Woodmont Center: Fall Care Plan Failures Flagged - VA
That finding sits at the center of a complaint inspection completed at Woodmont Center, an 11 Dairy Lane facility in Fredericksburg, on August 27, 2025. Inspectors reviewed multiple falls involving residents and found the same gap each time: the care plans were never reviewed and never revised to reflect what had happened or what should happen next.
The resident whose fall drew the most detailed documentation had sustained an injury to his left intercostal area, the tissue between the ribs. He also had a contracture in his left lower leg, a condition in which the joint stiffens and loses range of motion. Inspectors noted his alertness was at his baseline and that his doctor had been reached and ordered neurological checks, with instructions to call back if anything changed. The responsible party and the director of nursing were both told.
What followed, according to inspectors, was nothing. The care plan was not reviewed. It was not revised. There was no documentation showing anyone had gone back to the plan that was supposed to guide his care and updated it to account for the fall, the rib injury, or the monitoring orders the doctor had put in place.
The acting director of nursing, identified in the report as Administrative Staff Member 2, did not dispute any of it. When inspectors sat down with her on the morning of August 27 and walked through the falls and the care plans one by one, she confirmed what they had found. There was no evidence, she said, that the care plans had been reviewed and revised for these falls.
The word "these" is doing significant work in that sentence. The inspection report refers to multiple falls, plural, and the acting director of nursing's acknowledgment covered them collectively. This was not a single oversight on a single bad shift. Inspectors found a pattern.
Care plans in a nursing home are not paperwork for paperwork's sake. They are the document that tells every nurse, aide, and therapist who walks into a resident's room what that person's risks are, what precautions are in place, and what to watch for. When a resident falls, the plan is supposed to be revisited: Was there a contributing factor that wasn't previously identified? Does the fall risk level need to change? Are there new interventions, new monitoring requirements, new instructions for staff? A plan that hasn't been updated after a fall is a plan that still describes a resident as he was before he got hurt.
For the resident with the rib injury, that gap is not abstract. He had a doctor's order for neurological checks following the fall. Whether that order made it into his care plan, and whether staff consulting the plan would have known to carry it out, is exactly the kind of question an updated care plan is supposed to answer.
The administrator, identified as Administrative Staff Member 1, was notified of the findings along with the acting director of nursing at 3:11 in the afternoon on the day of the inspection. The report notes that no further information was provided before inspectors left the building.
The inspection was conducted in response to a complaint. The report does not identify who filed it or what the original allegation was.
Woodmont Center received a deficiency citation for the care plan failures. The level of harm was listed as minimal harm or potential for actual harm, and the citation noted that some residents were affected.
The resident with the rib injury and the leg contracture had people who knew what happened to him: his doctor, his responsible party, the director of nursing. The phone calls were made. The orders were issued. On paper, the system worked. What didn't happen was the quieter, less visible work of going back to the document that governs his daily care and making sure it reflected the person he was after the fall, not before it.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 2, 2026 · Our methodology
WOODMONT CENTER in FREDERICKSBURG, VA was cited for violations during a health inspection on August 27, 2025.
That finding sits at the center of a complaint inspection completed at Woodmont Center, an 11 Dairy Lane facility in Fredericksburg, on August 27, 2025.
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.