Health inspection·May 15, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on the review of clinical records, review of facility policy, staff interviews, it was determined that the facility failed to provide adequate supervision and failed to maintain an environment free of potential hazards for one resident with elopement risk (Resident R14). One of four residents reviewed. (Resident R1) Findings include: Review of undated facility policy Resident Elopement Follow-Up Procedure, revealed that Guidelines: After an elopement,. The following actions will be initiated: 1) A photograph will be taken and placed at the reception desk identifying the resident as an elopement risk. 2) The receptionist will be familiarized with the resident. 3) Elopement Risk will be added to resident's Care Plan. 4) An elopement assessment will be conducted for residents on incident and at least quarterly thereafter. 5) If a president is no longer an elopement risk, he/she will be reassessed and care [plan will be updated as appropriate. The facility strives to prevent resident/patient elopement. The facility also recognizes mobility as a strength to be supported and promoted. Review of facility documentation dated May 01, 2025, revealed that during routine rounds, it was discovered that resident was not in his room. His room was located on the first floor, the resident had broken the window block, kicked out the screen and squeezed through the window. Resident was able to walk off without injury due to the room window being on the first floor and close to the ground. Resident R1 was found at his family home by police, and the police returned the resident (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 396076 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 396076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Monumentalpostacutecare at Woodside Park 4001 Ford Road Philadelphia, PA 19131 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)