Edenbrook Rochester West

Penalties

• Oct 24, 2023 — Fine ($14,518)

Inspection findings

1. May 13, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0725 Nursing and Physician Services Deficiencies

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

     Corrected Jun 22, 2026 · CMS health inspection

2. Nov 20, 2025 Health · 24 findings
   • Not serious Scope/severity D Complaint

     F0628 Resident Rights Deficiencies

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

     Corrected Dec 19, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

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

     Corrected Dec 19, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0658 Resident Assessment and Care Planning Deficiencies

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

     Corrected Dec 19, 2025 · CMS health inspection

   • Serious Scope/severity G

     F0691 Quality of Life and Care Deficiencies

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

     Corrected Dec 19, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0710 Nursing and Physician Services Deficiencies

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

     Corrected Dec 19, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0726 Nursing and Physician Services Deficiencies

     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.

     Corrected Dec 19, 2025 · CMS health inspection

   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Dec 19, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0756 Pharmacy Service Deficiencies

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

     Corrected Dec 19, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0801 Nutrition and Dietary Deficiencies

     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.

     Corrected Dec 19, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Dec 19, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0921 Environmental Deficiencies

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

     Corrected Dec 19, 2025 · CMS health inspection

   • Not serious Scope/severity F

     K0222 Egress Deficiencies

     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.

     Corrected Jan 9, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Jan 9, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jan 9, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Jan 9, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Jan 9, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jan 9, 2026 · CMS fire safety

   • Not serious Scope/severity C

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Jan 9, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jan 9, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Jan 9, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Jan 9, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Jan 9, 2026 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jan 9, 2026 · CMS fire safety

   • Not serious Scope/severity D

     K0920 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure proper usage of power strips and extension cords.

     Corrected Jan 9, 2026 · CMS fire safety

3. Sep 12, 2025 MDH complaint investigation · 1 finding
   • Severity not stated

     H53063380C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

4. Sep 8, 2025 Health · 1 finding
   • Serious Scope/severity J Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Sep 26, 2025 · CMS health inspection

5. Mar 31, 2025 MDH complaint investigation · 1 finding
   • Severity not stated

     H53061701C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

6. Dec 17, 2024 MDH complaint investigation · 1 finding
   • Severity not stated

     H53061487C Substantiated complaint (MDH Office of Health Facility Complaints)

     MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

     Statement of deficiencies (PDF)

7. Dec 10, 2024 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Jan 9, 2025 · CMS health inspection

8. Oct 23, 2024 Health · 12 findings
   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Nov 26, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Nov 26, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Nov 26, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Nov 26, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0291 Egress Deficiencies

     Install emergency lighting that can last at least 1 1/2 hours.

     Corrected Nov 27, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Nov 27, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Nov 27, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0355 Smoke Deficiencies

     Properly select, install, inspect, or maintain portable fire extinguishes.

     Corrected Nov 27, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Nov 27, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Nov 27, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     CMS fire safety

9. Nov 30, 2023 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0561 Resident Rights Deficiencies

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

     Corrected Jan 9, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0636 Resident Assessment and Care Planning Deficiencies

     Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

     Corrected Jan 9, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0694 Quality of Life and Care Deficiencies

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

     Corrected Jan 9, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Jan 9, 2024 · CMS health inspection

10. Nov 2, 2023 Health · 16 findings
    • Not serious Scope/severity E

      F0584 Resident Rights Deficiencies

      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.

      Corrected Dec 20, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0610 Freedom from Abuse, Neglect, and Exploitation Deficiencies

      Respond appropriately to all alleged violations.

      Corrected Dec 20, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0622 Resident Rights Deficiencies

      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.

      Corrected Dec 20, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0644 Resident Assessment and Care Planning Deficiencies

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

      Corrected Dec 20, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0689 Quality of Life and Care Deficiencies

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

      Corrected Dec 20, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0695 Quality of Life and Care Deficiencies

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

      Corrected Dec 20, 2023 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0725 Nursing and Physician Services Deficiencies

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

      Corrected Dec 20, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0726 Nursing and Physician Services Deficiencies

      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.

      Corrected Dec 20, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0758 Pharmacy Service Deficiencies

      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.

      Corrected Dec 20, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0761 Pharmacy Service Deficiencies

      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.

      Corrected Dec 20, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0805 Nutrition and Dietary Deficiencies

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

      Corrected Dec 20, 2023 · CMS health inspection

    • Not serious Scope/severity F

      F0851 Administration Deficiencies

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

      Corrected Dec 20, 2023 · CMS health inspection

    • Not serious Scope/severity F

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Dec 20, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0883 Infection Control Deficiencies

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

      Corrected Dec 20, 2023 · CMS health inspection

    • Severity not stated

      H53066530C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

    • Not serious Scope/severity F

      K0521 Services Deficiencies

      Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

      CMS fire safety

11. Oct 24, 2023 Health · 4 findings
    • Not serious Scope/severity D Complaint

      F0554 Resident Rights Deficiencies

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

      Corrected Nov 21, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0755 Pharmacy Service Deficiencies

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

      Corrected Nov 21, 2023 · CMS health inspection

    • Serious Scope/severity J Complaint

      F0760 Pharmacy Service Deficiencies

      Ensure that residents are free from significant medication errors.

      Corrected Oct 9, 2023 · CMS health inspection

    • Not serious Scope/severity E Complaint

      F0880 Infection Control Deficiencies

      Provide and implement an infection prevention and control program.

      Corrected Nov 21, 2023 · CMS health inspection

12. Sep 1, 2023 MDH complaint investigation · 2 findings
    • Severity not stated

      H53064490C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

    • Severity not stated

      H53064618C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

13. Aug 22, 2023 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0689 Quality of Life and Care Deficiencies

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

      Corrected Sep 18, 2023 · CMS health inspection

14. Jul 19, 2023 MDH complaint investigation · 1 finding
    • Severity not stated

      H53063564C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

15. Nov 18, 2022 MDH complaint investigation · 1 finding
    • Severity not stated

      H53065343C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

16. Apr 16, 2022 MDH complaint investigation · 1 finding
    • Severity not stated

      H5306076C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

17. Nov 16, 2021 MDH complaint investigation · 1 finding
    • Severity not stated

      H5306058C Substantiated complaint (MDH Office of Health Facility Complaints)

      MDH substantiated this complaint. The finding and its severity are in MDH's investigation report (linked).

      Statement of deficiencies (PDF)

Owners and managers (as published by CMS)

• HANSON, GREGORY — adp of the snf, NOT APPLICABLE, since 12/01/2024
• HANSON, GREGORY — operational/managerial control, NOT APPLICABLE, since 12/01/2024
• KALLSTROM, SCOTT — adp of the snf, NOT APPLICABLE, since 12/01/2024
• KALLSTROM, SCOTT — operational/managerial control, NOT APPLICABLE, since 12/01/2024
• LERMAN, YECHOVED — 5% or greater direct ownership interest, 7%, since 12/01/2024
• LERMAN, YECHOVED — adp of the snf, NOT APPLICABLE, since 12/01/2024
• MAUER, DOVIE — direct ownership interest, NOT APPLICABLE, since 12/01/2024
• POLSTEIN, MORDECHAI — adp of the snf, NOT APPLICABLE, since 12/01/2024
• POLSTEIN, MORDECHAI — 5% or greater direct ownership interest, 30%, since 12/01/2024
• STESEL, MAXIM — managing control - governing body, NOT APPLICABLE, since 12/01/2024
• STESEL, MAXIM — 5% or greater direct ownership interest, 45%, since 12/01/2024
• STESEL, MAXIM — adp of the snf, NOT APPLICABLE, since 12/01/2024
• STESEL, MAXIM — operational/managerial control, NOT APPLICABLE, since 12/01/2024
• ZARKH, GLEB — 5% or greater direct ownership interest, 10%, since 12/01/2024
• ZARKH, GLEB — adp of the snf, NOT APPLICABLE, since 12/01/2024