Edenbrook of Rochester: Safety Hazard Violations - MN
Inspectors documented the finding on February 10, 2026. The resident, identified in the report as R31, had a contracture of her right hand, leaving her with limited range of motion. She was right-handed. When she went outside to smoke, she had to use her left hand to light her cigarette instead, and that's when the burns happened. "She was upset about the burn holes because her jacket was brand new and it already had holes in it," the inspection report states.
Her smoking care plan had no interventions for clothing protectors. Her smoking assessments, completed from May 2024 through December 2025, cleared her to smoke without supervision. None of them accounted for what her hand contracture actually meant when she tried to hold a lighter.
The nurse manager told inspectors that if staff observed burn holes in clothing, they would assess the resident for wounds and conduct a new smoking assessment. Then she said she hadn't known about R31's jacket.
The director of nursing described a process that included observing residents smoke from start to finish, and said residents needed to be free of burn holes in clothing to continue smoking independently. She also said she hadn't known. "Staff don't routinely check clothing for clothing burns," she told inspectors.
R31 told inspectors she felt mostly safe smoking outside alone, other than the two burn holes. She said the burns happened shortly after she got the coat, a couple of months before inspectors arrived.
The facility's own smoking policy requires reassessment upon admission, quarterly, or when a resident's condition changes. R31's condition, a contracture affecting her dominant hand, was documented in her care plan. The connection between that condition and what happens when she tries to light a cigarette was not.
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.
Inspectors documented the finding on February 10, 2026.
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.