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Inspection visit

Health inspection

EDENBROOK ROCHESTER WESTCMS #24530611 citations on this visit
11 citations recorded

Citations

11 citations recorded*CMS

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.

  • 0628GeneralS&S Dpotential for harm

    F628 - Documentation

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

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

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

  • 0658GeneralS&S Dpotential for harm

    F658 - Comprehensive Care Plans

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

  • 0691SeriousS&S Gactual harm

    F691 - Colostomy, urostomy, or ileostomy care

    Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

  • 0710GeneralS&S Dpotential for harm

    F710 - Physician Services

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

  • 0726GeneralS&S Epotential for harm

    F726 - Nursing Services

    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.

  • 0732GeneralS&S Cno actual harm

    F732 - Nurse Staffing Information

    Post nurse staffing information every day.

  • 0756GeneralS&S Dpotential for harm

    F756 - Drug Regimen Review

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

  • 0801GeneralS&S Epotential for harm

    F801 - Staffing

    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.

  • 0812GeneralS&S Epotential for harm

    F812 - Food safety requirements

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

  • 0921GeneralS&S Dpotential for harm

    F921 - Other Environmental Conditions

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

FAQ · About this visit

Common questions about this visit

What happened during the November 20, 2025 survey of EDENBROOK ROCHESTER WEST?

This was a inspection survey of EDENBROOK ROCHESTER WEST on November 20, 2025. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at EDENBROOK ROCHESTER WEST on November 20, 2025?

Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.