Rochester Rehab: Heart Failure Monitoring Failures - MN
She also hadn't put the wraps on that morning. Too busy, she said.
The resident, identified in inspection records only as R3, had congestive heart failure and required daily compression wraps to be applied each morning before she got out of bed. She also needed her weight taken regularly, a standard practice for heart failure patients because sudden weight gain can signal dangerous fluid accumulation before other symptoms appear. Inspectors found the wraps had not been applied and not been recorded in the medication administration record on August 6 and again on August 11. Her weight had not been obtained on either of those dates either.
On August 15, inspectors interviewed the registered nurse, identified as RN-B, who was responsible for R3's care. RN-B said the wraps were supposed to go on at 7:00 a.m. but she hadn't applied them that day because she was too busy. When inspectors asked her to describe what she would look for to evaluate signs and symptoms of fluid overload related to congestive heart failure, she couldn't answer. She couldn't explain the rationale for the compression wraps. She couldn't describe how she would determine whether a resident's edema was worsening.
"I feel I could benefit from some training," RN-B told inspectors.
She said she had never received any formal training in edema monitoring.
The director of nursing confirmed the gaps. In an interview on August 11, the DON acknowledged that R3's weight had not been obtained on August 6 or August 11 and should have been. In a follow-up interview on August 15, the DON said the compression wraps should have been applied before R3 got up for the day and signed off in the medication administration record, but were not documented on either date.
The DON went further. Residents with heart failure and edema should be monitored daily for worsening symptoms, the DON said, but that had not been done consistently. And nurses, the DON confirmed, had not received any specific training on edema or congestive heart failure monitoring.
The facility had a heart failure patient care policy, revised as recently as August 2024, that laid out in precise detail what nurses were supposed to do. The policy called for asking patients about chest pain, shortness of breath at rest and with exertion, difficulty sleeping, cough, fatigue, dizziness, sudden weight gain, and swelling. It called for weighing patients at the same time each day on the same scale in similarly weighted clothing. It called for assessing extremities for color and temperature, checking capillary refill time, palpating peripheral pulses, and grading pitting edema on a scale from zero to four.
RN-B could not describe any of it.
Inspectors classified the violation under the federal standard requiring facilities to provide care and services consistent with professional standards of practice. The level of harm was listed as minimal harm or potential for actual harm.
R3's situation, as inspectors found it, was this: a woman with a progressive cardiac condition, in a facility that had written down exactly what her care required, being cared for by a nurse who had never been trained to deliver it. The wraps sat unapplied. The scale went unused. And on the mornings when no one was checking, there was no way to know whether the fluid was building.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Rochester Rehabilitation and Living Center from 2025-08-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 3, 2026 · Our methodology
Rochester Rehabilitation And Living Center in ROCHESTER, MN was cited for violations during a health inspection on August 22, 2025.
She also hadn't put the wraps on that morning.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.