Edenbrook Rochester West: Discharge Documentation Failures - MN
The problems surfaced during a complaint inspection on November 20, 2025. Federal inspectors focused on the discharge of Resident 37, a woman transferred to an assisted living facility with family support. What they found was a chain of missing documentation at nearly every step.
The Director of Nursing told inspectors that her only contact with the assisted living facility, referred to in the report as ALD-A, was a single email response received after business hours on August 20, 2025. She never spoke to anyone there by phone. The facility faxed discharge orders to the assisted living, she said, but when inspectors asked for proof, the facility had none. No fax transmission record existed. And Resident 37's own medical file contained no signed physician discharge orders at all.
The hospital bed was its own problem. A discharge order for the durable medical equipment was never written. The inspection report lists it simply: "DME ordered- N/A."
The Director of Nursing confirmed all of this during her follow-up interview.
Discharge documentation requirements aren't complicated in concept. A physician writes an order. A summary goes to whoever is taking over the resident's care. That summary covers the diagnoses, the course of treatment, the medications, the procedures, the lab and radiology results. Before the resident walks out the door, the receiving provider has what they need. The facility's own policy, last revised in November 2020, spelled out exactly this sequence, including a full reconciliation of all medications, both prescription and over-the-counter, from before and after discharge.
None of that happened in a way the facility could document.
What makes this harder to dismiss is the timing. The after-hours email on August 20 was the Director of Nursing's only communication with the assisted living facility. That means the person responsible for overseeing Resident 37's care transition never had a real-time conversation with the people who would be assuming that care. If there were questions about medications, about the hospital bed, about what had happened during Resident 37's stay, there was no conversation in which to ask them.
The facility's inability to produce a fax confirmation is a separate failure from the missing signed orders, but together they point to the same gap. The discharge summary that the facility's own policy describes as something that "must" be furnished at the time the resident leaves, containing diagnoses, treatment history, medication reconciliation, and final status, either wasn't sent or was sent without any record of transmission. The medical file for Resident 37 doesn't resolve that question. It just confirms the orders weren't in it.
Inspectors classified the violation under F0628, with a harm level of minimal harm or potential for actual harm, affecting few residents.
Resident 37 went home to her husband and her family. Whether the assisted living facility received what it needed to care for her, and whether the hospital bed was eventually arranged through some other means, the inspection report doesn't say. What it says is that the nursing home couldn't show it had done what it was supposed to do before she left.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Edenbrook Rochester West from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 28, 2026 · Our methodology
EDENBROOK ROCHESTER WEST in ROCHESTER, MN was cited for violations during a health inspection on November 20, 2025.
The problems surfaced during a complaint inspection on November 20, 2025.
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.