Pearl Nursing Center: Pressure Sore Prevention Failures - NY
The Pearl Nursing Center of Rochester failed to implement preventative measures for a resident at risk of skin breakdown, allowing the development of a sacral wound that required treatment orders only after the damage had already occurred.
Resident #9's medical records revealed no documented evidence that preventative measures or treatment orders for the sacrum area had been ordered prior to November 22, 2024. The treatment order for the sacral wound appeared in the resident's medical records on that same date, suggesting staff only acted after the pressure sore had formed.
The facility's own wound care recommendations included cleaning the affected area with wound cleanser, patting dry the surrounding skin, and leaving the wound open to air every shift. Additional protocols called for reducing pressure on the affected area to promote healing, using pressure redistribution cushions, and applying barrier cream three times daily and after incontinence episodes.
Staff interviews revealed confusion about basic pressure sore prevention protocols. During questioning on September 9, Certified Nursing Assistant #1 stated they would know if a resident required skin prevention interventions by checking the resident's Kardex, a medication administration record system.
Licensed Practical Nurse #1 told inspectors the next day that residents at risk for skin breakdown should be repositioned every two hours. The nurse said if they identified new skin problems, they would document findings in the medical provider book.
Registered Nurse #1 described standard prevention measures during a September 10 interview: turning and repositioning residents, encouraging them to get out of bed, providing timely incontinence care, and promoting good nutrition. The nurse stated they would find repositioning instructions in the resident's medical orders.
But the Director of Nursing revealed a critical gap in the facility's approach during a follow-up interview. The administrator stated that orders for preventative measures "do not have to be in place for staff to provide them" and that certified nursing assistants should be turning and repositioning residents every two to three hours "even if it is not documented in the resident's Kardex."
This admission highlighted the disconnect between what staff believed they needed for guidance and what administrators expected them to do independently.
Licensed Practical Nurse Manager #1 described the facility's reactive approach to skin problems. When staff identified new skin concerns, a registered nurse would assess the resident and follow general wound care processes or verbal orders until the resident could be seen by the wound care provider during weekly skin rounds.
Medical Doctor #2 confirmed this system during their interview, stating the Director of Nursing or nurse managers inform physicians of new wounds. Once identified, residents are added to a list for weekly skin rounds where medical providers follow up on treatment.
The Director of Nursing outlined the expected response protocol: nurses should contact the nursing supervisor upon identifying new skin concerns, obtain general orders for treatment until the wound care team could evaluate the resident, and document their findings in the medical provider book.
The administrator emphasized that documentation should include wound descriptions, interventions taken, and notification records.
During the follow-up interview, the Director of Nursing acknowledged that staff could help prevent pressure injuries through timely incontinence care, promoting nutrition and hydration, and implementing preventative measures like barrier cream application.
The nursing director also stated that care plans should include wounds and appropriate interventions, with nurse managers responsible for monitoring and updating these plans.
The inspection findings suggest a systemic failure in the facility's pressure injury prevention program. While staff understood individual components of skin care, the lack of clear, documented preventative orders for at-risk residents created gaps that allowed preventable wounds to develop.
Federal regulations require nursing homes to ensure residents receive treatment and care to prevent pressure sores and that existing pressure sores do not worsen. The facility's approach of waiting until wounds developed before implementing formal treatment protocols violated these standards.
The case of Resident #9 demonstrates how administrative gaps in prevention protocols can lead to resident harm, even when staff possess knowledge of proper wound care techniques.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Pearl Nursing Center of Rochester from 2025-09-10 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: June 21, 2026 · Our methodology
The Pearl Nursing Center of Rochester in Rochester, NY was cited for violations during a health inspection on September 10, 2025.
Staff interviews revealed confusion about basic pressure sore prevention protocols.
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.