Public Record
Edenbrook Rochester West
From CMS
Facility profile
- CMS overall rating
- 2 / 5
- Certified beds
- 48
- Avg. residents per day
- 28.2
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 62
- Inspections on file
- 11
- Last inspection
- 2025-11-20
*CMS
*CMS
*CMS
Citations
62 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0291Generalpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0222Generalpotential for harm
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.
- 0691Seriousactual harm
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
- 0710Generalpotential for harm
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
- 0726Generalpotential for 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.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0801Generalpotential for harm
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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0921Generalpotential for harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 0628Generalpotential for harm
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0920Generalpotential for harm
Ensure proper usage of power strips and extension cords.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0521Generalpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0374Generalpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0372Generalpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0355Generalno actual harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0684Seriousimmediate jeopardy
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0291Generalpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0355Generalno actual harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0374Generalpotential for harm
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- 0521Generalpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0636Generalpotential for harm
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- 0694Generalpotential for harm
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
- 0760Generalpotential for harm
Ensure that residents are free from significant medication errors.
- 0561Generalpotential for harm
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0644Generalpotential for harm
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- 0584Generalpotential for 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.
- 0805Generalpotential for harm
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- 0761Generalpotential for 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.
- 0725Generalpotential for harm
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
- 0521Generalpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- 0851Generalpotential for harm
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0622Generalpotential for harm
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.
- 0758Generalpotential for harm
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.
- 0726Generalpotential for 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.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0554Generalpotential for harm
Allow residents to self-administer drugs if determined clinically appropriate.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0760Seriousimmediate jeopardy
Ensure that residents are free from significant medication errors.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
FAQ
Questions and answers
- What is Edenbrook Rochester West?
- Edenbrook Rochester West is a Medicare- and Medicaid-certified nursing home in Rochester, MN, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 245306.
- What is the CMS rating for Edenbrook Rochester West?
- Edenbrook Rochester West has a CMS overall rating of 2 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Edenbrook Rochester West have?
- Edenbrook Rochester West is certified for 48 beds. It serves an average of 28.2 residents per day.
- How many citations does Edenbrook Rochester West have?
- Edenbrook Rochester West has 62 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Edenbrook Rochester West last inspected?
- Edenbrook Rochester West was last inspected on November 20, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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