The Pearl Nursing Center of Rochester

Inspectors wroteBased on observations, interviews, and record review conducted during an Abbreviated Survey (Intake ID: 2655452 and NY00386123/571480) completed on 12/11/2025, for three (3) (first, second, and third floors) of three (3) resident sleeping floors, the facility did not provide maintenance services necessary to maintain a safe, comfortable, and homelike environment. Specifically: ambient temperatures were not maintained between 71 and 81 degrees Fahrenheit ( F), supplemental heating devices in resident rooms were not functional and damaged, and automatic door opening features for handicap use were not functional.

Inspectors wroteBased on interviews, and record review conducted during an Abbreviated Survey (Intake ID: NY00371613/571460) completed on 12/11/2025, the facility did not ensure services were provided to meet professional standards of quality for one (1) (Resident #1) of one (1) resident reviewed. Specifically, Resident #1 had medical orders for care of a peripherally inserted central catheter (used for long term intravenous (administered directly into the bloodstream through a vein) medication administration) and vital signs monitoring that were not documented on numerous opportunities, and the facility was unable to provide evidence these required services were completed as ordered.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interviews, and record review 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 a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one (1) (Resident #9) of three (3) residents reviewed. Specifically, Resident #9 was identified to be at risk for pressure ulcers, did not have care planned interventions in place to prevent skin breakdown, and later developed a pressure ulcer. Additionally, there was no documented evidence interventions to promote healing of the new pressure ulcer were implemented until three (3) days after the wound was first identified. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during an Abbreviated Survey (Intake ID: Complaint 2576858) conducted on 08/22/2025, it was determined for one (resident room [ROOM NUMBER]) of 72 resident rooms, the facility did not provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, and homelike environment. Specifically, there was mold and evidence of water leaks, wall, and floor damage in a resident bathroom.

Inspectors wroteBased on observations, interviews, and record review conducted during an Abbreviated Survey (NY00360750), the facility did not ensure there was a system, supported by policies and procedures, to ensure there was an adequate number of staff in the facility at all times who were properly trained and/or certified in cardiopulmonary resuscitation (CPR - life saving measures performed when the heart and or lungs cease functioning). Specifically, the facility did not maintain an updated list of staff currently certified and/or trained in Cardiopulmonary Resuscitation and did not maintain evidence of nursing staff education and training related to the facility's policy for Cardiopulmonary Resuscitation. This was evidenced by the following: [...]

Inspectors wroteBased on interviews and record review conducted during an Abbreviated Survey (NY00360750), the facility was not administered in a manner that enabled it to use its resources efficiently and effectively. Specifically, the facility did not have a system in place to monitor and maintain a list of facility staff who were currently certified in cardiopulmonary resuscitation (CPR [life saving measures performed when the heart and or lungs cease functioning]). This is evidenced by the following: The facility policy Emergency Procedure-Cardiopulmonary Resuscitation, revised February 2018, included to obtain and maintain American Red Cross or American Heart Association certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation for clinical staff members who would direct resuscitation efforts, including non-licensed staff. [...]

Inspectors wroteBased on observations and interviews conducted during the Recertification Survey, for three (first, second, and third floors) of three resident-use floors and one of one basement, the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically: exhaust ventilation was not functional, plumbing fixtures were not maintained and/or working properly, hot water temperatures were not maintained between 90 and 120 degrees Fahrenheit (°F), lighting was not functional, light lenses and covers were missing, there were cracked and damaged tiles, doors and walls were damaged, a resident room lacked a means for securing valuables, there were resident care items stored on the floor, and there was an accumulation of bugs in stairwells.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey and complaint investigation (NY00319773), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for two (Residents #30 and #42) of five residents reviewed. Specifically, the facility could not provide evidence that physician-ordered wound care treatments were provided as ordered. This is evidenced by the following: 1. Resident #30 had diagnoses including chronic ulcers of left leg, chronic obstructive pulmonary disease (COPD-disease of the lungs causing difficulty to breath), and diabetes. The Minimum Data Set Resident assessment dated [DATE] documented that Resident #30 was cognitively intact and had a skin ulcer that required a dressing. [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey for one (Resident #42) of six residents reviewed, one of one basement laundry room and nine (Resident Rooms #106, 108, 111, 120, 122, 208, 220, 306, and 307) of nine resident rooms reviewed, the facility did not ensure the environment remained free from accident hazards. Specifically, for Resident #42, who was known to vape in their room, the facility did not ensure the resident was assessed for and care planned for the use of electronic cigarettes in the facility. The basement laundry room had a significant buildup of lint behind dryers creating a fire hazard and multiple resident rooms had water temperatures above 120 degrees Fahrenheit at points of use. This is evidenced by the following: 1. [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey, for two (1st and 2nd floor units) of three residential care units reviewed, the facility did not ensure that an accurate reconciliation of all controlled substances (narcotic medications) was consistently completed. Specifically, the narcotic count logs which included reconciliation of narcotic medications at the end of each shift were not consistently signed to indicate the count had been done and the correct count of narcotic medications had been verified by two nurses. This was evidenced by the following: The facility policy Medication - Controlled Substances, dated April 2019, included that narcotics would be counted with two professional nurses and documentation that the count was completed and accurate would be completed at the beginning and end of each shift. [...]

Inspectors wroteBased on observations and interview conducted during the Recertification Survey, the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. Specifically, laundry equipment was not maintained in proper working condition.

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey, the facility did not ensure that services were provided and/or arranged for the accepted standards of quality that should have been provided for two (Residents #9 and #70) of five residents reviewed. Specifically, lab services were not provided as recommended by pharmacy and ordered by the Physician. This is evidenced by the following: When requested, the facility was unable to provide any policies related to obtaining lab work or a blood draw protocol. 1. Resident #70 had diagnoses that included dysphagia (difficulty swallowing), pneumonitis (inflammation of lung tissue), and diabetes. The Minimum Data Set Resident assessment dated [DATE] documented the resident was moderately impaired cognitively and did not exhibit behaviors or refusals of care at that time. [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey and complaint investigation (NY00313302), it was determined that for one (Resident #10) of six residents reviewed for medication administration, the facility did not ensure that the residents were free from significant medication errors. Specifically, there was no documented evidence that Resident #10 had received their antipsychotic medication (medications used to treat mental illness) on multiple days. This is evidenced by the following: Resident #10 had diagnosis that included paranoid schizophrenia (a type of mental illness), Crohn's disease (an inflammatory bowel disease), and diabetes. The Minimum Data Set Resident assessment dated [DATE] documented the resident had moderate impairment of cognitive function and no refusals of care or behaviors at that time. [...]

Inspectors wroteBased on observations and interview conducted during the Recertification Survey, it was determined that the facility did not properly dispose of garbage and refuse. Specifically, garbage and refuse were not contained within dumpsters and receptacles were not covered.

Inspectors wroteBased on observations and record review conducted during the Recertification Survey, it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances.

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey for eight (Residents #9, 22, 32, 36, 70, 78, 102, and 112) of eight residents reviewed for Baseline Care Plans, the facility did not ensure that a Baseline Care Plan summary was provided to the residents and/or resident representatives. Specifically, the facility was unable to provide evidence that a written summary of their Baseline Care Plan (developed within 48 hours of admission and included minimum healthcare information necessary to properly care for the immediate needs of the residents and that they were able to understand) had been provided to any of the residents and/or their representatives. This is evidenced by, but not limited to the following: The facility's policy, Care Plans - Baseline revised in March 2022, documented: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey, it was determined the facility did not ensure that resident-identifiable information was kept confidential. This was observed on two (second and third floor residential care units) of three units and outside the facility by the garbage receptacle. Specifically, there were several observations of empty medication blister packets (a way to package medications) with resident identifiable information on them in open bins on the units and accessible to all staff, residents, and visitors. Additionally, a medication blister packet with resident identifiable information on it was observed outside the facility on the ground next to a garbage receptable also accessible to the public. [...]

Inspectors wroteBased on interviews and record review conducted during an Abbreviated Survey (complaint #'s NY00321305, NY00322131, NY00312328), it was determined that for three of three residents reviewed, the facility failed to ensure that the residents were free from significant medication errors. Specifically, Resident #3 did not receive multiple doses of Zonisamide (anti-seizure medication) and levothyroxine (thyroid hormone replacement medication). Resident #5 did not receive multiple doses of multiple medications including but not limited to Bactrim (antibiotic), Seroquel (an antipsychotic medication) and levothyroxine. Resident #6 did not receive multiple doses of valproate (anti-seizure medication). This is evidenced by: [...]

Inspectors wroteBased on observations, interviews, and record review conducted during an Abbreviated Survey (complaint #NY00320053, #NY00321305, and #NY00322131) it was determined that for three (first, second, and third floors) of three resident use floors the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. Specifically, the telephone and fax systems were not functional or not functioning properly.

Inspectors wroteBased on observations, interview, and record review conducted during an Abbreviated Survey (complaint investigations #NY00312328, #NY00320053, #NY00321305, #NY00322131) it was determined that for two (second and third floors) of three resident use floors the facility did not properly maintain the resident call system. Specifically, the nurse call systems were not functional.?

Inspectors wroteBased on observations, interviews, and record review conducted during an Abbreviated Survey (complaints #NY00323332, #NY00322131) it was determined that for 2 (Residents #3 and #6) of 13 residents reviewed, the facility did not ensure that the residents received treatment and care in accordance with professional standards of practice and medical orders. Specifically, Resident #3 had insufficient monitoring of bowel function and a delay of treatment for complications and Resident #6 had insufficient monitoring and physician orders for bowel interventions were not followed in a timely manner. This is evidenced by the following: The facility policy Lab and Diagnostic Test Results/ Clinical Protocol Policy, revised November 2018, documented that the physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs. [...]

Inspectors wroteBased on observations, interviews and record review conducted during an Abbreviated Survey (#NY00312328), it was determined that for one (Unit two) of one unit reviewed for medication storage, the facility did not ensure that medications were properly supervised and secured. Specifically, a large number of prescription medications were unlocked and unsupervised in a resident's dresser drawer and a blister packet (28 pills) of a prescription medication was left unsecured and unsupervised on top of a medication cart with no nurse in sight. This is evidenced by the following: The facility policy Medication Storage reviewed on 1/3/23 documented that medications are stored in an orderly manner in cabinets, drawers, or carts sufficient to size to prevent crowding. All medication in medication carts and treatment carts are locked. 1. [...]

Inspectors wroteBased on observations and interviews conducted during the Standard Recertification Survey completed on 12/16/22 and complaint investigations (NY00299364, NY00269879, NY00281833, NY00282526, NY00283899, and NY00287604) it was determined that for three (first, second, and third floors) of three resident-use floors and one of one basement, the facility did not provide housekeeping or maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically: [...]

Inspectors wroteBased on record review and interview conducted during the Standard Recertification Survey completed on 12/16/22, it was determined that for five of five newly hired employees the facility did not implement written policies and procedures to prevent abuse, neglect, exploitation, and misappropriation of resident property related to screening prospective employees. Specifically, a nurse aide registry abuse screening was not completed for newly hired employees prior to starting work.

Inspectors wroteBased on interviews and record reviews conducted during the Recertification Survey, completed on 12/16/22, it was determined that for two (Resident #46 and #87) of six residents reviewed for rehabilitation services, two (Residents #13 and #57) of six residents reviewed for unnecessary medications, and the facility's Infection Control and Prevention Program, the facility did not safeguard medical record information against loss or was readily accessible. Specifically, the facility could not provide Resident #46 and Resident #87's Physical Therapy records, could not provide monthly pharmacy reviews and recommendations, if any, for Resident #13 and Resident #57 and could not provide evidence of a consistent infection prevention program or an antibiotic stewardship program. This is evidenced by the following: 1. [...]

Inspectors wroteBased on observations, interview, and record review conducted during the Standard Recertification Survey and complaint investigation #NY00283899 completed on 12/16/22, it was determined that the facility did not properly maintain the resident call system. Specifically, elements of the nurse call system were damaged and/or not functioning properly.

Inspectors wroteBased on observations, interviews, and record review conducted during the Recertification Survey, completed on 12/16/22 it was determined that for one (Resident #52) of two residents reviewed for choices, the facility did not allow each resident the right to make choices in regard to their bathing preferences consistent with their wishes. Specifically, the resident was not showered once weekly per their plan of care or stated preference. This is evidenced by the following: Resident #52 was admitted to the facility with diagnoses that included morbid obesity, cellulitis left lower limb, and heart failure. [...]

Inspectors wroteBased on interviews and record review conducted during the Recertification Survey and complaint investigation (#NY00304062 and #NY00289336) completed 12/16/22 it was determined that for one (Residents #37) of four residents reviewed, the facility did not ensure that alleged violations of abuse, mistreatment or neglect, including injuries of unknown injury and misappropriation of property were thoroughly investigated. Specifically, the facility did not initiate an investigation of the resident's missing cell phone or report the incident to the state agency. This was evidenced by the following: Resident #37 was admitted to the facility with diagnoses that included, cellulitis of the left lower leg, respiratory failure, and morbid obesity. The Minimum Data Set (MDS) Assessment, dated 10/16/22, revealed the resident was cognitively intact. [...]

Inspectors wroteBased on interviews and record review during the Recertification Survey completed on 12/16/22, the facility did not ensure written notice of the facility's bed hold policy was provided to the resident and/or the resident's representative for three (Residents #200, #57, and #64) of three residents reviewed. Specifically, there was no documented evidence a written notice of the facility's bed hold policy was provided to the resident or/or their representative upon discharge or as soon after as possible following hospitalizations.

Inspectors wroteBased on interviews, and record reviews conducted during the Recertification Survey and complaint investigations (#NY00300460), completed on 12/16/22, it was determined that for one (Resident #46) of 36 residents reviewed for Professional Standards of Quality, the facility did not ensure the services provided or arranged by the facility as outlined in the resident's Comprehensive Care Plan (CCP) met professional standards of quality. Specifically, there was lack of documentation that Resident #46's wound care treatments were administered as ordered by the medical team. This is evidenced by the following: Resident #46 had diagnoses of sepsis, gangrene (infected dead tissue) of the gallbladder, and obesity. The Minimum Data Set assessment dated [DATE], documented that Resident #46 was cognitively intact, and had a surgical wound requiring wound care. [...]

Inspectors wroteBased on observations, interviews and record review conducted during the Recertification Survey completed on 12/16/22, it was determined that the facility did not ensure that the environment remained as free of accident hazards as possible. Specifically, Resident #46 who had a history of keeping vaping materials in their room, was observed with vaping materials at bedside. Additionally, there was no evidence that any interventions had been done following the initial incident with the vaping materials. This is evidenced by the following: Resident #46 was admitted to the facility on [DATE], with diagnoses including sepsis (serious infection in the blood), gangrene (infected dead tissue) of the gallbladder, and obesity. [...]

Inspectors wroteBased on observations conducted during the Standard Recertification Survey completed 12/16/22, it was determined that the facility did not properly dispose of garbage and refuse. Specifically, garbage and refuse were not contained within dumpsters and receptacles were not covered.

Inspectors wroteBased on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigations (#NY00288521, #NY00296879, and #NY00300460), completed on 12/16/22, it was determined that for one (Resident #401) of six residents reviewed for Rehabilitation, the facility did not ensure specialized rehabilitative services were provided as ordered. Specifically, Resident #401 did not receive consistent physical therapy as ordered by a physician. This is evidenced by the following: Resident #401 was admitted to the facility on [DATE] with diagnoses of bilateral knee osteoarthritis, morbid obesity, and pulmonary embolism (blood clot in lung). The Minimum Data Set Assessment, dated 11/11/22, documented that the resident was cognitively intact. [...]

Inspectors wroteBased on observations, record review, and interview conducted during the Standard Recertification Survey completed on 12/16/22 it was determined that the facility did not ensure compliance with all applicable State codes. Specifically, the facility was not in compliance with section 915 of the 2015 edition of the International Fire Code as adopted by New York State, which requires the use of carbon monoxide detection in a building that has fuel-burning appliances.

Inspectors wroteBased on observations, interviews, and record review conducted during the Standard Recertification Survey completed on 12/16/22, it was determined that the facility did not properly maintain all essential mechanical, electrical, and resident care equipment in safe operating condition. Specifically, laundry equipment, a suction machine, and resident beds were not in proper working condition.

Inspectors wroteBased on observations and interviews during the Recertification Survey, it was determined that for three (first, second and third floors) of three resident sleeping floors and one of one basement, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. Specifically, there were dirty shower rooms, missing and stained ceiling tiles, water leaks, a dirty sit-to-stand lift, non-functioning light fixtures, a loose handrail, soiled resident items, and a broken heater cover. This is evidenced by the following: 1. Observations during the initial tour of the facility on 9/8/20 from 12:48 p.m. to 2:37 p.m. revealed the following: a. There was black, pink, and brown residue, mold, and mildew along the base of the floor and wall located in the shower stall of the third floor shower room closest to room [ROOM NUMBER]. b. [...]

Inspectors wroteBased on observations, interviews, and record reviews during the Recertification Survey, it was determined that for one (Resident #83) of one resident reviewed, the facility did not provide services with reasonable accommodation of resident's needs and preferences directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being to the extent possible. Specifically, the resident was not toileted per their preferences. This is evidenced by the following: Resident #83 has diagnoses including a stroke, depression, and heart failure. The Minimum Data Set Assessment, dated 8/19/20, revealed the resident was cognitively intact, required extensive assist of staff for toileting, and was always incontinent of bladder and bowel. [...]

Inspectors wroteBased on observations, interviews, and record reviews during the Recertification Survey, it was determined that for one (Resident #94) of one resident reviewed, the facility did not provide the treatment and services in the resident's plan of care to maintain functional ability. Specifically, the resident was not consistently ambulated by staff per the resident's individualized plan of care. This is evidenced by the following: Resident #94 had diagnoses including depression, blindness in one eye, and recent cellulitis of the right knee. The Minimum Data Set Assessment, dated 8/13/20, included that the resident had severely impaired cognition and required extensive assist of staff for ambulation. The Comprehensive Care Plan (CCP), dated as last revised on 8/14/20, and the current Certified Nursing Assistant (CNA) [NAME] included that the resident has limited physical mobility. [...]

Inspectors wroteBased on observations, interviews, and record reviews during the Recertification Survey, it was determined that for one (Resident #95) of three residents reviewed, the facility did not provide specialized care needs for the provision of respiratory care in accordance with professional standards of practice and the resident's care plan. Specifically, oxygen therapy was not provided per physician orders. This is evidenced by the following: Resident #95 was readmitted to the facility on [DATE] following an acute stay for hypoxic (low oxygen levels) respiratory failure and pulmonary hypertension. The Minimum Data Set Assessment, dated 8/13/20, revealed the resident had severely impaired cognition and was on oxygen. The hospital Discharge summary, dated [DATE], included the resident was being discharged on 5 liters of oxygen and to wean if possible. [...]