Care Pavilion Nursing And Rehabilitation Center

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

minutes later at 5:30 P.M. through an entrance at the rear of the facility. The incident was recorded, and we could see the events that led to the resident exit. On September 9, 2025, at 12:02 p.m., tried to interview Resident Resident R2, in her room. Resident Resident R2 was cognitively not able to answer the questions. On September 9, 2025, Employee E4 was not available for face-to-face interview. On September 9, 2025, at 3:12p.m., attempted to interview Receptionist, Employee E4 over telephone, Employee E4 did not answer the telephone call. On September 9, 2025, Employee E5 was not available for face-to-face interview. On September 9, 2025, at 3:14p.m., tried to interview Employee E5 over telephone, Employee E5 did not attend the telephone call. Review of Elopement Risk Evaluation dated August 5, 2025, for Resident Resident R2, indicated that the resident was not at risk for elopement at that time. Review of Elopement Risk Evaluation dated August 19, 2025, for Resident R2, indicated Resident Resident R2 was at risk for elopement at that time. Elopement Risk Evaluation dated August 19, 2025, directed for intervention as; nurse should implement interventions as appropriate until IDT (interdisciplinary team) reviews for final decisions. Review of Resident Resident R2's care plan failed did not include interventions to prevent elopement, based on the elopement risk assessment,

the traffic of the facility at the front desk/main entrance, and the need for positioning of sufficient number of staff overseeing front desk or main entrance traffic. On September 10, 2025, at 1:30 p.m., during an

interview with the Administrator, and the Director of Nursing, confirmed the above findings. 28 Pa Code 211.10 (c)(d) Resident care policies28 Pa Code 211.12(d)(1)(3)(5) Nursing services

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

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 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

completed - 8/27/25Re-direction was completed with smoking monitors on smoking safety and updated smoking policy. - date completed- 8/27/25Dialysis staff educated regarding process for returning residents to nursing unit when the complete dialysis and not to allow resident to leave until a facility staff member comes to transport them back to their nursing unit. -9/5/25A new attendance sheet/safety check sheet was implemented with smoking monitors for each smoke break to ensure there are no safety concerns such as O2 use before initiating smoking. - 8/28/25Facility smoking times and schedules were reviewed for assigning units/times in an effort to decrease volume of resident at one time. -8/27/25A new Security Attendant safety check form and process was implemented for resident who leave the facility on independent LOAs. - 8/27/25Facility smoking policy was reviewed and revised to include resident that are

on continuous O2 will not be permitted to smoke and will be offered smoking cessation alternatives. -8/27/25NHA or designee will complete 5 smoke break observations per week x4 weeks. Results will be reviewed during facilities monthly QAPI meeting to determine further need for auditing. -8/29/25DON or designee will complete weekly audits of 5 residents that smoke to ensure assessment, care plan and O2 use is assessed and care planned x4 weeks. Results will be reviewed during facilities monthly QAPI meeting to determine further need for auditing. -8/29/25 Review was conducted of clinical records, facility documentation, staff education, and facility audits. Residents and visitors smoking rules were revised and staff education completed. Interview with staff revealed that the staff was knowledgeable about the facility's rules of no oxygen allowed in the smoking courtyard. Dialysis staff were in-serviced related to returning residents to nursing unit once dialysis treatment was completed. It was determined that the plan of correction was implemented and identified as past non-compliance. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management

Event ID:

Facility ID:

If continuation sheet