Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Monumentalpostacutecare At Woodside Park during CMS and state inspections, most recent first.
Unsafe hot water temperatures were found in resident shower rooms, hand sinks, and room sinks on multiple units. Surveyors measured water temperatures above 110 degrees Fahrenheit, including readings as high as 120.7 degrees Fahrenheit, and found both boilers set at 125 degrees Fahrenheit. Staff reported that thermometers were not available in shower areas and that water was sometimes checked by hand instead of with a thermometer. Water logs reviewed by surveyors showed only temperatures under the required limit, despite the elevated readings found during observation.
Unsafe and unclean conditions were observed in multiple resident rooms and common care areas, including broken dressers, a ripped mattress, soiled privacy curtains, bent blinds, a leaking faucet, and a heating unit missing a grid with a cover coming off. One resident on a trach and feeding tube had significant dirt and debris on the nightstand, bed frame, and floor around the tube feeding pole, and another resident had no dresser or table for a lamp with broken dresser drawers.
A resident with COPD and intact cognition did not receive a prescribed Breztri inhaler because it was misplaced and documented as not available for weeks. The MAR showed repeated entries by an LPN that the inhaler was unavailable, and the record had no documentation that the physician was notified of the missed medication. The DON confirmed the inhaler had been misplaced and that staff should have notified the DON so it could be replaced.
Repeated PRN Haldol Orders Renewed Without Required Evaluation: A resident had multiple PRN orders for Haldol injection entered in successive 14-day periods, but the record contained no documentation that the attending physician or prescribing practitioner evaluated the resident for the appropriateness of continued use. The DON confirmed the order was renewed multiple times after 14 days without the required evaluation.
A resident was discharged AMA, but the record lacked documentation of discharge instructions, a capacity assessment, contact with the resident’s representative, physician notification, and notice to the State LTC Ombudsman. The deficiency was cited under resident rights requirements.
A resident with legal blindness and CVA with L hemiplegia was assessed as needing total assistance with eating, but the care plan did not address his blindness-related feeding needs. During observation, the resident requested help with lunch and was seen with food in his hands and on the tray while no staff were assisting him; an LPN stated he is typically fed his meals.
Failure to notify the physician of repeated elevated blood glucose readings for a resident with DM. The resident had standing orders for Accu Checks before meals and at bedtime, with instructions to call the physician for glucose above 350, and facility policy also required notification for hyperglycemia. The MAR showed multiple BG results over 350, but the clinical record contained no documentation that the physician was informed.
Tracheostomy care was not properly maintained for a resident with a trach. The trach tube, O2 tubing, trach collar, and stoma dressing were not dated, the trach tube was stored in a dirty container, and respiratory equipment inspection dates were overdue. An RN manager confirmed the tubing and dressing should have been dated and that the equipment was past due for inspection.
Incomplete dialysis communication was identified for a resident receiving hemodialysis and diagnosed with ESRD. The facility’s dialysis communication binder had multiple incomplete sheets, including missing nursing signatures, missing dates, and absent pre- and post-treatment summaries, and the DON confirmed the communication had been requested by the facility.
A resident with dementia, depression, and bipolar disorder did not receive timely behavioral health interventions after a psych NP recommended starting Depakote DR for mood stabilization during a risperidone dose reduction. At follow-up, the resident reported worsening depression and daily low mood, yet the psychotropic regimen remained unchanged for about a month after the initial recommendation.
A resident with a bedside refrigerator had personal food items stored without proper labeling, and the refrigerator did not have a thermometer or temperature log. The resident stated the facility did not educate him on maintaining food at safe temperatures, and the DON and Maintenance Director confirmed the findings.
Unsafe Hot Water Temperatures in Resident Bathrooms: The NHA and DON failed to manage water temperatures in resident shower rooms and hand sinks, with multiple observations showing hot water above safe levels and no thermometers available in the shower rooms. The Maintenance Director confirmed the temperatures were too high and stated the boilers were set at 125 degrees Fahrenheit instead of the expected 110 degrees Fahrenheit. Staff also reported using their hands to test water because thermometers were not available.
Staff failed to follow EBP during direct resident care. A nurse aide provided incontinence care without a gown, with the scrub top touching the bed, and later the nurse aide and an LPN provided tracheostomy care without gowns, despite a room sign indicating EBP and the resident having an indwelling tracheostomy tube.
A resident who required a two-person mechanical lift transfer was manually transferred by an LPN after the mechanical lift was found to be non-functional. The LPN did not seek an alternative battery or lift, and the manual transfer resulted in the resident sustaining a comminuted fracture of the upper arm. Staff statements and resident interviews confirmed the transfer was not performed according to the care plan, leading to actual harm.
A nurse aide reported finding a resident in a Geri chair with saturated clothing and an incorrectly sized Hoyer pad, with no documentation of recent toileting or care. The administration did not report the allegation of neglect to the State Survey Agency or conduct an investigation, despite multiple requests and facility policy requirements.
Two residents were placed at risk when staff failed to provide adequate supervision during care and did not properly secure air mattresses to beds. One resident with severe cognitive and physical impairments fell from bed when the mattress shifted during incontinence care, while another was found with an unsecured air mattress, a practice confirmed by maintenance staff.
A resident was involved in an incident in the front lobby during a family visit, but staff did not document the event in the clinical record as required by facility policy. Interviews with the Administrator and weekend supervisor confirmed the absence of documentation for this occurrence.
A resident identified as an elopement risk was able to exit the facility by breaking and climbing through a first-floor window. The resident's care plan required staff to monitor his whereabouts and display his photograph at the reception desk, but the photograph was not present as required. This failure to implement established elopement prevention measures allowed the resident to leave the facility unsupervised.
Staff did not assist several residents out of bed by the expected time, despite facility policy and resident preferences. One resident with paralysis who requires transfer assistance preferred to be in a wheelchair during the day shift but remained in bed, along with eight other residents, past the designated time.
Multiple areas of the facility were found unclean and not maintained in a homelike manner, including a common shower room with used towels and hygiene products left on the floor, resident rooms with stained ceiling tiles, water leaks, soiled linens, foul odors, and discarded personal care items. A family member also reported finding used gloves, tissues, and improperly stored dentures in a resident's room.
The facility failed to maintain smoke-resistant separation in hazardous areas across all three levels. Observations revealed that doors in the basement's Laundry and Boiler Rooms did not close and latch, soiled linen carts were stored in second-floor corridors, and the Annex Diaper Room on the first floor had unsealed door penetrations. These deficiencies were confirmed by the Facility Administrator and Maintenance Director.
The facility did not maintain its fire alarm system properly, as the fire alarm panel at the 2 B Well Nurses Station showed multiple trouble codes. This issue was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain and inspect its emergency generator system, lacking documentation for required tests and inspections. Observations revealed multiple trouble lights on the annunciator panel and inadequate emergency lighting in the generator set location, with access to the manual stop station obstructed by a locked room.
The facility failed to maintain operable egress doors with Special Locking Arrangements, as observed when one leaf of the East Annex double doors near the reception desk on the first floor did not close properly. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility did not maintain the smokeproof enclosure of a stairwell, as observed when a cleaning cart was stored under basement Stairway number 3. This was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain the kitchen suppression system according to NFPA 101 standards. Documentation review revealed the absence of records for semi-annual inspections and servicing of the system. This was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain alcohol-based hand rub dispensers according to safety regulations. An ABHR dispenser was observed mounted directly above an electrical outlet on the first floor, East, near room 124, which violates the requirement that dispensers should not be installed within 1 inch of an ignition source. This was confirmed during an interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain its sprinkler system documentation, affecting two out of four inspections. During a document review, it was found that the facility could not provide records for the First and Third Quarter sprinkler inspections conducted in the previous 12 months. This was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain smoke barrier walls free of unsealed penetrations, affecting two of four smoke compartments. Observations revealed unsealed penetrations around data wires above smoke doors near a resident room on the second floor. This issue was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain smoke-tight resistance in smoke barrier doors, as observed when the double smoke doors on the second floor, West, next to a resident room, did not close properly. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director, affecting two of the three levels in the facility.
The facility did not maintain its HVAC systems according to NFPA 101 standards, as a portable AC unit was improperly used as a permanent part of the system in the basement corridor next to Boiler Room #2. This was confirmed by the Facility Administrator and Maintenance Director.
The facility failed to maintain heating units free of combustible materials, as required by NFPA 101. Combustible materials were observed on heating units in two resident rooms, affecting two of the three facility levels. This was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility was found to have a non-GFCI outlet within 6 feet of the kitchen hand wash sink, violating safety standards for electrical systems in wet locations. This deficiency was confirmed during an interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain proper oxygen storage requirements, as observed in the second floor west nursing station medical room. The entry door lacked the required precautionary signage, and there was no signage to differentiate between "Empty" and "Full" oxygen cylinders inside the room. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
Monumental Post-Acute Care at Woodside Park was found deficient in its Emergency Preparedness Training program, lacking written policies and procedures for training all staff and volunteers. This deficiency was confirmed during a survey and an exit interview with facility leadership.
The facility was found to have unprotected structural steel columns and beams above the suspended ceiling assemblies, and pan-style ceiling diffusers lacked full 'blanket' protection. This led to the building being classified as unprotected ordinary construction, with the story height exceeding the maximum allowed for such construction by one story. The deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
The facility failed to maintain and inspect portable fire extinguishers as per NFPA 10 standards, affecting the entire facility. During a document review, it was discovered that the facility lacked an appropriate certificate for the technician conducting the annual fire extinguisher inspections. This issue was confirmed in an interview with the Facility Administrator and Maintenance Director.
The facility failed to meet food safety standards, with observations of unsanitary practices such as a bucket with soapy water on a preparation table and unlabeled food items in the refrigerator. Additionally, dishes were improperly dried with limited airflow, and hot food was placed near drying dishware, violating professional food service safety standards.
The facility failed to properly dispose of garbage and refuse, as observed during a survey of the Food Service Department. The blue dumpster was found fully open and overflowing with cardboard boxes, with additional piles of refuse on the ground around it. A follow-up observation confirmed the ongoing issue, and the FSD acknowledged the findings.
Monumental Post Acute Care at Woodside Park failed to notify the State Long-Term Care Ombudsman and a resident's representative about emergency hospital transfers. The deficiency was identified through a review of nursing notes and clinical records, revealing that the facility did not provide the required notifications in writing and in a language and manner understood by the resident's representative.
A facility failed to provide a resident's representative with the required bed hold notice during a transfer to the hospital. The resident, who had severely impaired cognition, was transferred following a seizure, but there was no documentation of the bed hold policy being communicated. The Social Services Director confirmed the absence of such documentation.
The facility inaccurately documented restraint use in the MDS for two residents. One resident was noted as having a chair that prevents rising, but was observed ambulating freely. Another resident was documented as using limb restraints, but had no restraints and no physician order for them. Staff confirmed the facility was restraint-free and the MDS was inaccurately coded.
A facility failed to update the PASRR for a resident who was newly diagnosed with Undifferentiated Schizophrenia. Initially, the resident's PASRR Level I Form indicated no need for further evaluation. However, after the new diagnosis, there was no documented evidence of a referral for a Level II PASARR evaluation, as confirmed by the Director of Social Services.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. A resident with dementia did not have a care plan for dementia care, another resident who smoked lacked a safety plan, and a resident with cancer did not have a pain management plan despite having physician orders for pain medications. These oversights were confirmed by the facility's administration.
A resident's care plan was not updated in a timely manner after a change in hospice status. Despite a physician order to discontinue hospice care, the care plan remained unchanged, contrary to facility expectations for prompt updates with major changes.
The facility failed to provide evidence of competency evaluations for licensed nurses in key areas such as medication administration and wound care. During a survey, the facility's educator admitted that the necessary documentation was not available, indicating a deficiency in ensuring nursing staff had the required skills to meet residents' care needs.
A facility failed to dispose of controlled medications for a resident in a timely manner. The resident, who was discharged against medical advice, had prescriptions for Morphine Sulfate and Lorazepam. These medications were not disposed of until 11 weeks after discharge, as confirmed by the DON. This delay constitutes a deficiency in the facility's pharmacy services.
A facility failed to maintain effective infection control by not using PPE for a resident on Enhanced Barrier Precautions. A nurse was observed cleansing a resident's G-tube site without PPE, despite the resident's room indicating the need for such precautions. This oversight was confirmed with the nurse at the time.
The facility did not meet the required minimum of 3.2 hours of direct nursing care per resident per day on four days in January 2025. Staffing hours were insufficient, with care hours ranging from 3.04 to 3.18 PPD, as confirmed by the Nursing Home Administrator.
A facility failed to create a care plan to prevent lice reinfestation for a resident with bipolar disorder. The resident experienced two lice infestations after visits with his sister, requiring treatment for himself, his roommate, and their room. Despite these incidents, no care plan was developed to prevent future infestations related to family visits or infested items. Interviews with the LNAC and DON confirmed the lack of a preventive care plan.
Unsafe Hot Water Temperatures on Resident Units
Penalty
Summary
The facility failed to ensure that hot water temperatures in resident bathrooms, shower rooms, and hand sinks were maintained at a safe level. Review of the facility policy stated that hot water outlets accessible to residents were to be controlled so the water temperature did not exceed 110 degrees Fahrenheit. During observations with the Maintenance Director, shower room and sink temperatures on multiple nursing units were measured above that limit, including 117.3 degrees Fahrenheit in one shower room, 118.2 degrees Fahrenheit at a sink and 117.8 degrees Fahrenheit in a shower on another unit, and 120.7 degrees Fahrenheit at a sink and 115.7 degrees Fahrenheit in a shower on a different unit. Additional observations of resident room hand sinks on the first and second floor units showed multiple temperatures above 110 degrees Fahrenheit, including 118.2, 117.5, 119.6, 120, 115.3, 118.7, 120.7, and 116.6 degrees Fahrenheit. The boiler room contained two domestic water storage tanks, and both boilers were observed set at 125 degrees Fahrenheit. The Maintenance Director confirmed the incoming water temperature of the boilers was high and should have been set at 110 degrees Fahrenheit. Staff interviews revealed that thermometers were not available in the shower rooms, that a nursing aide was using his hand to test water temperature, and that the unit manager stated the nursing station did not have water thermometers available for shower checks. Review of water temperature logs for November through December 3, 2025 showed no temperatures out of range, with all documented temperatures recorded as under 110 degrees Fahrenheit. The Maintenance Director stated he had turned up the boiler temperatures about one month earlier to address resident complaints that the water was too cold. Based on the observations, interviews, and documentation, the facility was cited for failing to maintain safe hot water temperatures on three nursing units, and Immediate Jeopardy was identified.
Unsafe and Unclean Resident Room Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in resident care areas on two nursing units, including the 1st floor East and 2nd floor [NAME] Nursing units. Facility policy for Physical Environment: Common Areas stated that the facility will be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel, and the public. During observations, a unit manager confirmed that room [ROOM NUMBER]B had no grid on the heating unit and the cover of the heating unit was coming off. The Maintenance Director also confirmed that room [ROOM NUMBER]B had a broken bedside dresser with broken sides, a large amount of woodchip inside the first drawer, three broken shelves with rails that were displaced and not closing appropriately, and a trashcan with no liner. Additional observations on the 2-West nursing unit found multiple environmental issues in resident rooms and support areas. In one room, the bed A mattress had a large rip along the right side and the privacy curtain was soiled; the blinds were broken and bent; the utility closet faucet was leaking; and the B-bed dresser had a front panel missing from a drawer. In another room, Resident R127, who was on a tracheostomy and feeding tube, had a bedside nightstand with significant dirt and debris on top around tracheostomy equipment, a bed frame visibly soiled with debris and tube feeding formula, and dust/debris buildup on the floor around the tube feeding pole. An RN confirmed the dirty environment in that room. In a separate room, Resident R62 had no dresser or table to support a lamp, and the dresser drawers were broken.
Unavailability of Resident Inhaler
Penalty
Summary
The facility failed to safeguard a resident’s prescribed medication when Resident R7’s Breztri Aerosphere inhaler was not available for administration. Resident R7 had a diagnosis of COPD and was documented as cognitively intact. The resident’s care plan identified a potential for inadequate respiratory function and included an intervention to provide medication as ordered. The physician order summary showed an order for Breztri Aerosphere inhalation aerosol twice daily. Resident R7 reported that the inhaler had not been received in weeks and stated that nursing staff lost it. The medication administration record showed the inhaler was first documented as not available by an LPN and then repeatedly documented as not available from November 18 through December 9, 2025. The clinical record contained no documentation that the physician was notified of the unavailable and missed medication. The DON confirmed the inhaler had been misplaced and stated that nursing staff should have notified the DON so the facility could replace it.
Repeated PRN Haldol Orders Renewed Without Required Evaluation
Penalty
Summary
The facility failed to ensure that PRN orders for an antipsychotic medication were limited to 14 days and were not renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of continued use. For Resident R10, review of October 2025 through December 2025 physician orders showed multiple PRN orders for Haldol injection 5 mg/ml, ordered intramuscularly every six hours as needed, each entered for a 14-day period. The orders included a start date of October 31, 2025 through November 14, 2025, another starting November 14, 2025 through November 28, 2025, and an order active on December 1, 2025 through December 15, 2025. Review of the record found no documentation that the attending physician or prescribing practitioner evaluated the resident for the appropriateness of continued use as required. The DON confirmed that the medication order was renewed multiple times after 14 days and that no such documentation was present.
Failure to Document AMA Discharge Notifications and Resident Rights Requirements
Penalty
Summary
The facility failed to document required discharge-related actions for Resident R166, who was discharged against medical advice. Review of the clinical record showed no documentation that staff attempted to provide discharge summaries or discharge instructions, assessed the resident’s capacity to make decisions, contacted the resident’s representative or family, or notified the physician. The record also did not contain documentation that the Office of the State Long-Term Care Ombudsman was notified of the discharge. A Social Services Director confirmed that the resident had been admitted to the facility and later discharged with AMA status, and the cited deficiency was identified under 28 Pa Code 201.29(a)(c.3)(2) resident rights.
Care plan did not address blindness and feeding assistance needs
Penalty
Summary
The facility failed to ensure the care plan was updated and revised to address a resident’s legal blindness and required assistance with eating. Review of the quarterly MDS dated November 25, 2025, showed the resident was admitted with diagnoses including legal blindness and CVA with left hemiplegia, and was dependent for most functional abilities. The assessment indicated the resident required total assistance with eating, meaning the helper performed all of the effort or the resident required two or more helpers to complete the activity. The resident’s care plan dated June 21, 2024 identified a self-care deficit requiring assistance with ADLs related to contractures, decreased mobility, decreased vision, and weakness, but it did not address the resident’s legal blindness specifically with eating. On December 10, 2025, at 12:30 PM, the resident was observed in his room with a lunch tray set up over the bed, requested assistance with his meal, and was seen with food in his hands and on the tray. At approximately 12:35 PM, an LPN stated the resident is typically fed his meals and confirmed there was no staff assisting the resident at the time of the observation.
Failure to Notify Physician of Repeated High Blood Sugars
Penalty
Summary
The facility failed to implement physician orders related to elevated blood sugars for one resident with diabetes mellitus. The resident’s annual MDS dated September 30, 2025, identified a diagnosis of diabetes mellitus, and the resident was documented as cognitively intact. The physician order summary included an order dated February 3, 2023, for Accu Checks before meals and at bedtime, with instructions to call the physician if glucose was less than 60 or greater than 350. Facility policy on Diabetic Management defined hyperglycemia as a blood glucose level greater than 300 and required physician notification when blood sugar was greater than 300, with documentation of the event and outcome in the nurse’s progress note. Review of the resident’s medication administration record showed multiple blood glucose readings greater than 350, including values of 439, 386, 423, 379, 469, 434, 383, 422, and 400 on various dates and times in November and December 2025. During an interview on December 9, 2025, the resident reported a history of elevated blood sugars, especially in the morning. Review of the entire clinical record revealed no documented evidence that the physician was made aware of the elevated blood sugars.
Tracheostomy Equipment Not Properly Maintained
Penalty
Summary
Safe and appropriate respiratory care was not provided for Resident R127, who was observed on December 9, 2025, with a tracheostomy. The tracheostomy tube was not dated to show when it was last changed, the oxygen tubing was not dated, and the tracheostomy tube was placed in a container that was dirty. The trach collar and the dressing around the stoma were also not dated to indicate when the dressing had been changed. Observation of the respiratory equipment showed that the humidifier had a last inspection date of February 14, 2020, with a next inspection due date of February 14, 2021, and the suction machine had been inspected on July 29, 2025, with the inspection due date also listed as July 29, 2025, indicating both pieces of equipment were past their inspection due dates. The unit manager confirmed that tracheostomy tubing and dressings should be dated when changed and that the tracheostomy equipment was past due for quality inspection.
Incomplete Dialysis Communication
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was deficient when the facility failed to maintain effective communication with the dialysis provider for one of two residents reviewed receiving hemodialysis. Resident R82 was admitted with a diagnosis of End Stage Renal Disease. Facility policy titled Hemodialysis stated that dialysis pre- and post-treatment summaries would be communicated to the facility. During review of the dialysis communication binder, several communication sheets for R82 were found to be incomplete, with missing nursing signatures, missing dates, and absent dialysis pre- and post-treatment summaries. The section titled Communication from Dialysis Center was not completed on multiple dates, and the DON confirmed that dialysis communication for R82 had been requested by the facility.
Delayed Behavioral Health Intervention for Resident With Bipolar Disorder and Depression
Penalty
Summary
The facility failed to timely implement behavioral health interventions for a resident with diagnoses of dementia, depression, and bipolar disease. A psychiatry note documented that the resident was being seen for evaluation and management of bipolar disease and dementia, reported mood was all right with no sadness or anxiety, and was getting out of bed more and taking walks. The psychiatric nurse practitioner noted the resident was tolerating a dose reduction of risperidone and stated that risperidone can help stabilize mood, but that a dose reduction could lead to a failed dose reduction in the absence of a mood stabilizer. The nurse practitioner recommended starting Depakote DR 125 mg PO BID for bipolar disorder and mood stabilization. At a follow-up visit, the note stated that the prior recommendation to start Depakote had not been implemented, and the resident reported feeling depressed and that it had worsened over the last couple of weeks, with feeling down at least daily. The nurse practitioner again recommended starting Depakote DR 125 mg PO BID and increasing mirtazapine for depression, but the psychotropic regimen remained unchanged until about one month after the initial recommendation.
Unsafe Storage of Personal Food Items
Penalty
Summary
The facility failed to ensure safe and sanitary storage and handling of personal food products brought in from outside sources for one resident. The facility policy stated that perishable food items provided by residents' representatives or family were to be brought to the dietary department, stored in a temperature-controlled designated area, and dated and labeled with a use-by date not to exceed 2 days. During an observation of Resident R45's room, the resident had a small refrigerator next to the bed with no thermometer inside and no thermometer log to monitor the refrigerator temperature. The resident also had two personal food containers inside the refrigerator that were not labeled, one food container on top of the refrigerator, and cheese in a Ziplock bag that was not labeled. Resident R45 stated that the facility did not educate him on how to maintain food items at safe temperatures when he obtained the refrigerator. The Maintenance Director confirmed that the refrigerator did not have a thermometer, and the DON confirmed the unlabeled food items and the lack of a thermometer.
Unsafe Hot Water Temperatures in Resident Bathrooms
Penalty
Summary
The Nursing Home Administrator and Director of Nursing failed to effectively manage the facility to ensure that hot water temperatures in resident bathroom hand sinks and shower rooms were maintained at a safe temperature. The report states that the Administrator is responsible for the overall management and operation of the facility, including resident safety, a sanitary and safe environment, and systems for resident and employee safety. The DON is responsible for overseeing nursing programs, maintaining quality assurance standards, and ensuring compliance with federal, state, and local regulations. Observations in shower rooms on the first floor East, second floor East, and second floor West found no thermometers in the shower rooms. Hot water temperatures measured in the shower rooms and hand sinks were above safe levels, including 117.3 degrees Fahrenheit in one shower room, 118.2 degrees Fahrenheit in a hand sink and 117.8 degrees Fahrenheit in the shower, and 120.7 degrees Fahrenheit in a hand sink with 115.7 degrees Fahrenheit in the shower. The Maintenance Director confirmed that the temperatures were too high and stated that the incoming water temperature of the boilers should be set at 110 degrees Fahrenheit. Additional observations of resident room hand sinks across the nursing units showed multiple elevated temperatures, including 118.2, 117.5, 119.6, 120, 115.3, 118.7, 120.7, and 116.6 degrees Fahrenheit. The boiler room contained two domestic water storage tanks, and both boilers were set at 125 degrees Fahrenheit. The Maintenance Director stated he had increased the boiler temperatures about one month earlier to address resident complaints that the water was too cold. Staff interviews also revealed that nursing aides were testing water with their hands because water thermometers were not available in the showers, and a unit manager confirmed that the nursing station did not have water thermometers available for shower water testing.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to follow the facility’s infection control practices during care for a resident with an indwelling tracheostomy tube and incontinence needs. The facility policy on Enhanced Barrier Precautions states that gown and glove use is required during high-contact resident care activities, including changing briefs or assisting with toileting and device care or use for a tracheostomy, for residents with indwelling medical devices such as tracheostomy tubes. During observation of the resident’s room, a sign outside the room indicated Enhanced Barrier Precautions. While a nurse aide was providing incontinence care, the aide was not wearing a gown, and the aide’s scrub top was observed touching the resident’s bed. During tracheostomy care shortly afterward, both the nurse aide and an LPN who were providing direct contact with the resident were not wearing gowns as required by the facility’s Enhanced Barrier Precautions policy.
Failure to Follow Transfer Protocol Results in Resident Fracture
Penalty
Summary
A resident with a history of muscle weakness and difficulty walking was care planned to require a two-person transfer using a mechanical lift for all transfers, as documented in the clinical record and care plan. On the day of the incident, nurse aides attempted to use two different mechanical lifts to transfer the resident from a wheelchair to bed, but both lifts were not functioning. The aides requested assistance from a licensed nurse, who, upon entering the room, observed the resident seated on a lift pad in the wheelchair with the non-functioning lift nearby. Due to the limited space and the lift not working, the licensed nurse decided to perform a one-person manual transfer, contrary to the resident's care plan requirements. Following the transfer, the resident reported hearing a pop in the shoulder but initially felt okay once in bed. Over the next two days, swelling and bruising developed on the resident's left upper arm and lateral breast area. The injury was reported to nursing staff, and subsequent assessments revealed pain, swelling, and discoloration. The resident consistently reported to multiple staff members that the injury occurred during a manual transfer by a male caregiver who lifted the resident under the arms because the mechanical lift was not working. An in-house x-ray was inconclusive, and the resident was sent to the emergency room, where imaging confirmed an acute comminuted fracture of the proximal left humerus. Interviews with staff confirmed that there were two mechanical lifts per floor and that extra batteries were available in the medication room. The licensed nurse involved admitted to performing the manual transfer because the lift's battery was not charged and did not attempt to locate another battery. The facility's failure to follow the resident's care plan for mechanical lift transfers resulted in actual harm, specifically a left humeral fracture, constituting neglect as defined by facility policy and regulatory requirements.
Failure to Report and Investigate Alleged Neglect
Penalty
Summary
The facility failed to report an allegation of neglect to the State Survey Agency and did not conduct an investigation as required. Specifically, a nurse aide reported via email to the Nursing Home Administrator that, at the start of a shift, a resident was found seated in a Geri chair with clothing, a Hoyer pad, and the chair itself saturated with urine. The Hoyer pad in use was not the correct size for the resident according to the care plan, and there was no documentation indicating the resident had been toileted or changed prior to the shift. This information was communicated to the facility administration, but there was no documented evidence that the incident was reported or investigated. Interviews with facility staff confirmed that the administration was not aware of any incontinence neglect related to the resident, and the personnel file for the nurse aide involved was not immediately available due to the Human Resources Director being out sick. Despite multiple requests for investigation, there was no response from administration, and no documentation was provided to show that the required reporting and investigation procedures were followed in response to the allegation of neglect.
Failure to Provide Adequate Supervision and Secure Air Mattresses
Penalty
Summary
The facility failed to provide adequate supervision and ensure that air mattresses were properly secured for two residents. One resident, who had severe cognitive impairment, muscle weakness, and a history of falls, required two-person assistance for transfers and incontinence care, as well as a mechanical lift. During routine care, two staff members were providing incontinence care when the mattress shifted, causing the resident to fall from the bed onto a floor mat, resulting in a small hematoma on the forehead. The nurse aide involved admitted to standing approximately two feet away from the bed, which created a gap that allowed the resident to fall, contrary to his training to close the gap with his body. Additionally, another resident was observed with an air mattress that was not fastened to the bed with the required six straps. The Maintenance Director confirmed that it was common practice for evening or night staff to not secure air mattresses after changing them, which could result in the mattress shifting. Both deficiencies were confirmed by staff interviews and direct observation, indicating a failure to follow facility policy and care plan interventions designed to prevent accidents and ensure resident safety.
Failure to Document Resident Incident in Clinical Record
Penalty
Summary
The facility failed to maintain complete documentation in the clinical record for one resident following an incident. According to the facility's Incident and Accidents Documentation policy, all unusual occurrences, including actual, alleged, or suspected abuse, must be documented. On August 24, 2025, an incident involving a resident occurred in the front lobby during a family visit. Staff confirmed during interviews that there was no documentation of this incident in the resident's clinical record, despite the policy requirements. This lack of documentation was verified by both the Administrator and the weekend supervisor.
Failure to Implement Elopement Prevention Measures for At-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free of potential hazards for a resident identified as being at risk for elopement. According to facility documentation, the resident was able to break a window block, kick out the screen, and exit through a first-floor window without injury. The resident subsequently left the premises and was later found at his family home by police, who returned him to the facility. The resident's care plan identified him as an elopement risk and included interventions such as staff checking on his whereabouts throughout the shift and placing his picture at the receptionist desk. Upon review, it was observed that the required photograph of the resident was not present at the reception area, as specified in both the facility's elopement policy and the resident's care plan. Staff interviews confirmed that this intervention was not implemented following the resident's elopement. The failure to follow established policies and care plan interventions contributed to the resident's ability to leave the facility unsupervised.
Failure to Accommodate Resident Preferences for Assistance Out of Bed
Penalty
Summary
Facility staff failed to reasonably accommodate the needs and preferences of nine residents regarding assistance out of bed. According to facility policy, residents' abilities in activities of daily living should not diminish unless clinically unavoidable. Observations on unit 2-West at 11:15 am found nine residents still in bed, despite at least one resident expressing a preference to be assisted into a wheelchair during the day shift. An interview with a licensed nurse confirmed that residents are to be assisted out of bed by 11:00 am, yet this was not done for the identified residents. One resident, who is paralyzed on the right side and requires assistance with transfers, specifically stated a preference to be in a wheelchair during the day shift, but was observed still in bed.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for residents in multiple areas. Observations in the common shower room revealed used towels and paper towels on the floor, shower gel and shampoo bottles left on the floor, and used hygiene products on an unclean shower bed. These findings were confirmed with the facility's director of nursing. In one resident room, a stained ceiling tile was observed near a bed, and a resident reported that water leaks through the ceiling tile and HVAC during rainy weather, with a towel placed under the HVAC to address the leak. Further observations included a resident sitting on a bed stained with feces, urine-soaked linen on the bed, a foul odor, and trash on the floor, with the resident attempting to pick up a soiled brief. In another room, a used urinal was attached to a trash bin, briefs and a washbasin were on the floor, and used washcloths and toilet paper were on the bedside table. A grievance report from a family member described finding used latex gloves, tissues, and a wet washcloth left in a resident's room, and dentures left in an unsafe location. These findings indicate a lack of adherence to facility policy regarding the maintenance of a safe and clean environment.
Deficient Smoke-Resistant Separation in Hazardous Areas
Penalty
Summary
The facility failed to ensure that hazardous areas were adequately protected with smoke-resistant separation in sprinklered locations, affecting all three levels of the building. During an observation conducted on January 22, 2022, several deficiencies were noted. On the basement level, the Maintenance and Housekeeping Laundry Room door and Boiler Room door #2 were found to be defective as they failed to close and latch properly. This failure in door functionality compromised the smoke-resistant separation required for these hazardous areas. Additionally, on the second floor, soiled linen carts filled with linen were improperly stored in the corridors, which is against the regulations for hazardous area management. On the first floor, the Annex Diaper Room was found to have multiple unsealed penetrations in the entry door, further compromising the smoke-resistant barrier. These observations were confirmed during an exit interview with the Facility Administrator and Maintenance Director, indicating a lack of maintenance in hazardous enclosures.
Plan Of Correction
Maintenance and Housekeeping Basement level laundry room doors have been repaired. Boiler rm #2 door has been repaired. Soiled linen carts have been removed. Annex Diaper Room penetrations have been sealed with an approved through-penetration fire sealant. Maintenance conducted environmental rounds throughout the facility and there were no further hazardous areas. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to 0321: Hazardous Areas. The interdisciplinary team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported on monthly QAPI.
Fire Alarm System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain its fire alarm system in proper operating condition, as evidenced by an observation on January 22, 2025. At 1:05 p.m., the fire alarm panel located at the 2 B Well Nurses Station displayed multiple trouble codes, indicating issues with the system. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director at 2:00 p.m. on the same day.
Plan Of Correction
Corrected on site. The generator company was in the facility at the same time of Life Safety Inspection. They were working on the generator, which caused the trouble codes. The Fire Alarm Panel at 2nd Floor Be Well nurses station does not have any further trouble codes. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to 0345- Fire Alarm Testing and Maintenance. Maintenance team will inspect Fire Alarm Panel weekly x 4 weeks to ensure there are no trouble codes. Results will be reported on monthly QAPI.
Failure to Maintain and Inspect Emergency Generator System
Penalty
Summary
The facility failed to maintain and inspect its emergency generator system, which is crucial for ensuring the safety and functionality of the facility during power outages. During a document review, it was found that the facility could not provide documentation for several required tests and inspections, including weekly inspections of battery electrolyte levels or voltage, a December 2024 test of battery electrolyte specific gravity or conductance, monthly 30-minute under load tests, evidence of wet-stacking, an annual 90-minute load bank test, a 3-year 4-hour load test, and an annual fuel quality test. These omissions were confirmed during an exit interview with the Facility Administrator and Maintenance Director. Additionally, observations revealed further deficiencies in the emergency generator system. The emergency generator annunciator panel, located on the second floor at the 2 B Well Nurses Station, had multiple trouble lights illuminated when tested, indicating potential issues with the system. Furthermore, the emergency generator set location on the second floor lacked battery back-up emergency lighting, and the manual stop station was located inside a locked room, obstructing access to emergency equipment. These issues were also confirmed during the exit interview with the Facility Administrator and Maintenance Director.
Plan Of Correction
The following inspections have been scheduled/ conducted for the Generator: a. Weekly Visual inspection b. Battery electrolyte levels/ or battery voltage c. Battery Electrolyte specific gravity or conductance d. Monthly 30-minute load test e. Evidence of Wet Stacking f. 3 yrs., 4 hrs. load test g. Annual 90 min. Load Bank h. Monthly Load Test i. Annual Fuel Quality test j. Monthly testing and recording of battery specific gravity or conductance testing Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to 0918 Electrical Systems- Essential Electric Systems. The maintenance Director or Designee will audit routine and periodic facility maintenance requirements monthly to ensure all are in compliance. Results will be reported in monthly QAPI.
Failure to Maintain Operable Egress Doors
Penalty
Summary
The facility failed to maintain doors with Special Locking Arrangements (SLA's) in operable condition, specifically affecting one of the three levels. During an observation on January 22, 2025, at 1:40 p.m., it was noted that the East Annex double doors near the reception desk on the first floor had a malfunction. One leaf of the door failed to close when tested, despite being equipped with a magnetic locking feature. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day at 2:00 p.m. The failure of the door to close properly indicates a lapse in maintaining the required egress door standards as outlined by NFPA 101, which mandates that doors in a required means of egress must be operable and not require a tool or key from the egress side unless specific conditions are met.
Plan Of Correction
East doors near reception desk are now functioning appropriately (SLA part replaced). All other egress doors in the facility were inspected and are functioning as designed. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to 0222: EGRESS. Maintenance Director or Designee will conduct weekly inspections on all egress doors weekly x 3 weeks to ensure all are working as designed. Results will be reported in monthly QAPI.
Failure to Maintain Smokeproof Enclosure in Stairwell
Penalty
Summary
The facility failed to maintain the smokeproof enclosure of a stairwell, specifically affecting one of the three levels. During an observation on January 22, 2025, at 1:15 p.m., it was noted that basement Stairway number 3 had a cleaning cart stored under the stairwell. This was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day at 2:00 p.m.
Plan Of Correction
Storage cleaning cart has been removed from stairway #3. Maintenance conducted rounds and there were no other items stored under any stairs. Maintenance Director or Designee will conduct in-service education for housekeeping staff on the importance of adherence to 0225: Stairways and smoke proof enclosures. The Maintenance team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported on monthly QAPI.
Failure to Maintain Kitchen Suppression System
Penalty
Summary
The facility failed to maintain the kitchen suppression system as required by NFPA 101 standards. During a document review on January 22, 2025, it was discovered that the facility could not provide documentation showing that the kitchen suppression system had been inspected and serviced on a semi-annual basis. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
The Kitchen Suppression System will be repaired on 2/6/25 and inspected prior to 3/21/25. The Maintenance Director will in-service Maintenance staff on the importance of adherence to: 0324 - Cooking Facilities. The Maintenance Director or Designee will audit routine and periodic facility maintenance requirements monthly to ensure all are in compliance. Results will be reported in Monthly QA.
Improper Placement of ABHR Dispenser
Penalty
Summary
The facility failed to maintain alcohol-based hand rub dispensers in compliance with safety regulations. During an observation on January 22, 2025, it was noted that on the first floor, East, near room 124, an alcohol-based hand rub dispenser was mounted directly above an electrical outlet. This placement does not adhere to the requirement that dispensers should not be installed within 1 inch of an ignition source. The deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
The ABHR dispensers near rm 124 has been removed. Maintenance Staff inspected all other ABHR dispensers in the facility. None are too close to receptacles/outlets. All are in compliance with the code. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to 0325: Alcohol Based Hand Rub Dispenser (ABHR). The interdisciplinary team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported on monthly QAPI.
Failure to Maintain Sprinkler System Documentation
Penalty
Summary
The facility failed to maintain its sprinkler system as required, affecting two out of four inspections. During a document review on January 22, 2025, it was discovered that the facility could not provide documentation for the First and Third Quarter sprinkler inspections conducted in the previous 12 months. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
Sprinkler inspections are up to date and documentation is available. The Maintenance Director or Designee will conduct in servicing for maintenance staff on the importance of adherence to 0353- Sprinkler System Maintenance and Testing. The Maintenance Director or Designee will audit routine and periodic facility maintenance requirements monthly to ensure all are in compliance. Results will be reported in Monthly QA.
Unsealed Penetrations in Smoke Barrier Walls
Penalty
Summary
The facility failed to maintain smoke barrier walls free of unsealed penetrations, which is a requirement for ensuring a 1/2-hour fire resistance rating. During an observation on January 22, 2025, at 12:55 p.m., it was noted that on the second floor, above the smoke doors near resident room 253, there were unsealed penetrations around data wires. This deficiency affected two of the four smoke compartments in the facility. The issue was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day at 2:00 p.m.
Plan Of Correction
The unsealed penetrations near 253 have been sealed with an approved through-penetration fire sealant. Environmental rounds have been conducted through the facility. There were no further penetrations. The Maintenance Director or Designee will conduct in servicing for maintenance staff on the importance of adherence to 0372 Subdivision of Building spaces - Smoke Barrier. The interdisciplinary team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported on monthly QAPI.
Smoke Barrier Door Deficiency
Penalty
Summary
The facility failed to maintain smoke barrier doors with smoke-tight resistance, as required by NFPA 101 standards. During an observation on January 22, 2025, at 12:30 p.m., it was noted that the double smoke doors on the second floor, West, next to resident room 227, did not close properly. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director later that day at 2:00 p.m. The issue affected two of the three levels in the facility, indicating a lapse in maintaining the required fire safety measures.
Plan Of Correction
Double smoke door near rm 227 is working as designed. It only closes if the fire alarm is activated. Environmental rounds have been conducted through the facility. There were no malfunctioning doors. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to: 0374 Subdivision of Building spaces- smoke barriers. The Maintenance team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported in monthly QAPI.
Improper Use of Portable AC in HVAC System
Penalty
Summary
The facility failed to maintain its HVAC systems in compliance with NFPA 101 standards, specifically affecting one of three levels. During an observation, it was noted that a portable air conditioning unit was ducted into the ceiling in the Maintenance and Housekeeping basement corridor, next to Boiler Room #2. This portable AC unit was confirmed by the Facility Administrator and Maintenance Director to be used as a permanent part of the HVAC system, which is not in accordance with the manufacturer's specifications or the required standards.
Plan Of Correction
Portable air conditioning unit removed from boiler rm #2. Maintenance Director conducted rounds in the facility and there were no other air conditioners installed out of compliance. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to: 0521- HVAC. The interdisciplinary team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported in monthly QAPI.
Combustible Materials on Heating Units
Penalty
Summary
The facility failed to maintain heating units free of combustible materials, which is a requirement under NFPA 101 for HVAC systems. During an observation conducted on January 22, 2025, between 12:30 p.m. and 1:15 p.m., it was noted that combustible materials were placed on top of heating units in resident rooms 240 and 108. This deficiency affected two of the three levels of the facility. The issue was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day at 2:00 p.m.
Plan Of Correction
Combustible materials removed from HVACs in 108 and 240. Maintenance Director conducted facility rounds and there were no other HVACs covered with combustible materials. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to: 0522-HVAs- Any Heating Device. The Maintenance team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported in monthly QAPI.
Non-GFCI Outlet Found Near Kitchen Sink
Penalty
Summary
The facility failed to maintain electrical systems in compliance with safety standards, specifically in wet locations. During an observation on January 22, 2025, at 2:05 p.m., it was noted that a non-GFCI outlet was installed within 6 feet of the kitchen hand wash sink. This is a violation of the requirement for ground-fault circuit interrupters (GFCI) in wet areas to ensure safety. The deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
The outlet near the kitchen hand wash sink has been replaced with an appropriate GFCI outlet. The Maintenance Director conducted facility rounds and there were no other NON-GFCI outlets located within 6 inches of a sink. The Maintenance Director or Designee will conduct in servicing for maintenance staff on the importance of adherence to: 0912- Electrical Systems - Receptacles. The Maintenance team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported in monthly QAPI.
Oxygen Storage Signage Deficiency
Penalty
Summary
The facility failed to maintain proper oxygen storage requirements on the second floor west nursing station medical room. During an observation on January 22, 2025, it was noted that the entry door to the medical room lacked the required precautionary signage. The sign should have included the wording "CAUTION: OXIDIZING GAS(ES) STORED WITHIN, NO SMOKING." This omission indicates a failure to comply with safety protocols for storing oxidizing gases. Additionally, inside the room, there was an absence of signage to differentiate between "Empty" and "Full" oxygen cylinders. This lack of proper labeling could lead to confusion and mishandling of oxygen cylinders. The deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director, who acknowledged the missing signage.
Plan Of Correction
Cautionary, (NO SMOKING), Empty, and Full signs have been placed in 2 west nsg station medical room. Maintenance Director conducted facility rounds and all other oxygen storage areas had appropriate signage. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to: 0923- Storage. The Maintenance team will conduct environmental rounds weekly x 4 weeks to ensure compliance with fire codes, and State, federal and local regulations. Results will be reported in monthly QAPI.
Deficiency in Emergency Preparedness Training Program
Penalty
Summary
Monumental Post-Acute Care at Woodside Park was found to have deficiencies in its Emergency Preparedness Training program during a survey conducted on January 22, 2025. The survey revealed that the facility failed to develop a comprehensive training program based on its emergency plan, risk assessment, policies and procedures, and communication plan. This deficiency affected the entire facility, as it did not include written policies and procedures identifying the training program for all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. The documentation reviewed during the survey indicated that the Emergency Preparedness plan lacked the necessary written policies and procedures for training. This omission was confirmed during an exit interview with the Facility Administrator and Maintenance Director. The absence of a structured training program meant that the facility did not meet the requirements set forth in 42 CFR 483.73, which mandates initial and ongoing training in emergency preparedness for all relevant personnel. The deficiency was identified through a combination of document review and interviews with facility staff. The lack of a documented training program suggests that the facility did not adequately prepare its staff and volunteers for emergency situations, potentially impacting their ability to respond effectively in such events. However, the report does not provide specific details about any incidents or patient outcomes related to this deficiency.
Plan Of Correction
MPAC has an Ep plan which includes education and training of Staff on Hire and annually. Maintenance Director and team will be re-in-serviced BY nha on MPAC Emergency Preparedness' Plan. The Maintenance Director or Designee will conduct random Drills/quizzes monthly to ensure Staff are aware of and follow MPAC EP guidelines during emergencies. Results of Random Drills will be reported in Monthly QAPI.
Building Construction Deficiency Due to Unprotected Structural Elements
Penalty
Summary
The facility failed to maintain building construction requirements, as evidenced by unprotected structural steel columns and beams above the suspended ceiling assemblies and pan-style ceiling diffusers lacking full 'blanket' protection. This resulted in the building being classified as unprotected ordinary construction. The building, classified as two stories, exceeds the maximum height allowed for unprotected ordinary construction by one story. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director.
Plan Of Correction
The facility was evaluated by an engineering firm in 2018. The evaluation determined that the building is permitted to be of Type II (000) construction, which means that the steel in the building is permitted to be non-rated and unprotected. An analysis of the facility structure type was conducted by an engineer. The analysis provided concluded that the "construction type of the two-story, sprinkler protected, existing health care building is permitted to be Type II (000)." Type II (000) is an unprotected non-combustible construction. The facility has been classified as a Type III (200), unprotected ordinary construction. A request for a Time Limited Waiver was submitted to the Director of Safety Inspection on 9/8/21, to last through 1/1/2025. The FSES worksheets will be reviewed and revised by an engineer to identify if alternative corrections will be needed. The FSES worksheets (5.5) from the 2010 edition of the NFPA Guide on Alternative approaches to Life Safety will be included in the analysis.
Failure to Maintain and Inspect Portable Fire Extinguishers
Penalty
Summary
The facility failed to maintain and inspect portable fire extinguishers in accordance with NFPA 10, affecting the entire facility. During a document review on January 22, 2025, it was found that the facility could not provide an appropriate certificate for the technician responsible for conducting the annual fire extinguisher inspections. This deficiency was confirmed during an exit interview with the Facility Administrator and Maintenance Director on the same day.
Plan Of Correction
Information Regarding the qualifications of the Tech/s conducting annual fire extinguisher inspections are available on site in the facility. Maintenance Director or Designee will conduct in servicing for maintenance staff on importance of adherence to 0355- Portable Fire Extinguishers. The maintenance Director or Designee will audit routine and periodic facility maintenance requirements monthly to ensure all are in compliance. Results will be reported in Monthly QA.
Food Safety Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations and interviews. During a tour of the main kitchen, it was noted that a bucket with soapy water and a rag was placed on the preparation table while a cook was assembling sandwiches, which is a breach of sanitary food preparation practices. Additionally, the main refrigerator contained three rolls of 10-pound ground beef, a bag of raw mixed chicken, and a bag of raw chicken thighs that were unlabeled and undated. The Food Service Director confirmed that these items had been removed from the freezer two days prior and should have been labeled with a pull date, as per the facility's policy. Further observations revealed that dishes were drying on the tray line with limited airflow, and prepared hot food was placed nearby, which is not in accordance with proper food safety standards. The drying racks, which should have been used to allow proper draining and airflow, were not utilized. These findings indicate a failure to store, prepare, distribute, and serve food in a manner that meets professional standards for food service safety, as required by the regulations.
Plan Of Correction
The Soapy water and bucket were removed immediately. The dishes were removed from the tray line. The Ground Beef and chicken have since been labeled and used. All other Food items in the kitchen have been inspected by Food Services Director and dated as appropriate. The Food Services Director or Designee will In-service dietary staff on importance of sanitation practices, using the drying rack for dishes, and labeling and dating items when pulled. The Dietary Director or designee will conduct Kitchen inspections weekly for 4 weeks to ensure compliance. Results will be reported in monthly QAPI.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as evidenced by observations made during a survey of the Food Service Department. On an initial tour, it was noted that the blue dumpster was fully open and overflowing with cardboard boxes, with additional piles of cardboard and boxes scattered on the ground around the dumpster. A follow-up observation confirmed that the situation remained unchanged, with the dumpster still overflowing and surrounded by refuse. An interview with the Food Service Director corroborated these findings, indicating a lack of proper waste management practices in the facility.
Plan Of Correction
The recycling container has since been emptied and no other trash or garbage container on facility property is overflowing. Dietary, housekeeping and maintenance staff will be in-serviced by staff the educator or designee on importance of breaking down boxes prior to dumping in the recycle bin. Dietary Director or Designee will conduct observations weekly times 4 weeks to ensure that the recycle bin not overflowing. Results will be reported in monthly QAPI.
Failure to Notify Ombudsman and Resident's Representative of Emergency Transfers
Penalty
Summary
Monumental Post Acute Care at Woodside Park was found to be non-compliant with the requirements of 42 CFR part 483, Subpart B, specifically regarding the notice requirements before transfer or discharge of residents. The facility failed to notify the Office of the State Long-Term Care Ombudsman about facility-initiated emergency transfers to the hospital for a resident. Additionally, the facility did not inform the resident's representative of the transfer and the reasons for the move in writing and in a language and manner they understand. The deficiency was identified through a review of nursing notes and clinical records for a resident who experienced a seizure and was transferred to a local hospital for evaluation. Further documentation revealed another instance where the resident was admitted to the hospital for altered mental status. Despite these transfers, there was no documentation available to indicate that the Ombudsman was notified, as required. Interviews with staff confirmed the lack of notification to both the Ombudsman and the resident's representative.
Plan Of Correction
State Long Term Care Ombudsmen have been notified of Transfers/discharge for R136. The Social Services team have been educated on the importance of adherence to regulations re: F623. All discharges, transfers, and discharges have been reviewed for the past three months. There were no further discrepancies in notification. State Long Term Care Ombudsmen will be notified of emergency transfers in writing by Social Services or designee monthly. Notification of State Long Term Care Ombudsmen will be reviewed/audited monthly for accuracy by Social Services, and the results will be reported in monthly QAPI.
Failure to Provide Bed Hold Notice During Resident Transfer
Penalty
Summary
The facility failed to provide appropriate bed hold notice to a resident's representative during a facility-initiated transfer to the hospital. This deficiency was identified for one of four residents reviewed for transfers. The resident in question, who had severely impaired cognition, was transferred to a local hospital for evaluation following a seizure. Despite the transfer, there was no documentation in the resident's clinical record indicating that the resident's representative was provided with the required written information about the duration of the state bed-hold policy. An interview with the Social Services Director confirmed the absence of documented evidence that the resident's representative was notified of the bed hold policy at the time of the transfer. The lack of documentation was corroborated by the Social Services Director, who acknowledged that no such records were available for review during the survey. This oversight is a violation of the regulatory requirements for notifying residents or their representatives about bed-hold policies during transfers.
Plan Of Correction
R136 is now aware of MPAC's bed hold policy. The Social Services team have been educated by the NHA on the importance of adherence to regulations re: F625. All discharges, transfers, and discharges have been reviewed by social services staff for the past three months. There were no further discrepancies in notification of bed hold policy. Notification of resident representatives re: facility bed hold policy will be reviewed/audited monthly for accuracy by Social Services. Results will be reported monthly in QAPI.
Inaccurate MDS Coding for Restraints
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status concerning restraints for two residents. Resident R9, who was admitted with diagnoses of schizophrenia, anxiety, and dementia, was inaccurately documented in the Minimum Data Set (MDS) as having a chair that prevents rising, used less than daily. However, observations revealed that Resident R9 was ambulating freely, and interviews with the Nursing Home Administrator and Director of Nursing confirmed that the facility was restraint-free and the MDS was coded inaccurately. Similarly, Resident R38, with diagnoses including anxiety disorder and non-Alzheimer's dementia, was documented in the MDS as using a limb restraint in a chair or out of bed, used less than daily. Observations showed that Resident R38 had no restraints, and there was no physician order for restraints. Interviews with the resident and facility staff confirmed that the resident never had any restraints, and the MDS was inaccurately coded. These inaccuracies in the MDS assessments led to the deficiency findings.
Plan Of Correction
MDS has been corrected for R9 and R38. MDS coordinators or designees will audit all current MDS's to ensure there are no further discrepancies. MDS coordinators will be in-serviced by NHA or designee on importance of assessment accuracy. MDS audits will be conducted by MDS coordinators or designees to ensure assessment accuracy monthly for 3 months, then quarterly thereafter. Results will be reported in QA.
Failure to Update PASRR Following New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to update the Pennsylvania Pre-Admission Screening Resident Review (PASRR) for a resident who was newly diagnosed with a serious mental disorder. The resident, admitted on March 4, 2021, had initial diagnoses including Acute Kidney Failure, Injury of Unspecified Body Region, and Type 2 Diabetes Mellitus. The PASRR Level I Form completed on the admission date indicated a negative screen for Serious Mental Illness, Intellectual Disability/Developmental Disability, or other related conditions, and no further evaluation was deemed necessary at that time. However, on June 4, 2021, the resident received a new diagnosis of Undifferentiated Schizophrenia, a serious mental disorder. Despite this significant change in the resident's mental health status, there was no documented evidence that the facility considered or initiated a referral for a Level II PASARR evaluation and determination. This oversight was confirmed during an interview with the Director of Social Services, indicating a failure to comply with the requirement to update the PASRR following a significant change in the resident's condition.
Plan Of Correction
R103 PASARR has been updated. Social Services staff have been educated regarding the importance of ensuring that residents who have a new schizophrenia are reevaluated for a new or updated PASARR. All residents with PASARRS have been reviewed by social services staff and all are accurate and up to date. All residents with PASARRS will be audited monthly for 3 months by social services or designee to ensure they are up to date. Results will be reported in monthly QAPI.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their specific needs. Resident R7, who was admitted with diagnoses including Type 2 Diabetes Mellitus and Dementia, did not have a care plan developed for dementia care. This was confirmed during an interview with the Nursing Home Administrator and the Director of Nursing. Similarly, Resident R28, who was observed taking smoke breaks, did not have a care plan addressing safety during smoking. The Unit Manager, Nurse Employee E14, was unaware of why a care plan for smoking was not developed. Additionally, Resident R155, who was admitted with prostate cancer and septic pulmonary embolism, was observed to be in pain without a corresponding care plan for pain management. Despite having physician orders for hospice services and pain medications, no care plan was developed to address the resident's pain related to the cancer diagnosis. This oversight was confirmed in an interview with the Nursing Home Administrator and the Director of Nursing, who acknowledged the expectation that care plans should be developed for all resident care needs.
Plan Of Correction
Care plans for R7, R28, R155 have been updated to reflect dementia, smoking, and pain management as appropriate. All residents' care plans have been reviewed and updated. Unit managers will be educated by staff development or designee on the importance of ensuring up to date and accurate care plans. Care plans will be audited by unit managers or designee monthly x 3 months then quarterly thereafter. Results will be reported in monthly QAPI.
Failure to Update Care Plan for Hospice Status Change
Penalty
Summary
The facility failed to ensure that care plans were updated in a timely manner for a resident who was receiving hospice care. The resident, who had been admitted to the facility with diagnoses including congestive heart failure, ventricular tachycardia, and the presence of a pacemaker, had a physician order on October 10, 2023, to have the pacemaker turned off due to hospice status. The care plan was updated on the same day to reflect this change. However, a subsequent physician order dated December 2, 2024, discontinued hospice care, but the care plan was not updated to reflect this change as of January 10, 2025. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed that the facility's expectations were for care plans to be reviewed and updated promptly with every major change, such as signing on to or discontinuing hospice care. It was acknowledged that the care plan for this resident had not been updated as required, leading to a deficiency in meeting the regulatory requirements for care plan timing and revision.
Plan Of Correction
The Care plan is revised as appropriate for R31. DON or designee will conduct in-service education on the importance of updated and accurate care plans. Unit managers or designees will update all residents' care plans who have pacemakers, to ensure that they reflect the resident's current pacemaker status. Care plans will be audited by unit managers or designee monthly x 3 months then quarterly thereafter. Results will be reported in monthly QAPI.
Deficiency in Nursing Staff Competency Documentation
Penalty
Summary
The facility was found to be deficient in ensuring that licensed nursing staff had the necessary competencies and skills to provide adequate care to residents. This deficiency was identified during a survey conducted on January 10, 2024, when the surveyor requested evidence of skills competency evaluations for licensed nurses. The requested competencies were related to medication administration, dementia and behavioral care, catheter and tracheostomy care, wound care, and abuse prevention and reporting. During an interview with the facility's educator, identified as Employee E12, it was revealed that the facility was unable to provide the requested documentation of skills competencies for the nurses. Employee E12 admitted that the facility did not have the necessary records to demonstrate that the nursing staff had been evaluated for the required competencies. This lack of documentation indicates a failure to ensure that the nursing staff possessed the specific skills needed to meet the residents' care needs as outlined in their individual care plans.
Plan Of Correction
Staff Educator conducted competency assessments for licensed nurses. Licensed Nurses who currently work in the facility now have skills competency evaluations for: Medication Administration, Dementia and Behaviors, Urinary Catheters, Tracheostomy care, wound Care and Abuse prevention and reporting. Staff Educator or Designee will conduct Skills competency evaluations for all licensed nurses at least annually. Staff Educator or Designee will conduct Skills competency evaluation audits Quarterly. Results will be kept on file and reported on Monthly QAPI.
Delayed Disposal of Controlled Medications
Penalty
Summary
The facility failed to ensure the timely disposal of controlled medications for a resident, identified as Resident R162, who was admitted on September 23, 2024, and discharged against medical advice on October 24, 2024. During her stay, she had prescriptions for Morphine Sulfate, a Schedule 2 controlled medication, and Lorazepam, a Schedule 4 controlled substance. These medications are known for their potential for misuse and dependence. Upon review, it was found that the controlled medications were not disposed of until January 9, 2025, which was 11 weeks after the resident's discharge. The delay in the disposal of these medications was confirmed through an interview with the Director of Nursing, Employee E2, who acknowledged that the disposal was not conducted in a timely manner. The nursing note from January 9, 2025, indicated that all medications, including the controlled substances, were counted and destroyed on that date. However, the facility's failure to dispose of these medications promptly after the resident's discharge constitutes a deficiency in their pharmacy services, as it did not comply with the requirement for timely reconciliation and disposal of controlled drugs.
Plan Of Correction
All medication for R162 have been destroyed. The Staff educator or designee will in-service all Licensed nurses on the importance of timely disposal of medications after discharge. All Medication Carts and Medication rooms were inspected by unit managers and there are no further incidents of untimely disposal of medication. Unit managers or designees will conduct audits on discharge residents weekly for 4 weeks to ensure timely disposal of medications. Results will be reported in monthly QAPI.
Infection Control Deficiency: Failure to Use PPE
Penalty
Summary
The facility failed to maintain an effective infection control program concerning Transmission Based Precautions for Resident R113. The deficiency was identified during an observation on January 10, 2025, when a Licensed Nurse, Employee E17, was seen cleansing Resident R113's G-tube site without wearing the required personal protective equipment (PPE). This was despite the fact that Resident R113 was on Enhanced Barrier Precautions, as indicated by a guiding description on the door of the resident's room. Resident R113 had a physician's order dated July 11, 2024, to cleanse the G-tube site daily with soap and water during the day shift. The failure to use PPE during this procedure was confirmed with Employee E17 at the time of the observation. Enhanced Barrier Precautions are infection control measures designed to reduce the transmission of novel or Multi-Drug Resistant Organisms, requiring the use of targeted PPE during high-contact activities.
Plan Of Correction
PPE is now worn for high contact activities with R113. All residents who are on Enhanced Barrier precautions have been reviewed by DON/ educator. PPE is available on the unit for all residents who require use during high contact activities. Licensed nurses will be in-serviced by the educator or designee on the importance of wearing PPE for high contact activities with residents who are on Enhanced Barrier Precautions. Staff educators or designee will conduct random audits during resident care weekly times 4 weeks to ensure PPE is being used appropriately. Results will be reported in monthly QAPI.
Failure to Meet Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident per day on four specific days in January 2025. A review of nursing staffing hours revealed that on January 3, 2025, the facility provided 509 care hours for 164 residents, resulting in 3.1 hours per patient day (PPD). On January 4, 2025, 502 care hours were provided for 165 residents, totaling 3.04 PPD. On January 5, 2025, 524.5 care hours were provided for 165 residents, resulting in 3.18 PPD. On January 6, 2025, 507.5 care hours were provided for 161 residents, totaling 3.15 PPD. These staffing levels were confirmed by the Nursing Home Administrator, Employee E1, as not meeting the required minimums.
Plan Of Correction
The multidisciplinary team has reviewed the dates: January 3rd, 4th, 5th, and 6th. There were no resident negative outcomes as a result of substandard staffing on those days. DON or designee will calculate PPD daily for accuracy prior to the start of the day. Daily PPD will be documented and kept on file for ongoing review and reporting. DON or designee will review all PPDs for the past 3 months to ensure none were below the current required minimum of 3.2. Results will be reported in Monthly QAPI.
Failure to Implement Lice Prevention Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan to prevent reinfestation of lice for a resident diagnosed with bipolar disorder. The resident, who was admitted to the facility with this diagnosis, experienced two separate incidents of lice infestation after visits with his sister. On both occasions, the resident returned to the facility with lice, necessitating treatment for himself, his roommate, and their room and clothing. Despite these incidents, the resident's care plan did not include measures to prevent further lice infestations related to family visits or infested items being brought into the facility. Interviews with the LNAC and the Director of Nursing confirmed the absence of such a care plan, highlighting a deficiency in addressing the resident's specific needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Philadelphia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Inglis House | 0.5 mi | ★★★★★ | 7 | 0 |
| Simpson House Inc | 0.5 mi | ★★★★★ | 2 | 0 |
| Kearsley Rehabilitation And Nursing Center | 0.7 mi | ★★★★★ | 1 | 0 |
| Aristacare At East Falls | 1.6 mi | ★★★★★ | 10 | 0 |
| Centennial Healthcare And Rehabilitation Center | 1.8 mi | ★★★★★ | 25 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.