Care Pavilion Nursing And Rehabilitation Center

F-F600.

28 Pa. Code 201.14 (a) Responsibility of licensee.

28 Pa. Code 211.12 (c) Nursing services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 32 395893 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 395893 B. Wing 02/18/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Care Pavilion Nursing and Rehabilitation Center 6212 Walnut Street Philadelphia, PA 19139

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 39343 potential for actual harm Based on observations, review of facility policies, review of facility documentation, clinical record review and Residents Affected - Few interviews with staff, it was determined that the facility failed to maintain an effective infection control program related with Enhanced Barrier Precautions for one of two residents reviewed (Residentb Resident R96).

Findings include:

Review of literature revealed that Enhanced Barrier Precautions are infection control Intervention designed to reduce the transmission of novel or Multi-Drug-Resistant Organisms. Enhanced Barrier Precautions require to employ the use of targeted personal protective equipment (PPE) during high contact patient/resident activities.

On February 18, 2025, at 11:28 a.m. review of physician order for Resident Resident R96 revealed an order dated February 12, 2025, for Enhanced Barrier Precautions: Gown and Gloves during high contact care/activities with resident, every shift for prophylaxis secondary to peg tube, and chronic wound.

Observation on February 18, 2025, at 11:39 a.m. revealed that a Licensed nurse, Employee E28, was cleaning the peg tube site of Resident R 96; but Licensed nurse, Employee E28 did not wear the PPE, even though Resident Resident R96 was on Enhanced Barrier Precautions. At the time of the finding, confirmed the same with Licnesed nurse, Employee E28.

28 Pa. Code 211.10(d) Resident care policies

28 Pa. Code 211.12(d)(1) Nursing services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 32 395893