Care Pavilion Nursing: O2 Smoking Safety Failure - PA
Care Pavilion Nursing and Rehabilitation Center, a nursing and rehabilitation facility in Philadelphia, was cited following a complaint inspection completed in late August 2025. The deficiency was tagged at the actual harm level, meaning inspectors determined residents were hurt, not merely placed at risk.
The core failure was straightforward: residents on continuous supplemental oxygen were being permitted to smoke. Oxygen accelerates combustion. A lit cigarette near a flowing oxygen source can flash into a fire that moves faster than a person in a wheelchair or hospital bed can escape. The facility's own revised policy, written after the inspection, acknowledged the danger plainly enough to prohibit it going forward.
That the policy needed to be written at all was the problem.
Inspectors also found a separate breakdown involving dialysis. Residents who finished dialysis treatment were being allowed to leave on their own before a facility staff member arrived to transport them back to their nursing unit. Dialysis patients are often physically depleted after treatment, their blood pressure unstable, their balance compromised. The facility's correction required dialysis staff to hold residents at the treatment area until a nursing unit employee came to retrieve them. That process, too, had apparently not existed in a reliable form before inspectors arrived.
The facility's plan of correction, submitted to regulators, laid out a series of steps taken in the days following the inspection. Smoking monitors were retrained on safety protocols and a new attendance and safety check sheet was created for each smoke break, specifically to flag whether any resident was using oxygen before lighting up. The revised smoking policy drew a hard line: residents on continuous oxygen would not be permitted to smoke at all and would instead be offered smoking cessation alternatives.
A new security attendant safety check form was also put in place for residents who leave the facility on independent passes, a process that had apparently operated without consistent documentation. Facility administrators scheduled five smoke break observations per week for four weeks, with results to be reviewed at the monthly quality meeting. The director of nursing was assigned to audit five smoking residents per week over the same period, checking that assessments, care plans, and oxygen use were properly documented.
The plan described interviews with staff after the corrections were implemented. Those staff, inspectors noted, were knowledgeable about the no-oxygen rule in the smoking courtyard by the time the review concluded. That knowledge, the record suggests, was not reliably in place before.
The deficiency was cited under Pennsylvania licensing code covering licensee responsibility and facility management.
What the inspection report does not say is how many residents were affected before the policy changed, what form the actual harm took, or how long the facility had been operating without the safeguards it put in place after the complaint was filed. The cited level of harm, actual harm affecting a few residents, is the regulatory language. What that meant for the people sitting in the smoking courtyard with oxygen tubing running to their nose is not described in the record.
The correction was marked as past non-compliance, meaning inspectors reviewed the facility's documentation and determined the fixes had been implemented. Audits were ongoing.
Care Pavilion now has a policy that says residents on continuous oxygen cannot smoke. It has a form to check for oxygen use before each smoke break. It has a process to make sure dialysis patients are not left to find their own way back from treatment.
Those are the things it did not have before someone filed a complaint.
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 deficiency was tagged at the actual harm level, meaning inspectors determined residents were hurt, not merely placed at risk.
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.