Monumental Post Acute Care at Woodside Park: Records Failure - PA
The incident involved Resident R9. The facility's own policies listed the categories of events serious enough to require an incident report, a list that included abuse in its many forms, allegations of assault, and any unusual occurrence or event. Whatever took place in that lobby on a Sunday evening qualified, at minimum, as an unusual occurrence. The weekend supervisor, identified in inspection records as Employee E13, was the one who responded to the situation. She later confirmed to inspectors that nothing about it had been entered into Resident R9's clinical record.
The inspection was a complaint investigation, meaning someone had already raised a concern before the September 4 visit. Inspectors reviewed nine resident records in total. Only one was found to have this problem. That resident was R9.
When inspectors sat down with the administrator and Employee E13 that afternoon, at 2:35 p.m., the answer they got was straightforward: no documentation existed. Not a nursing note. Not an incident report. Not a supervisor's summary. The weekend supervisor confirmed it herself.
The facility's incident and accident documentation policy, which inspectors noted was undated, laid out the categories of events that require a written record. The list was specific. Actual, alleged, or suspected abuse. Verbal abuse, oral, written, or gestured. Sexual abuse. Harassment, coercion, assault. Physical abuse, including hitting, slapping, pinching, kicking, pushing, pulling, rough handling. The policy language covered a wide range of possible events, and the facility had apparently agreed, by adopting that policy, that all of them warranted documentation.
What the policy did not have was a date. There is no way to know, from the inspection record, when the facility wrote it, whether it had been revised, or whether staff had been trained on it recently.
The gap between what the policy required and what actually happened in R9's record is the core of what inspectors cited. The facility failed to maintain complete documentation of a resident's clinical record. One resident, nine reviewed, one gap, and that gap was an entire incident involving a family visit in the front lobby of the building.
Inspectors classified the level of harm as minimal harm or potential for actual harm. That classification sits at the lower end of the federal scale, below the thresholds that trigger immediate jeopardy findings or widespread harm designations. It means inspectors did not find evidence that R9 was physically hurt as a direct result of the missing paperwork. What it does not mean is that nothing happened. It means the harm from the documentation failure itself, the absence of a record, was assessed as minimal or potential. What occurred in the lobby remains, in the clinical record, as if it never happened at all.
Documentation in a nursing home is not a bureaucratic formality. A resident's clinical record is the primary tool through which care is tracked, patterns are identified, and concerns are escalated. When an incident goes unrecorded, the next nurse to care for R9 has no way of knowing something occurred. A physician reviewing the chart sees nothing. A family member who later asks what happened during that visit has no facility record to reference. If R9's condition changed in the days following August 24, there would be no documented baseline from which to measure that change.
The facility cited three sections of Pennsylvania state code in connection with the finding. The first, 28 Pa. Code 201.14, addresses the responsibility of the licensee. The second, 201.18, addresses management. The third, 201.29, addresses resident rights. The inclusion of the resident rights citation is notable. Incomplete clinical records are not only a management failure. Under Pennsylvania's framework, they are also a rights issue, because residents are entitled to have their care and the events affecting them accurately reflected in their records.
The complaint inspection covered four pages of findings. This documentation failure appeared on the final page. The inspection record does not describe what else inspectors examined or whether other deficiencies were cited in the pages that preceded this one. What is clear is that this finding stood alone as the documented outcome of the complaint that triggered the visit.
The administrator, Employee E1, was present for the interview. The record does not indicate that either the administrator or the weekend supervisor offered an explanation for why no documentation had been created. Employee E13 confirmed the gap. The administrator was present when that confirmation was given. The record stops there.
Resident R9 had a family visit on August 24. Something happened. The person responsible for responding to it was the weekend supervisor. She responded. And then, for eleven days, the clinical record reflected nothing. A resident's file, which is supposed to be a complete account of their care and the events of their life inside that facility, had a blank where an incident report should have been.
The inspection closed on September 4, 2025. The lobby incident was ten days in the past by then, the paperwork gap already more than a week old. What R9's family understood about what had been documented, or not documented, about that evening is not reflected in the inspection record. What R9 understood is not reflected either.
What is reflected is a single line from the weekend supervisor: there was no documentation in Resident R9's clinical record regarding the incident. She was the one who had been there. She confirmed it herself.
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: 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 25, 2026 · Our methodology
MONUMENTALPOSTACUTECARE AT WOODSIDE PARK in PHILADELPHIA, PA was cited for violations during a health inspection on September 4, 2025.
The incident involved Resident R9.
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.