Edenbrook Rochester West

Certification

Medicare-certified.

Ratings

Inspection history (41)

Records from August 2023 to May 2026.

• November 30, 2023

  Tag F0561

  Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected January 9, 2024.

• November 30, 2023

  Tag F0694

  Provide for the safe, appropriate administration of IV fluids for a resident when needed.

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected January 9, 2024.

• November 2, 2023

  Tag F0622

  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.

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected December 20, 2023.

• November 2, 2023

  Tag F0805

  Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected December 20, 2023.

• November 2, 2023

  Tag F0851

  Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

  Severity F: widespread, no actual harm, potential for more than minimal harm. Corrected December 20, 2023.

• November 2, 2023

  Tag F0883

  Develop and implement policies and procedures for flu and pneumonia vaccinations.

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected December 20, 2023.

• November 2, 2023

  Tag F0761

  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.

  Severity E: pattern, no actual harm, potential for more than minimal harm. Corrected December 20, 2023.

• November 2, 2023

  Tag F0725

  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  Severity E: pattern, no actual harm, potential for more than minimal harm. Corrected December 20, 2023.

• November 2, 2023

  Tag F0695

  Provide safe and appropriate respiratory care for a resident when needed.

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected December 20, 2023.

• November 2, 2023

  Tag F0610

  Respond appropriately to all alleged violations.

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected December 20, 2023.

• November 2, 2023

  Tag F0644

  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected December 20, 2023.

• November 2, 2023

  Tag F0726

  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.

  Severity E: pattern, no actual harm, potential for more than minimal harm. Corrected December 20, 2023.

• November 2, 2023

  Tag F0758

  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 l….

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected December 20, 2023.

• November 2, 2023

  Tag F0880

  Provide and implement an infection prevention and control program.

  Severity F: widespread, no actual harm, potential for more than minimal harm. Corrected December 20, 2023.

• November 2, 2023

  Tag F0689

  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  Severity E: pattern, no actual harm, potential for more than minimal harm. Corrected December 20, 2023.

• November 2, 2023

  Tag F0584

  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.

  Severity E: pattern, no actual harm, potential for more than minimal harm. Corrected December 20, 2023.

• October 24, 2023

  Tag F0880

  Provide and implement an infection prevention and control program.

  Severity E: pattern, no actual harm, potential for more than minimal harm. Corrected November 21, 2023.

• October 24, 2023

  Tag F0554

  Allow residents to self-administer drugs if determined clinically appropriate.

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected November 21, 2023.

• October 24, 2023

  Tag F0760

  Ensure that residents are free from significant medication errors.

  Severity J: isolated, immediate jeopardy. Corrected October 9, 2023.

• October 24, 2023

  Tag F0755

  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  Severity D: isolated, no actual harm, potential for more than minimal harm. Corrected November 21, 2023.

Penalties (3)

Total fines: $14,518

• November 20, 2025 · Fine

  CMS recorded a civil money penalty of $59,040 against this nursing home on November 20, 2025.

• September 8, 2025 · Fine

  CMS recorded a civil money penalty of $87,080 against this nursing home on September 8, 2025.

• October 24, 2023 · Fine

  CMS recorded a civil money penalty of $14,518 against this nursing home on October 24, 2023.

Staffing

4.24 nurse hours per resident per day in Q2 2026, about the same as in Q4 2025.

From the payroll records nursing homes file with CMS.

Ownership

For profit - Limited Liability company