Edenbrook of Rochester: Quality Standards Violation - MN
The resident, identified in inspection records as R31, has a contracture of her right hand, a condition that stiffens and shortens soft tissue until a person loses full range of motion. Her care plan documented the contracture and noted she needed help dressing and undressing. She is right-handed.
When inspectors observed her on the morning of February 10, 2026, the burn holes were visible on the right forearm of her coat. She told them the damage happened shortly after she got the coat, a couple months earlier. She had been struggling to light her cigarette with her left hand because her right hand couldn't do it anymore. She said she was upset. The coat was brand new.
She also said she felt mostly safe smoking outside alone.
Her smoking care plan had no interventions for a protective apron or clothing cover. Smoking assessments dating back to May 2024 had consistently cleared her to smoke without supervision. None of them accounted for what the contracture had done to her ability to handle a lighter.
The nurse manager told inspectors that if staff saw burn holes in a resident's clothing, they would assess the resident for wounds and redo the smoking assessment. She said she had not been aware of the holes in R31's jacket.
The director of nursing said the same thing. Staff, she explained, don't routinely check clothing for burns.
Both administrators described a reassessment process that, by their own account, requires someone to first notice a problem. In this case, nobody had.
The director of nursing said a resident with clothing burns should be reassessed immediately. R31's coat had been burned for roughly two months.
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 5, 2026 · Our methodology
EDENBROOK OF ROCHESTER in ROCHESTER, MN was cited for violations during a health inspection on February 12, 2026.
Her care plan documented the contracture and noted she needed help dressing and undressing.
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.