CONTACT INFORMATION REVIEWS & MORE DATA
Deficiency Records for Edenbrook Rochester West
View the most recent health deficiencies and inspection results for Edenbrook Rochester West. Stay informed about quality of care issues.
View the most recent health deficiencies and inspection results for Edenbrook Rochester West. Stay informed about quality of care issues.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2025-11-20 | 2026-01-09 | N |
| 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. | Fire Safety | 2025-11-20 | 2026-01-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-11-20 | 2026-01-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2025-11-20 | 2026-01-09 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2025-11-20 | 2026-01-09 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2025-11-20 | 2026-01-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2025-11-20 | 2026-01-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2025-11-20 | 2026-01-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2025-11-20 | 2026-01-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-11-20 | 2026-01-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-11-20 | 2026-01-09 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2025-11-20 | 2026-01-09 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2025-11-20 | 2026-01-09 | N |
| Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | Health | 2025-11-20 | 2025-12-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2025-11-20 | 2025-12-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-11-20 | 2025-12-19 | N |
| 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. | Health | 2025-11-20 | 2025-12-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2025-11-20 | 2025-12-19 | N |
| Post nurse staffing information every day. | Health | 2025-11-20 | 2025-12-19 | N |
| 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. | Health | 2025-11-20 | 2025-12-19 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2025-11-20 | 2025-12-19 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2025-11-20 | 2025-12-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2025-11-20 | 2025-12-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2025-11-20 | 2025-12-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2025-09-08 | 2025-09-26 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-12-10 | 2025-01-09 | Y |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-10-23 | 2024-11-27 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-10-23 | 2024-11-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-10-23 | 2024-11-27 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-10-23 | 2024-11-27 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-10-23 | 2024-11-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-10-23 | 2024-11-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-10-23 | 2024-11-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-10-23 | 2024-11-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-10-23 | 2024-11-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-10-23 | 2024-11-26 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-30 | 2024-01-09 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-11-30 | 2024-01-09 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-11-30 | 2024-01-09 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-11-30 | 2024-01-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-02 | 2023-12-20 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-11-02 | 2023-12-20 | Y |
| 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. | Health | 2023-11-02 | 2023-12-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-02 | 2023-12-20 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-02 | 2023-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-02 | 2023-12-20 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-11-02 | 2023-12-20 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-11-02 | 2023-12-20 | N |
| 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. | Health | 2023-11-02 | 2023-12-20 | N |
| 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. | Health | 2023-11-02 | 2023-12-20 | N |
| 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. | Health | 2023-11-02 | 2023-12-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-02 | 2023-12-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-02 | 2023-12-20 | N |
| 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. | Health | 2023-11-02 | 2023-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-24 | 2023-11-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-24 | 2023-11-21 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-10-24 | 2023-11-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-10-24 | 2023-10-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-22 | 2023-09-18 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-11-02 | Not Fixed | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-10-23 | Not Fixed | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-10-23 | Not Fixed | N |