complaint3 findings
  • Nov 4, 2016Standard4 findings
  • May 5, 2016Complaint1 finding
  • Feb 11, 2016Complaint3 findings
  • Nov 10, 2015Standard7 findings
  • Aug 25, 2015Complaint1 finding
  • Mar 17, 2015Complaint1 finding
  • Sep 12, 2014Standard and complaint18 findings
  • Feb 28, 2014Complaint1 finding
  • Nov 4, 2013—8 findings
  • Jun 7, 2013—1 finding
  • Apr 25, 2013—1 finding
  • Oct 17, 2012—8 findings
  • Nov 3, 2011—10 findings

Surveys that found no deficiencies are not in CMS’s files and do not appear here.

Comparable facilities

The nearest facilities to this one in the same peer group, by weighted findings.

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