The Pearl Nursing Center Of Rochester

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

surrounding skin, and leave open to air every shift and as needed. Additional recommendations included, but were not limited to, offloading (reducing pressure on the affected area to promote healing), use of the facility pressure injury prevention protocol, a pressure redistribution cushion per facility protocol, and applying barrier cream three (3) times daily and after incontinence episodes. Review of Resident #9's Order Summary Report (medical orders) revealed a treatment order for the sacral wound dated 11/22/2024. There was no documented evidence preventative measures or treatment orders for the sacrum had been ordered prior to 11/22/2024. During an interview on 09/09/2025 at 1:52 PM, Certified Nursing Assistant #1 stated

they would know if a resident was at risk for developing pressure ulcers and required skin prevention interventions by looking at the resident's Kardex. During an interview on 09/10/2025 at 9:27 AM, Licensed Practical Nurse #1, stated all residents at risk for skin breakdown should be repositioned every two (2) hours and if they identified new skin breakdown they would document it in the medical provider book.

During an interview on 09/10/2025 at 9:14 AM, Registered Nurse #1 stated skin breakdown prevention interventions for residents would include to turn and reposition, encourage them to get out of bed, provide timely incontinence care, and promote good nutrition. They stated they would find instructions for turning and repositioning in the resident's medical orders. During an interview on 09/09/2025 at 9:38 AM, Licensed Practical Nurse Manager #1 stated if a resident had a new skin concern, they would have a registered nurse assess the resident and follow the facility's general wound care process or verbal orders until the resident was seen by the wound care provider on their weekly skin rounds. During an interview on 09/10/2025 at 9:58 AM, Medical Doctor #2 stated the Director of Nursing or nurse managers inform them of new wounds. Once a new wound has been identified, the resident is added to the list for weekly skin rounds and the medical providers will follow up. During an interview on 09/09/2025 at 11:25 AM, the Director of Nursing stated if a nurse identifies a new skin concern, they should contact the nursing supervisor, obtain general orders for treatment until the resident is seen by the wound care team, and write their findings in

the medical provider book. The Director of Nursing stated upon identifying a new skin condition, they would expect nurses to document the description of the wound, any interventions, and who they notified.During a follow up interview on 09/10/2025 at 10:18 AM, the Director of Nursing stated staff can help prevent pressure injuries by providing timely incontinence care, promoting a resident's nutrition and hydration, and implementing preventative measures, such as applying a barrier cream. The Director of Nursing stated orders for preventative measures do not have to be in place for staff to provide them and certified nursing assistants should be turning and repositioning residents every two (2) to three (3) hours even if it is not documented in the resident's Kardex. They stated care plans are monitored and updated by nurse managers and should include wounds and appropriate interventions.10 NYCRR 415.12(c)(1-2)

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Pearl Nursing Center of Rochester

1335 Portland Avenue Rochester, NY 14621

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

Based on observations and interviews conducted during an Abbreviated Survey (ACTS Reference Number: NY00370341, Intake ID: Complaint 571451) from 09/08/2025 to 09/10/2025, the facility did not ensure each resident received and the facility provided food and drink that was palatable and at a safe and appetizing temperature for one (1) of one (1) test tray. Specifically, food and beverages during the lunch meal on 09/09/2025 were served at sub-optimal temperatures. This is evidenced by the following:During a tray line and lunch time observation on 09/09/2025, the tray delivery cart was loaded in the main kitchen and sent to Residential Unit 1 at 12:13 PM. The final meal tray was passed to a resident on the unit at 12:39 PM and test tray temperatures were taken at that time by a New York State Department of Health Surveyor, with the Food Services Director present, using the surveyor's calibrated thermometer. The findings included:Roasted potatoes: 101.3 degrees FahrenheitHoney ham: 110.6 degrees FahrenheitCooked asparagus: 101.8 degrees FahrenheitBlack coffee: 127.3 degrees Fahrenheit During an interview on 09/09/2025 at 12:44 PM, the Food Services Director stated they did not know the food would cool down that much between setting up the trays in the kitchen and passing them to residents on the units. They stated the food was cold and it was not okay. During an interview on 09/09/2025 at 1:17 PM, Resident #12 stated food that should be hot is sometimes served cold. 10 NYCRR 415.14(d)(1) Subpart 14-1.40(a)

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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