Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Edenbrook Rochester West during CMS and state inspections, most recent first.
A resident with diabetes and recent rhabdomyolysis experienced repeated episodes of low blood sugar that were not properly assessed or treated by nursing staff. Blood glucose monitoring was inconsistent, required interventions were not fully implemented or documented, and the provider was not notified as ordered. The resident continued to receive diabetes medications without appropriate checks, ultimately resulting in hospitalization for severe hypoglycemia.
A resident with chronic kidney disease and dialysis dependency experienced significant weight loss due to the facility's failure to provide physician-ordered nutritional supplements and daily weights. The resident's care plan did not address food preferences, leading to dissatisfaction with facility meals and reliance on family-provided food. Staff interviews revealed a lack of awareness and follow-through on dietary needs, contributing to the deficiency.
The facility failed to consistently monitor food temperatures before serving, risking foodborne illness. Observations revealed unclean refrigerators and freezers, with no cleaning schedule in place. Food temperatures were often not documented, and staff interviews confirmed the expectation for monitoring to ensure safe serving temperatures.
A resident with cognitive impairment and missing teeth was not properly assessed for dietary needs, resulting in inappropriate meal provisions. Despite observations of chewing difficulties, the nutritional assessment inaccurately reported no issues, and the care plan did not address the need for a mechanically altered diet. The dietitian admitted to not observing the resident eating and failing to pursue further evaluation, highlighting a significant oversight in the facility's assessment process.
A registered nurse failed to properly administer insulin using a FlexPen for a resident on sliding scale insulin. The nurse primed the pen without attaching the needle, contrary to the manufacturer's instructions. Despite having received training, the nurse was unaware of the correct procedure, leading to a significant medication error. The facility's policy and manufacturer's instructions clearly outlined the correct steps, which were not followed.
A resident with a feeding tube was under enhanced barrier precautions (EBP) due to the risk of multidrug-resistant organisms (MDROs). During care, a nursing assistant wore a hospital gown instead of the required disposable blue gown, contrary to facility policy. Interviews with the infection preventionist and director of nursing confirmed the failure to adhere to PPE guidelines.
Failure to Identify and Treat Hypoglycemia in Diabetic Resident
Penalty
Summary
The facility failed to identify, assess, monitor, and follow physician orders for signs and symptoms of hypoglycemia in a resident with diabetes, resulting in an immediate jeopardy situation. The resident, who had a diagnosis of diabetes mellitus and rhabdomyolysis, experienced multiple episodes of low blood sugar that were not properly addressed according to physician orders and facility protocols. Blood glucose levels were not consistently monitored, and there was a lack of timely intervention and notification to the provider when hypoglycemia was identified. On the day of the incident, the resident's blood sugar was recorded as 81 in the morning, and diabetes medications were administered. Later in the day, the resident's blood sugar dropped to 54, but there was no documented assessment for hypoglycemia symptoms, no recheck of blood sugar after a meal, and no notification to the physician. Despite a further drop in blood sugar to 39, the required interventions, including administration of glucagon and continuous monitoring, were inconsistently documented and not all actions were taken as ordered. The resident continued to receive diabetes medications without appropriate blood sugar checks, and staff failed to notify the provider or reassess the resident as required. Interviews with nursing staff revealed a lack of education and understanding regarding diabetic monitoring and hypoglycemia management. Staff did not follow hypoglycemic protocols, did not consistently document interventions, and failed to notify the provider in a timely manner. The resident ultimately became lethargic and was transferred to the emergency department, where a critically low blood sugar was confirmed, requiring intensive treatment. The facility's own policies and physician orders for hypoglycemia management were not followed throughout the incident.
Removal Plan
- Educated licensed nursing staff and agency staff about diabetic management of hypoglycemia and hyperglycemia monitoring, assessing, treatments, physician notification and standards of documentation with competency testing.
- Reviewed all residents with diagnosis of diabetes to ensure blood glucose levels were within range, had diabetic protocols in place, care plans were accurate and provider orders were followed.
- Reviewed facility Diabetic Monitoring and Change of Condition policies for accuracy.
Failure to Provide Adequate Nutritional Support
Penalty
Summary
The facility failed to ensure that a resident's nutritional needs were adequately met, as evidenced by the lack of comprehensive assessment of food preferences, unavailability of physician-ordered nutritional supplements, and failure to obtain daily weights as ordered by the physician. The resident, who had chronic kidney disease stage 5 and was dialysis-dependent, experienced significant weight loss over several months. Despite having orders for daily weights and nutritional supplements like Boost Breeze and ProHeal, these were not consistently provided or documented. The resident's care plan did not address goals for the nutritional supplements or food preferences, leading to inadequate nutritional support. The resident expressed dissatisfaction with the facility's food, preferring Mexican cuisine, and often relied on food brought by family members. Interviews with staff revealed that the resident frequently refused facility meals and supplements, citing nausea and preference for juice-based supplements over milk-based ones. Despite these refusals, there was no documentation of physician notification or alternative interventions being implemented. The facility's failure to provide the ordered nutritional supplements and daily weights, along with the lack of communication with the physician regarding the resident's refusals and weight loss, contributed to the deficiency. Staff interviews indicated a lack of awareness and follow-through on the resident's dietary needs and preferences, further exacerbating the resident's nutritional risk. The facility's policy on diet orders and monitoring was not adhered to, resulting in inadequate nutritional care for the resident.
Inconsistent Food Temperature Monitoring and Storage Issues
Penalty
Summary
The facility failed to consistently monitor food temperatures before serving, which could lead to foodborne illness. During a kitchen tour, it was observed that the resident refrigerator had loose debris and an unknown sticky substance, and items were not labeled. The freezer in the basement had loose frozen carrots, ice buildup, and frost around the door. The dietary manager admitted there was no cleaning log or schedule, and the refrigerator and freezer were shared by nursing and dietary staff. Additionally, during meal service, food temperatures were not consistently checked, with puree pasta and chicken being served at temperatures below the required holding temperature. The review of Service Line forms from October 1 to October 22 revealed multiple instances where food temperatures were not documented, particularly for pureed foods. Interviews with staff, including the dietary manager, regional dietary manager, dietician, and director of nursing, confirmed the expectation that food temperatures should be monitored to ensure safe serving temperatures. The dietician expressed concern about the cleanliness of the resident refrigerator and acknowledged the risk of foodborne illness if food is not held at appropriate temperatures.
Inadequate Oral Health Assessment Leads to Dietary Issues
Penalty
Summary
The facility failed to accurately assess a resident's oral health and dietary needs, leading to inappropriate meal provisions. The resident, who was moderately cognitively impaired and diagnosed with conditions including moderate protein calorie malnutrition and dementia, was observed having difficulty chewing due to missing teeth. Despite this, the resident's nutritional assessment inaccurately reported no difficulty chewing or swallowing, and the care plan did not address the need for a mechanically altered diet. Observations revealed the resident struggled to chew and consume meals, indicating a significant oversight in the assessment process. The registered dietitian admitted to not pursuing further evaluation after a preference assessment and did not observe the resident eating as part of the assessment. The dietitian also acknowledged that the resident should have been evaluated by speech therapy for chewing difficulties. The facility's nutritional assessment guidelines emphasize the importance of assessing oral health and dentition, which was not adequately done in this case. This deficiency highlights a failure in the facility's assessment process, resulting in the resident receiving meals that were not suitable for her condition.
Improper Insulin Administration with FlexPen
Penalty
Summary
The facility failed to ensure proper administration of insulin using a FlexPen for a resident receiving sliding scale insulin. During an observation, a registered nurse (RN) prepared to administer 8 units of Novolog Aspart insulin to a resident with a blood glucose reading of 264. The RN checked the pen against the medication administration record, dialed the pen to 2 units, and depressed the plunger without attaching the needle, which is contrary to the manufacturer's instructions. The RN was unaware that the needle should be attached before priming the pen, indicating a lack of knowledge about the correct procedure. The director of nursing and a corporate nursing consultant confirmed that the facility had a policy on medication administration, including insulin, and that staff had been trained accordingly. The facility's policy, as well as the manufacturer's instructions, clearly outlined the correct steps for insulin pen use, including attaching the needle before priming. Despite this, the RN did not follow the correct procedure, leading to a significant medication error. The incident highlights a gap in the RN's understanding of the insulin administration process, despite having received training.
Improper PPE Use for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure the proper use of personal protective equipment (PPE) for a resident under enhanced barrier precautions (EBP). The resident, identified as R8, was cognitively intact and had several medical conditions, including Parkinson's disease, severe protein-calorie malnutrition, and gastrostomy status. R8 required a feeding tube and was on EBP due to the presence of this indwelling medical device. During an observation, a nursing assistant (NA-A) was seen wearing gloves and a hospital gown instead of the required disposable blue gown while providing care to R8. This included assisting the resident with mobility, hygiene, and changing linens, which are high-contact activities necessitating the correct PPE. Interviews with the infection preventionist (IP) and the director of nursing (DON) confirmed that the facility's policy required the use of specific PPE, including disposable blue gowns, for residents on EBP to prevent the spread of multidrug-resistant organisms (MDROs). The IP and DON both acknowledged that NA-A did not adhere to the facility's PPE policy. The facility's policies on EBP and PPE clearly outlined the necessity of using appropriate gowns and gloves for high-contact care activities and the disposal of gowns in the correct waste receptacle.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rochester
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edenbrook Of Rochester | 0.3 mi | — | 16 | 0 |
| Madonna Towers Of Rochester | 1.1 mi | — | 4 | 0 |
| Samaritan Bethany Home On Eighth | 1.8 mi | — | 8 | 0 |
| Charter House Inc | 2 mi | — | 3 | 0 |
| Rochester Rehabilitation And Living Center | 2.3 mi | — | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.