All citations for Edenbrook Rochester West

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Edenbrook Rochester West

Last standard health inspection on record

November 20, 2025

Showing 26 to 50 of 62 citations

  1. No harm, with potential for more than minimal harm

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0812, Nutrition and Dietary Deficiencies. Inspection of October 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 26, 2024).

  2. No harm, with potential for more than minimal harm

    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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of November 2, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 20, 2023).

  3. No harm, with potential for more than minimal harm

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

    Pattern (more than a few residents). CMS level E.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of November 2, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 20, 2023).

  4. No harm, with potential for more than minimal harm

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0725, Nursing and Physician Services Deficiencies. Inspection of November 2, 2023. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (December 20, 2023).

  5. No harm, with potential for more than minimal harm

    Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0726, Nursing and Physician Services Deficiencies. Inspection of November 2, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 20, 2023).

  6. No harm, with potential for more than minimal harm

    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0761, Pharmacy Service Deficiencies. Inspection of November 2, 2023. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 20, 2023).

  7. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of October 24, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (November 21, 2023).

  8. No harm, with potential for more than minimal harm

    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0725, Nursing and Physician Services Deficiencies. Inspection of May 13, 2026. Found during a complaint inspection.

    The home gave a date the problem would be corrected (June 22, 2026).

  9. No harm, with potential for more than minimal harm

    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0628, Resident Rights Deficiencies. Inspection of November 20, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (December 19, 2025).

  10. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of November 20, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 19, 2025).

  11. No harm, with potential for more than minimal harm

    Ensure services provided by the nursing facility meet professional standards of quality.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0658, Resident Assessment and Care Planning Deficiencies. Inspection of November 20, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 19, 2025).

  12. No harm, with potential for more than minimal harm

    Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0710, Nursing and Physician Services Deficiencies. Inspection of November 20, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 19, 2025).

  13. No harm, with potential for more than minimal harm

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0756, Pharmacy Service Deficiencies. Inspection of November 20, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 19, 2025).

  14. No harm, with potential for more than minimal harm

    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0921, Environmental Deficiencies. Inspection of November 20, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 19, 2025).

  15. No harm, with potential for more than minimal harm

    Install emergency lighting that can last at least 1 1/2 hours.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0291, Egress Deficiencies. Inspection of November 20, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 9, 2026).

  16. No harm, with potential for more than minimal harm

    Have approved installation, maintenance and testing program for fire alarm systems.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of November 20, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 9, 2026).

  17. No harm, with potential for more than minimal harm

    Ensure proper usage of power strips and extension cords.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of November 20, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 9, 2026).

  18. No harm, with potential for more than minimal harm

    Provide enough food/fluids to maintain a resident's health.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0692, Quality of Life and Care Deficiencies. Inspection of December 10, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (January 9, 2025).

  19. No harm, with potential for more than minimal harm

    Ensure each resident receives an accurate assessment.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0641, Resident Assessment and Care Planning Deficiencies. Inspection of October 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 26, 2024).

  20. No harm, with potential for more than minimal harm

    Ensure that residents are free from significant medication errors.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0760, Pharmacy Service Deficiencies. Inspection of October 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 26, 2024).

  21. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0880, Infection Control Deficiencies. Inspection of October 23, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 26, 2024).

  22. No harm, with potential for more than minimal harm

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0561, Resident Rights Deficiencies. Inspection of November 30, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (January 9, 2024).

  23. No harm, with potential for more than minimal harm

    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0636, Resident Assessment and Care Planning Deficiencies. Inspection of November 30, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (January 9, 2024).

  24. No harm, with potential for more than minimal harm

    Provide for the safe, appropriate administration of IV fluids for a resident when needed.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0694, Quality of Life and Care Deficiencies. Inspection of November 30, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (January 9, 2024).

  25. No harm, with potential for more than minimal harm

    Ensure that residents are free from significant medication errors.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0760, Pharmacy Service Deficiencies. Inspection of November 30, 2023. Found during a complaint inspection.

    The home gave a date the problem would be corrected (January 9, 2024).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.