Monumental Post-Acute Care: Neglect Report Buried - PA
That sequence of events, reconstructed from inspection records and the aide's own email, sits at the center of a complaint inspection conducted September 4, 2025 at Monumental Post-Acute Care at Woodside Park, a nursing facility at 4001 Ford Road in Philadelphia. Federal surveyors found that the facility failed to investigate the aide's allegation of neglect and failed to report it to Pennsylvania's State Survey Agency, as required. The resident at the center of it, identified in inspection records as Resident R2, had been left in that condition long enough that the urine had soaked through all layers of clothing and through the Hoyer pad, a piece of lift equipment the aide noted was the wrong size for the resident's weight according to their own care plan. There was no documentation that anyone had toileted or changed Resident R2 before the aide's shift began.
The aide, identified in inspection records as Employee E14, sent her email to the nursing home administrator on August 23, 2025, at 5:53 in the evening. Her account was precise. Resident R2 was seated in a Geri chair. The clothing and the Hoyer pad were saturated with urine. The urine had soaked through all layers and into the chair. The Hoyer pad was a size not recommended for the resident's weight per the care plan. There was no indication or documentation that the resident had been toileted or changed before the start of her shift.
The facility's own incident and accident documentation policy, though undated, stated clearly that actual, alleged, or suspected neglect warranted an incident report. The email from Employee E14 described exactly that.
Nobody at the administration level appears to have done anything with it.
Surveyors sent two emails to the facility on September 4, the day of the inspection, requesting documentation of an investigation into the allegation. One went out at 2:29 in the afternoon. A follow-up went at 4:01. No response came back from administration. When surveyors interviewed the administrator, identified as Employee E1, at 2:45 that afternoon, the administrator said the facility was not aware of any incontinence neglect involving Resident R2. The administrator also told surveyors that the Human Resources Director, Employee E11, was out sick, and that the personnel file for Employee E14 could not be produced that day. It would be emailed the next morning, the administrator said.
It was. And when surveyors reviewed that file on September 5, Employee E14's email was in it, dated August 23, describing in detail what she had found. The allegation had been sitting in the administrator's inbox for nearly two weeks before inspectors arrived. There was no documented investigation. No report to the state. No record that anyone had looked into whether Resident R2 had been neglected.
Employee E14 had been terminated on August 29, 2025, six days after she sent that email.
The inspection report does not state the reason for the termination. It does not connect the firing explicitly to the email. What it establishes is the timeline: the aide reported what she saw, received no response, and was gone from the facility within a week.
The facility's policy on incident documentation listed neglect alongside abuse, sexual harassment, assault, and physical harm as occurrences that required a report. The policy language covered "actual, alleged, or suspected" neglect, meaning the threshold for triggering a report was not a confirmed finding but the allegation itself. Employee E14's email cleared that bar the evening of August 23. The facility had it. They did not act on it.
Surveyors cited the facility under three sections of Pennsylvania administrative code governing licensee responsibility, management, and resident rights. The deficiency was classified as causing minimal harm or potential for actual harm, and the inspection identified the problem as affecting few residents, with nine reviewed in total.
The classification of "minimal harm" in federal inspection language refers to the regulatory finding, not necessarily to what Resident R2 experienced. The inspection record does not describe the resident's medical condition, their cognitive state, or how long they had been sitting in the saturated chair before Employee E14 arrived for her shift. What it documents is that the urine had soaked through all layers of clothing, through the Hoyer pad, and into the chair itself, and that there was no record of anyone having addressed the resident's needs before the aide walked in.
The wrong-sized Hoyer pad is a detail that runs through the aide's account and did not generate a separate finding in the inspection report, but it carries weight. A Hoyer lift is used to transfer residents who cannot move themselves, typically people with significant mobility limitations. The pad is the piece of equipment that supports the resident's body during the transfer. Using a pad not sized for the resident's weight, according to the care plan that the facility itself had written, points to a breakdown that preceded the afternoon of August 23.
The administrator's statement that the facility was "not aware of any incontinence neglect" with respect to Resident R2 was made on September 4, nearly two weeks after Employee E14's email arrived. Whether that unawareness was genuine or whether the email had been read and set aside, the inspection record does not resolve. What it resolves is that no investigation was opened, no report went to the state, and the aide who raised the concern was no longer employed there.
Monumental Post-Acute Care at Woodside Park is a facility on Ford Road in the Wynnefield section of Philadelphia. The inspection was a complaint survey, meaning it was triggered by a report filed with regulators, not a routine visit. The complaint that prompted the inspection is not described in the publicly available findings.
The inspection record ends where the regulatory documentation ends: a finding of deficiency, a citation, a note that a plan of correction would be required for continued program participation. It does not describe what happened to Resident R2 after Employee E14 left the facility, or whether anyone went back to check on them in the days that followed, or whether the aide who sent the email at 5:53 on a Saturday evening ever learned that the report she filed had been sitting in an inbox for twelve days before anyone from the outside came to ask about it.
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.
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
MONUMENTALPOSTACUTECARE AT WOODSIDE PARK in PHILADELPHIA, PA was cited for neglect violations during a health inspection on September 4, 2025.
There was no documentation that anyone had toileted or changed Resident R2 before the aide's shift began.
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.