A list of the most recent deficiencies for Edenbrook of Rochester. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide and implement an infection prevention and control program. | Health | 2023-11-02 | 2023-12-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-20 | 2023-08-17 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-06-15 | 2023-06-30 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-06 | 2023-06-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-04-03 | 2023-06-15 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-03 | 2023-06-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-03 | 2023-06-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-03 | 2023-06-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-04-06 | 2023-06-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-04-03 | 2023-06-01 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-04-06 | 2023-05-30 | N |
| Keep all essential equipment working safely. | Health | 2023-04-06 | 2023-05-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-03 | 2023-05-30 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-04-06 | 2023-05-12 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-04-06 | 2023-05-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-06 | 2023-05-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-04-06 | 2023-05-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-06 | 2023-05-12 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-04-06 | 2023-05-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-06 | 2023-05-12 | 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 | 2023-04-06 | 2023-05-12 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-04-06 | 2023-05-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-03 | 2023-05-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-03 | 2023-05-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-03 | 2023-05-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-03 | 2023-05-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-18 | 2023-02-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-11-10 | 2022-12-08 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-11-10 | 2022-12-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-10 | 2022-12-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-10 | 2022-12-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-11 | 2022-11-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-28 | 2022-10-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-28 | 2022-10-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-26 | 2022-08-23 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-02-03 | 2022-03-15 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-02-03 | 2022-03-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-02-03 | 2022-03-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-03 | 2022-03-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-03 | 2022-03-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-03 | 2022-03-15 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-02-03 | 2022-03-15 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-03 | 2022-03-15 | Y |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2022-02-08 | 2022-03-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-02-03 | 2022-03-14 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-02-03 | 2022-03-14 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-02-03 | 2022-03-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-03 | 2022-03-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-08 | 2022-03-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-10 | 2021-12-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-10 | 2021-12-10 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-23 | 2021-07-23 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-01-13 | 2020-06-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-01-13 | 2020-06-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-13 | 2020-06-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-01-13 | 2020-02-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-01-13 | 2020-02-26 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-13 | 2020-02-26 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-01-13 | 2020-02-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-01-13 | 2020-02-26 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-01-13 | 2020-02-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-01-13 | 2020-02-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-01-13 | 2020-02-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-01-13 | 2020-02-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-01-13 | 2020-02-26 | 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 | 2020-01-13 | 2020-02-26 | 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 | 2020-01-13 | 2020-02-26 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-01-13 | 2020-02-26 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-01-13 | 2020-02-26 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2020-01-08 | 2020-02-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-08 | 2020-02-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-08 | 2020-02-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-08 | 2020-02-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-08 | 2020-02-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-01-08 | 2020-02-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-01-08 | 2020-02-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-08 | 2020-02-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-08 | 2020-02-26 | N |
