Monumental Post-Acute Care Woodside Park: Neglect Unreported - PA
The sequence of events came to light during a complaint inspection on September 4, 2025, when state surveyors arrived at the facility on Ford Road and began asking questions the administration could not answer.
The aide, identified in inspection records as Employee E14, sent the email on August 23, 2025, at 5:53 in the evening. The message was addressed directly to the nursing home administrator. In it, the aide described arriving for a second shift and finding the resident, identified as Resident R2, already seated in the Geri chair. The resident's clothing was saturated with urine. The Hoyer pad beneath the resident was saturated. The urine had soaked through all layers of clothing and through the pad itself, and the chair was wet. The aide noted that the Hoyer pad in use was not the size recommended by the resident's care plan for their weight. There was no indication, and no documentation, that anyone had toileted or changed the resident before the shift began.
That email sat with the administration.
On August 29, 2025, Employee E14 was terminated.
When inspectors arrived on September 4 and asked about incontinence neglect involving Resident R2, the administrator, identified as Employee E1, said the facility was not aware of any such allegation. The Human Resources Director, Employee E11, was out sick that day, and the administrator told surveyors the facility could not produce the personnel file for the terminated aide. Employee E1 said the file would be forwarded by email the following morning.
It was only then, on September 5, 2025, when inspectors reviewed the file they had been promised, that the August 23 email surfaced. Inside the personnel file of a fired employee was a written neglect report that had been sitting unaddressed for nearly two weeks.
The same day inspectors reviewed that file, they sent two requests to the facility, at 2:29 p.m. and again at 4:01 p.m., asking for documentation of any investigation into the allegation. No response came back.
There was no documented investigation. There was no report to the State Survey Agency. The inspection record is unambiguous on both points.
The facility's own incident and accident documentation policy, which was undated, states that the facility will document unusual occurrences and events, and lists among the occurrences that warrant an incident report any actual, alleged, or suspected abuse, including neglect. The policy exists. The allegation existed in writing. The connection was never made, or was made and ignored.
What the aide described is not ambiguous. A resident seated in a Geri chair with urine soaked through their clothing, through a pad, and into the chair itself is not a borderline situation requiring interpretation. It is a resident who was left wet long enough for moisture to saturate multiple layers and reach the furniture. The aide also flagged that the Hoyer pad in use was the wrong size for the resident's weight, a detail documented in the care plan, which means the mismatch was not a matter of staff discretion. Someone had selected equipment that the care plan indicated was not appropriate.
None of that prompted an investigation.
The inspection finding was cited under F0609, which addresses a facility's obligation to report suspected abuse, neglect, or theft to the State Survey Agency and to investigate the allegation. The level of harm was assessed as minimal harm or potential for actual harm, and the deficiency was noted to affect few residents. The citation does not address what happened to Resident R2 as a result of being left in that condition, because that is not what this particular citation measures. It measures whether the facility did what it was required to do after someone told them about it in writing. The facility did not.
The administrator's initial response to inspectors, that the facility was not aware of any incontinence neglect, deserves to sit with that timeline. The email was sent August 23. The aide was terminated August 29. Inspectors arrived September 4. The administrator said the facility was unaware. The email was in the personnel file of the employee who had just been fired.
Whether the administrator had read the email before inspectors arrived is not something the inspection report resolves. What the report does establish is that no investigation was opened, no report was filed with the state, and the first time the facility produced the document was when surveyors specifically requested the terminated aide's personnel file during a complaint inspection.
The inspection covered nine residents in total. The neglect allegation involving Resident R2 was the finding that generated the citation.
Monumental Post-Acute Care at Woodside Park is located at 4001 Ford Road in Philadelphia. The complaint inspection was completed September 4, 2025.
The aide who wrote the email, who described in specific terms what they found when they arrived for a second shift on an August afternoon, and who sent that email to the person responsible for running the facility, was no longer employed there by the time inspectors showed up to ask about it. What happened to Resident R2, who was found sitting in a urine-soaked chair with the wrong equipment beneath them, is not something the inspection record addresses beyond the moment the aide walked in and found them there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monumentalpostacutecare At Woodside Park from 2025-09-04 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: July 1, 2026 · Our methodology
MONUMENTALPOSTACUTECARE AT WOODSIDE PARK in PHILADELPHIA, PA was cited for neglect violations during a health inspection on September 4, 2025.
The aide, identified in inspection records as Employee E14, sent the email on August 23, 2025, at 5:53 in the evening.
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.