Health inspection·November 4, 2025

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, facility policies and facility documentation, and interview with staff, it was determined the facility failed to ensure Resident R1 was free of neglect which resulted in actual harm to Resident R1 who was transferred from chair to bed without the use of a mechanical lift and sustained a left humeral fracture for one of five residents reviewed. (Resident R1) Findings include: Review of an undated facility policy titled, Abuse Policy, revealed It is the policy of the facility to protect its residents from mistreatment, neglect, abuse, misappropriation of resident property and exploitation, and that all reports of abuse will be reported to the appropriate agencies and thoroughly investigated. The policy further defined neglect as the failure of the facility, its employees or service providers to provide goods and services necessary to avoid physical harm. Review of the clinical record for Resident R1 revealed the resident had been admitted to the facility on [DATE], with diagnoses including muscle weakness and difficulty walking. Further review of Resident R1's clinical record revealed a care plan initiated on September 14, 2018, indicating the resident required the assistance of two staff for incontinent care, toileting, turning, moving up in bed and transfers with 2-persons transfer using a mechanical lift. Review of Resident R1's October 7, 2025, quarterly MDS (Minimum Data Set- comprehensive resident assessment) revealed the resident was totally dependent on the assistance of two or more staff for a chair to bed transfer. The resident was assessed with a BIMS (Brief Interview of Mental Status) of 14 which indicated the resident was cognitively intact. Review of information submitted to the State Survey Agency on October 24, 2025, revealed, on Sunday, October 19, 2025, at 1:52 p.m. it was reported Resident R1 was observed with swelling and bruising to (her/his) left upper arm and left lateral breast area. When asked about the bruises Resident R1 reported it happened sometime Friday, October 17, 2025, during a one-person transfer by male staff later identified as Licensed nurse, Employee E4, who worked on the unit that day. Resident R1 went on to say that during the transfer (she/he) felt a pop in (her/his) shoulder but felt ok once (she/he) was lying in bed. Two days later, on Sunday the swelling and bruising was noted to the left side of the resident's body and the physician was notified and ordered an in-house x-ray of the left side which was inconclusive. Resident R1 was sent out to the emergency room (ER) for detailed radiologic studies which showed the resident sustained a comminuted fracture (broken bone with multiple pieces, usually caused by severe trauma) of the proximal left humerus (proximal humerus fracture is when the top part of the upper arm bone, which is shaped like a ball, is broken. It may also be referred to as a shoulder fracture). The report further revealed Licensed nurse, Employee E4 did not follow Resident R1's plan of care for transfers which was for two-person transfer using a mechanical lift. Review of facility documentation, revealed statement from nurse aide, Employee E5, which indicated, she was on duty on the second floor on October 17, 2025, and caring for Resident R1 on the evening shift. She and another nurse aide were preparing to put Resident R1 to bed Page 1 of 3 396076 396076 11/04/2025 Monumentalpostacutecare at Woodside Park 4001 Ford Road Philadelphia, PA 19131

F 0600 Level of Harm - Actual harm Residents Affected - Few and had tried two mechanical full body lifts, which were not working, and asked the Licensed nurse, Employee E4, for help. Review of Licensed nurse, Employee E4's statement revealed that he was the charge nurse on duty on the second floor on October 17, 2025, when around 8:00 p.m. the nurse aide, Employee E5, asked him for assistance putting Resident R1 back to bed. The statement indicated when I entered [Resident R1's] room I saw that [she/he] was sitting on the lift pad in [his/her] wheelchair next to the bed with the lift next to [her/him], but the lift was not working. The space between the wheelchair and the bed was small, so I decided to quickly transfer [him/her] to the bed using a one-person lift. Review of Licensed nurse, Employee E7's written statement indicated she was on duty on the 11:00 p.m. to 7:00 a.m. shift on October 17, 2025, on the second floor. Licensed nurse, Employee E7 indicated Resident R1's son had come out of the resident's room and requested more pain medication. She told Resident R1 that (she/he) had to wait six hours until [he/she] could have more medication and that Resident R1 indicated that [she/he] did have pain in [her/his] left arm when touched but that it was not bruised at the time. Review of nurse aide, Employee E8's written statement indicated that he was caring for Resident R1 in resident's room on the morning of October 19, 2025, when he noticed that the resident's left arm was swollen when he was washing the resident. Resident R1 told him that the injury happened when a male caregiver had picked [her/him] up under [his/her] arms and put [her/him] in bed because the lift was not working. Nurse aide, Employee E8 reported the swelling to the charge nurse. Review of Licensed nurse, Employee E9, written statement revealed that she was the charge nurse on the 7:00 a.m. to 3:00 p.m. shift on October 19, 2025, when nurse aide, Employee E8 reported to her that Resident R1 had swelling on [her/his] left upper arm. Licensed nurse, Employee E9's assessment of Resident R1 revealed the resident complained of pain from [her/his] left upper arm to [her/his] shoulder, and there was visible bruising to [her/his] bicep and left lateral breast. The statement also indicated that Resident R1 stated that it had happened during a transfer. Review of written statement of Nurse Supervisor, Employee E10, on duty on October 19, 2025, when the charge nurse called her to assess Resident R1. She noted redness, swelling and pain and asked the charge nurse to call the physician to obtain an x-ray. She further noted that the order was obtained for the x-ray and to continue current pain management that was in place. Review of the statement from Unit Manager, Employee E11, on October 20, 2025, revealed that she interviewed and assessed Resident R1 noting swelling and discoloration under the resident's left armpit and under (his/her) left arm. Resident R1 told her that a male caregiver was transferring (her/him) by lifting (her/his) into (her/his) bed because he said that the mechanical lift was not working. Unit Manager, Employee E11 notified maintenance about the lift and Resident R1 was sent out to the emergency room for evaluation. Review of the Social Work Director, Employee E6, interview of Resident R1 on October 20, 2025, revealed that Resident R1 remembered a male caregiver wrapping his arms around (her/him) and lifting (her/him). Resident R1 stated that is when the resident heard a crack and pain to the left side from (her/him) arm to (her/his) shoulder. Social Work Director, Employee E6 observed resident's left arm appeared to be swollen from above elbow to (her/his) shoulder. Review of Resident R1's CT (computed tomography scan- medical image use to create detail cross sectional images of the inside of the body) scan of the left shoulder dated October 20, 2025, revealed an acute comminuted left proximal humeral fracture. Interview with Licensed nurse, Employee E12, revealed that there were two mechanical lifts on each floor, one on each unit, and that the extra batteries were kept in the med-room on the charger. She further stated that the 11:00 p.m. to 7:00 a.m. staff switch the batteries each morning before the day shift comes on duty. Interview with Employee E1, Nursing Home Administrator (NHA), on November 3, 2025, at approximately 1:15 p.m. confirmed that when she interviewed Licensed nurse, 396076 Page 2 of 3 396076 11/04/2025 Monumentalpostacutecare at Woodside Park 4001 Ford Road Philadelphia, PA 19131

F 0600 Level of Harm - Actual harm Residents Affected - Few Employee E4 he admitted that he performed a one-person transfer of Resident R1 on October 17, 2025, at around 8:00 p.m. And that he was upset and tearful, stating that during the transfer he felt it did not feel right. Telephone interview with Licensed nurse, Employee E4, at 7:45 p.m. on November 4, 2025, confirmed that he was asked for help by nurse aide, Employee E5, to put Resident R1 back to bed because the mechanical lift was not working, and that he decided to perform a one-person lift because the resident's wheelchair was close to the bed, and that he understood that this usually calls for at least two-person lift. Licensed nurse, Employee E4 further stated that Resident R1 was not his resident but he was just trying to help, and that the lift was not working due to the battery not being charged, and that he did not look for another battery. The facility failed to ensure that Resident R1 was free of neglect which resulted in actual harm to Resident R1 who was transfer from chair to bed without the use of a mechanical lift as care plan and sustained a left humeral fracture. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 201.18(b)(3) Management 28 Pa. Code 201.29(c) Resident rights 28 Pa. Code 211.10(d) Resident care policies 28 Pa. Code 211.12(c) Nursing services 396076 Page 3 of 3