Facility profile · CCN 245306
Edenbrook Rochester West
40 federal citations on record , including 2 at the Immediate Jeopardy level, and 1 federal enforcement actions totaling $14,518.
Record summary
Federal record · Q1 202640
Total citations
40
Last 3 years
3
Actual harm+
1
Federal penalties
$14,518
Total fines
2
Overall ★ rating
Most common violation categories here
Most common F-tags at this facility
Citation history
40 on record| Survey | F-Tag | Violation | Severity | Source |
|---|---|---|---|---|
| Nov 20, 2025 | F628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D | Complaint |
| Nov 20, 2025 | F921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | D | Standard |
| Nov 20, 2025 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard |
| Nov 20, 2025 | F801 | Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | E | Standard |
| Nov 20, 2025 | F756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D | Standard |
| Nov 20, 2025 | F732 | Post nurse staffing information every day. | C | Standard |
| Nov 20, 2025 | F726 | 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. | E | Standard |
| Nov 20, 2025 | F710 | Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | D | Standard |
| Nov 20, 2025 | F691 | Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | G | Standard |
| Nov 20, 2025 | F658 | Ensure services provided by the nursing facility meet professional standards of quality. | D | Standard |
| Nov 20, 2025 | F656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | Standard |
| Sep 8, 2025 | F684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | J | Complaint |
| Dec 10, 2024 | F692 | Provide enough food/fluids to maintain a resident's health. | D | Complaint |
| Oct 23, 2024 | F880 | Provide and implement an infection prevention and control program. | D | Standard |
| Oct 23, 2024 | F812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | Standard |
| Oct 23, 2024 | F760 | Ensure that residents are free from significant medication errors. | D | Standard |
| Oct 23, 2024 | F641 | Ensure each resident receives an accurate assessment. | D | Standard |
| Nov 30, 2023 | F760 | Ensure that residents are free from significant medication errors. | D | Complaint |
| Nov 30, 2023 | F694 | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | D | Complaint |
| Nov 30, 2023 | F636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | D | Complaint |
| Nov 30, 2023 | F561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | D | Complaint |
| Nov 2, 2023 | F725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E | Complaint |
| Nov 2, 2023 | F622 | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | D | Complaint |
| Nov 2, 2023 | F610 | Respond appropriately to all alleged violations. | D | Complaint |
| Nov 2, 2023 | F883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. | D | Standard |
| Nov 2, 2023 | F880 | Provide and implement an infection prevention and control program. | F | Standard |
| Nov 2, 2023 | F851 | Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | F | Standard |
| Nov 2, 2023 | F805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | D | Standard |
| Nov 2, 2023 | F761 | 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. | E | Standard |
| Nov 2, 2023 | F758 | 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. | D | Standard |
| Nov 2, 2023 | F726 | 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. | E | Standard |
| Nov 2, 2023 | F695 | Provide safe and appropriate respiratory care for a resident when needed. | D | Standard |
| Nov 2, 2023 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | Standard |
| Nov 2, 2023 | F644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D | Standard |
| Nov 2, 2023 | F584 | 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. | E | Standard |
| Oct 24, 2023 | F880 | Provide and implement an infection prevention and control program. | E | Complaint |
| Oct 24, 2023 | F760 | Ensure that residents are free from significant medication errors. | J | Complaint |
| Oct 24, 2023 | F755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | Complaint |
| Oct 24, 2023 | F554 | Allow residents to self-administer drugs if determined clinically appropriate. | D | Complaint |
| Aug 22, 2023 | F689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | Complaint |
Federal enforcement history
Federal regulators have imposed 1 enforcement actions against this facility, including 1 civil money penalties totaling $14,518 .
| Date | Type | Fine | Payment denial |
|---|---|---|---|
| Oct 24, 2023 | Fine | $14,518 | — |
About this record
A citation is a finding by a state survey team working under federal contract. It is not a court
judgment. The description above is drawn verbatim from federal public datasets. Facilities have
the right to appeal findings through an Informal Dispute Resolution (IDR/IIDR) process.
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