Woodmont Center: Failed to Notify Family of Missing Med - VA
Woodmont Center on Dairy Lane violated federal requirements to immediately inform families of situations affecting their loved ones' care, according to a Centers for Medicare & Medicaid Services inspection report completed August 27.
The violation involved Resident #8, who was admitted with a left foot infection requiring Daptomycin, a powerful antibiotic used to treat serious bacterial infections. The physician ordered 500 milligrams of the medication to be administered intravenously every other day for 23 days to treat what medical records described as "left foot gangreen."
On August 15, the day the treatment was supposed to begin, pharmacy staff told nurses the medication would not be delivered until the next run. The electronic medication record showed "HD" — meaning "Hold/See Nurse Note" — for that day's scheduled dose.
A nurse documented in progress notes that the pharmacy would deliver Daptomycin on the next run and that the nurse practitioner was aware of the delay. But nowhere in the nursing notes for August 15 or 16 did staff document notifying the resident's responsible party about the medication being unavailable.
The resident had been assessed as alert with only some forgetfulness, according to clinical admission records from August 14.
When inspectors interviewed Licensed Practical Nurse #1 on August 26, she described the facility's standard procedure when ordered medications aren't available. Staff should call the pharmacy to determine the status, notify the nurse practitioner or physician, and notify the responsible party, she said. All of these notifications should be documented in progress notes.
After reviewing the nursing notes for Resident #8's Daptomycin situation, the nurse told inspectors she could not locate documentation showing the responsible party had been notified.
Inspectors also checked the facility's backup pharmacy inventory system. No Daptomycin was listed.
The facility's own policy requires immediate notification of patients and their representatives when there's "a need to alter treatment significantly" — including situations requiring discontinuation or changes to existing treatment due to adverse consequences, or when starting new treatments.
Daptomycin treats certain blood infections and serious skin infections caused by bacteria, according to medical information cited in the inspection report. Gangrene involves the death of body tissues.
The inspection was conducted in response to a complaint. Inspectors reviewed clinical records for 10 current residents and found the notification failure affected one resident.
Federal regulations require nursing homes to immediately tell residents, their doctors, and family members about situations that affect the resident's condition, including injuries, declines, or changes in treatment plans.
The violation was classified as causing minimal harm or potential for actual harm to few residents.
During the exit conference on August 27, administrators including the facility administrator and interim director of nursing were informed of the findings. The administrative staff member, administrator, and interim director of nursing provided no additional information before inspectors concluded their review.
The timing of the medication delay coincided with the start of what was intended to be a 23-day treatment course for a serious infection. Foot gangrene represents a potentially limb-threatening condition that typically requires prompt antibiotic intervention.
Woodmont Center's failure extended beyond the missing medication itself to the breakdown in family communication protocols. The facility had established procedures requiring notification of responsible parties when medications aren't available, but staff didn't follow them.
The licensed practical nurse who described the notification procedures to inspectors acknowledged she couldn't find any documentation showing the family had been contacted about the Daptomycin delay.
Federal oversight of nursing home notification requirements stems from recognition that families need timely information to make informed decisions about their loved ones' care. When facilities fail to communicate treatment delays or changes, families lose the opportunity to advocate for alternative arrangements or seek additional medical opinions.
The inspection found that while clinical staff properly documented the medication delay and informed the nurse practitioner, they stopped short of completing the required family notification. This created a gap between the facility's written policies and actual practice.
Resident #8's case illustrates how administrative oversights can affect medical treatment continuity. The resident required every-other-day dosing of a specialized antibiotic, making timing crucial for maintaining therapeutic levels in treating the foot infection.
The facility operates under federal regulations that mandate immediate notification not just for emergencies, but for any situation affecting residents' treatment plans. These requirements recognize that family members serve as important advocates and decision-makers in nursing home care.
Inspectors conducted their review as part of a complaint investigation, examining documentation from the facility's electronic medication administration records, nursing progress notes, and pharmacy inventory systems. The systematic review revealed the notification gap despite otherwise documented clinical awareness of the medication delay.
The violation adds to ongoing federal scrutiny of nursing home communication practices. Facilities must balance clinical care delivery with family engagement requirements, ensuring that administrative protocols don't fall through cracks during day-to-day operations.
Woodmont Center's interim director of nursing position suggests recent leadership changes that may have contributed to policy implementation gaps. The facility will need to demonstrate corrected procedures for medication delay notifications as part of its plan of correction submitted to state survey agencies.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodmont Center from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WOODMONT CENTER in FREDERICKSBURG, VA was cited for violations during a health inspection on August 27, 2025.
The electronic medication record showed "HD" — meaning "Hold/See Nurse Note" — for that day's scheduled dose.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.