Care Pavilion Nursing Home: Elopement Safety Failure - PA
The incident, captured on video, was the subject of a complaint inspection completed September 11, 2025 at the facility on Walnut Street in West Philadelphia.
The resident, identified in inspection records as Resident R2, had been formally assessed for elopement risk twice within a two-week span. On August 5, 2025, evaluators determined she was not at risk. Fourteen days later, on August 19, that assessment changed. A new evaluation marked her as an elopement risk and directed nursing staff to implement interventions "as appropriate" until the facility's interdisciplinary team could review her case and make final decisions.
No interventions were ever added to her care plan.
Inspectors found that her care plan contained nothing to address the elopement risk identified in the August 19 evaluation, no response to the volume of foot traffic at the facility's front desk and main entrance, and no provisions for positioning enough staff to monitor who was coming and going. The front entrance, inspectors noted, was a specific concern given how the resident left.
She walked out. The video showed it. She came back 28 minutes later through a rear entrance.
When inspectors tried to piece together what had happened and why no protections had been put in place, they ran into a wall of unavailability. Resident R2 herself could not be interviewed because of cognitive impairment. Employee E4, a receptionist who would have been positioned near the front entrance, was not available for a face-to-face interview. When inspectors called her by telephone at 3:12 p.m. on September 9, she did not answer. Employee E5 was also not available in person. Inspectors called at 3:14 p.m. that same afternoon. No answer.
Both staff members who might have explained what oversight, if any, existed at the front desk that day were unreachable.
On September 10, the administrator and the Director of Nursing sat down with inspectors. They confirmed what the records already showed: the care plan had no elopement interventions. No one disputed the findings.
The gap between the August 19 risk assessment and the elopement itself represents the core of what inspectors documented. The facility had the information it needed. A nurse had been directed to act on it. The interdisciplinary team was supposed to follow. Neither step produced anything that made it into the resident's care plan before she walked out the door.
Care plans at nursing facilities are meant to be living documents, updated when a resident's condition or risk profile changes. An elopement risk assessment that concludes a resident needs protection but generates no corresponding plan entries is, in effect, a warning that went nowhere.
Resident R2 was cognitively impaired, unable to explain to inspectors what she experienced during those 28 minutes, where she went, or what she encountered before finding her way back through the rear of the building. The inspection report does not say whether she was found outside by staff, whether she returned on her own, or whether anyone at the facility knew she was gone before she reappeared.
The deficiency was cited at a level of minimal harm or potential for actual harm. That classification reflects what was documented, not what could have happened on a different day, in different weather, on a block where a cognitively impaired woman was outside and unaccounted for while the people responsible for watching the front entrance did not pick up their phones.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Care Pavilion Nursing and Rehabilitation Center from 2025-09-11 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 29, 2026 · Our methodology
CARE PAVILION NURSING AND REHABILITATION CENTER in PHILADELPHIA, PA was cited for violations during a health inspection on September 11, 2025.
The incident, captured on video, was the subject of a complaint inspection completed September 11, 2025 at the facility on Walnut Street in West Philadelphia.
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.