Care Pavilion Nursing: False Wound Records 10 Days - PA
Nobody caught it for a week and a half.
The documentation began around November 2, 2025, and continued without interruption through November 11. Each entry described the same routine: the wound was being monitored, the treatment was in place, the resident was being repositioned. The entries were consistent. They were also wrong.
It was not until November 12, at 2:00 in the afternoon, that the Director of Nursing confirmed to inspectors what the resident's skin actually showed: no open areas, no wound requiring treatment, no reason for any of the documented interventions. When an inspector observed the resident directly the following day, November 13 at noon, the finding was the same. The gluteal area was intact.
The nursing home had not simply failed to catch an error in one note, or two. Staff had produced ten days of continuous clinical documentation describing the assessment, treatment, and repositioning of a wound that a physician had never ordered treatment for, because there was nothing to treat.
What makes the record worse is what the facility did alongside the false wound entries. Care Pavilion developed a formal care plan for Resident R6's fictitious left gluteal fold wound. Care plans are supposed to reflect a resident's actual clinical condition and drive the care they receive. This one was built around something that did not exist. And it went further than simply documenting the nonexistent wound: the care plan attributed problems with the resident's care to the resident. It noted non-compliance with turning and repositioning, refusal of showers, refusal of care.
The Director of Nursing, in her interview with inspectors, confirmed that the nursing progress notes told a different story entirely. The ongoing staff documentation showed the resident was being turned and repositioned, bathed, and cared for, with no noted non-compliance. The care plan blamed the resident for refusing the very interventions that nursing staff were simultaneously documenting as completed.
Those two records cannot both be true.
The inspection was a complaint survey, meaning someone had raised a concern that prompted investigators to come. The deficiency was cited at a level of minimal harm or potential for actual harm, and inspectors noted that some residents were affected. The citation references Pennsylvania nursing services regulations.
The clinical stakes of inaccurate wound documentation are not abstract. Pressure ulcers are among the most closely tracked conditions in long-term care because they develop fast, worsen fast, and can become life-threatening. When a wound is charted as present and worsening, clinical teams escalate. When a wound is charted as healing, they monitor and maintain. When there is no wound and staff are charting one anyway, the record that exists to protect the resident becomes noise, or worse, a document that misrepresents what is actually happening to that person's body.
For Resident R6, the immediate physical consequence appears to have been limited. The skin was intact when inspectors looked. But the resident also now has a care plan in their file documenting non-compliance with care and refusal of treatment, built on a wound that was never there, describing behavior that the facility's own nursing notes contradict.
That document does not disappear when the inspection ends.
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 2025-11-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 2, 2026 · Our methodology
CARE PAVILION NURSING AND REHABILITATION CENTER in PHILADELPHIA, PA was cited for violations during a health inspection on November 13, 2025.
Nobody caught it for a week and a half.
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.