Care Pavilion Nursing: Oxygen Safety Failures - PA
The inspection at Care Pavilion Nursing and Rehabilitation Center, completed September 11, 2025, stemmed from a complaint. Inspectors found that the facility's smoking policy had not prohibited residents on continuous oxygen from smoking. It took the investigation to change that.
On August 27, the facility revised its smoking policy to bar oxygen-dependent residents from the smoking courtyard and require that they be offered cessation alternatives instead. Staff told inspectors they already knew oxygen was not allowed in the smoking area. The written policy had not reflected that.
The gap between what staff said they knew and what the policy actually required was the problem inspectors documented. A resident on continuous oxygen had been permitted to smoke.
The facility's corrective plan required the nursing home administrator or a designee to observe five smoke breaks per week for four weeks. The director of nursing, separately, was assigned to audit five smoking residents each week over the same period, checking that oxygen use, assessments, and care plans were consistent with each other. Both sets of results were to go before the facility's monthly quality meeting.
Inspectors also found a separate breakdown in how dialysis patients were handled. Dialysis staff had not been returning residents to the nursing unit after treatment was completed. The facility ran an in-service to address it.
By the time inspectors finished their review, they determined the corrections had been made and classified the violations as past non-compliance. The harm, the inspection record notes, had already occurred.
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.
Download the official CMS inspection PDF from Medicare.gov
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 22, 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 inspection at Care Pavilion Nursing and Rehabilitation Center, completed September 11, 2025, stemmed from a complaint.
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.