Edenbrook of Rochester: Care Plan Violations - MN
Inspectors spotted them on February 10 during a visit to Edenbrook of Rochester. The resident, identified in inspection records as R31, told them the burns happened a couple months earlier, right after she got the jacket. She is right-handed, but a contracture in her right hand left her with limited movement. She had been trying to light her cigarettes with her left hand instead.
She said she was upset about the holes. It was a new coat.
R31 had been assessed as safe to smoke independently, without supervision, in every smoking evaluation on record dating back to May 2024. Her care plan noted the hand contracture and flagged that she needed help dressing and undressing because of it. The smoking plan had no provision for a clothing protector.
The nurse manager told inspectors that if staff observed burn holes in a resident's clothing, they would assess the resident for wounds and conduct a new smoking assessment. She said she had not been aware of the burn holes in R31's jacket.
The director of nursing said the same. She added that staff don't routinely check clothing for burns.
Both described a smoking assessment process that included observing a resident from start to finish, confirming they could extinguish cigarettes properly, and providing safety equipment like an apron or blanket if needed. R31 had none of that equipment.
The facility's own smoking policy calls for assessments upon admission, quarterly, and whenever a resident's condition changes. A hand contracture severe enough to require dressing assistance and force a dominant-hand smoker to switch hands mid-light would seem to qualify. The quarterly assessments continued. The clothing protector was never added.
R31 told inspectors that other than the burn holes, she feels mostly safe smoking outside alone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Edenbrook of Rochester from 2026-02-12 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: August 4, 2026 · Our methodology
EDENBROOK OF ROCHESTER in ROCHESTER, MN was cited for violations during a health inspection on February 12, 2026.
Inspectors spotted them on February 10 during a visit to Edenbrook of Rochester.
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.