Woodmont Center: Fall Prevention Failures Cause Harm - VA
Federal inspectors who arrived at the facility on August 27, 2025 found the gap in black and white. A review of the resident's clinical record, covering nurses' notes from August 3 through August 25, turned up no evidence that staff had responded to the fall with any protective measures. Not a monitoring schedule. Not a toileting plan. Not a single documented effort to keep it from happening again.
The inspection was triggered by a complaint.
The resident, identified in inspection records only as Resident 9, had already been assessed as someone who needed a care plan in place. That plan existed on paper. What it did not contain, after a documented fall, was any updated response to the fall itself.
When inspectors interviewed a licensed practical nurse at the facility on August 26, the nurse described exactly what should have happened. After a resident falls, the LPN said, staff should implement interventions including monitoring, keeping the resident occupied, and toileting the resident to reduce the chance of another fall. The nurse laid out the standard. The records showed none of it had been done.
The gap between what the nurse described and what the records showed was the finding. Inspectors classified the deficiency as causing actual harm.
The administrator and the interim director of nursing were informed of the violation on August 27 at 3:12 in the afternoon, in the final hours of the inspection. No additional information was provided before inspectors left the building.
Falls are among the most serious and most preventable injuries in nursing home settings. For older adults, a single fall can mean a broken hip, a head injury, a hospitalization, or a cascade of complications that never fully resolve. The clinical logic behind post-fall intervention is straightforward: a resident who has fallen once is at elevated risk of falling again, and the window immediately following a fall is when targeted responses matter most.
Woodmont Center's own nurse articulated that logic without prompting. The problem was not a knowledge gap. Staff knew what should be done. The records simply showed it had not been done for Resident 9.
The care plan dated February 12 remained the operative document for more than six months. After the August 3 fall, three weeks passed before inspectors arrived. In that time, nurses' notes documented the incident and continued through August 25. None of them reflected a change in approach, an added safeguard, or a revised plan.
The facility is located at 11 Dairy Lane in Fredericksburg. The inspection was completed August 27, 2025.
What the record does not show is whether Resident 9 fell again.
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.
Federal inspectors who arrived at the facility on August 27, 2025 found the gap in black and white.
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.