Woodmont Center: False Assessment Records - VA
Woodmont Center failed to accurately assess Resident 105, who was admitted with muscle wasting, a sacral pressure ulcer, and atrial fibrillation. The facility's Medicare assessment dated November 8 incorrectly coded that the resident did not have an indwelling catheter, contradicting extensive documentation proving otherwise.
The resident's comprehensive care plan from October 20 explicitly stated: "Resident has foley catheter." It included specific interventions for catheter care, instructing staff to provide skin care and encourage fluid intake.
Multiple hospital records confirmed the catheter's presence. The discharge summary noted "urethral catheter" as an active line. A hospital admission report from October 27 documented "Patient with Foley." Another discharge summary specified the catheter was a "16 FR due to stage III/IV pressure ulcers on trunk, perineal wounds, necrotizing infection."
The facility's own physician examination on October 20 recorded: "Has a new Foley catheter and continue with outpatient nephrology follow-up as planned."
Treatment records showed staff had been providing indwelling catheter care every day and evening shift starting November 11. Physician orders from that same date specified an "Indwelling catheter 16 FR with 10 cc balloon" and instructed staff to "Empty catheter drainage bag at least once every eight hours."
When inspectors interviewed the resident on November 12, they confirmed the obvious discrepancy. "My catheter has been in for several weeks," the resident told them.
The next day, inspectors confronted RN #2, the facility's MDS coordinator responsible for the assessments. When shown the care plan documenting the catheter and the contradictory assessment coding, she immediately acknowledged the error.
"Yes, I should have checked 'yes' on the 10/25/25 MDS Section H, since it was on the care plan, on the hospital discharge summary and in the physician note," RN #2 told inspectors. She said the facility follows the RAI manual as their standard for assessments.
The assessment error wasn't limited to one document. Two separate Medicare assessments on October 25 and October 27 both incorrectly coded that Resident 105 did not have an indwelling catheter, despite the mounting evidence in medical records.
Federal assessment guidelines are explicit about catheter documentation. The Resident Assessment Instrument requires facilities to examine residents for urinary appliances and review medical records for current or past use. The coding instructions state facilities must check "yes" for any appliance used at any time in the past seven days.
The inspection revealed a pattern of inattention to basic assessment accuracy. While the resident scored perfectly on cognitive testing, indicating no mental impairment, they required maximum assistance for bathing, transferring, dressing, and toileting, and needed supervision for eating.
Accurate MDS assessments determine Medicare reimbursement rates and care planning. When facilities underreport medical devices like catheters, it can affect both payment calculations and the development of appropriate care plans for residents' complex medical needs.
The resident's condition required significant medical intervention. Hospital records showed the catheter was necessary due to severe pressure ulcers and necrotizing infection. The facility's care plan recognized this, instructing staff to provide specialized skin care and monitor fluid intake specifically because of the catheter.
Yet the same facility's official assessments told a different story, one that ignored weeks of documented catheter care and the resident's own confirmation of the device's presence.
Three facility administrators were notified of the assessment failures on November 13: the executive director, director of nursing, and regional clinical regulatory nurse. The inspection report notes that no additional information was provided before inspectors completed their review.
Resident 105 remains at Woodmont Center with ongoing medical needs that require accurate documentation and appropriate care planning. The catheter that the facility failed to acknowledge in official assessments continues to require the daily care that staff had been providing all along.
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.
Woodmont Center failed to accurately assess Resident 105, who was admitted with muscle wasting, a sacral pressure ulcer, and atrial fibrillation.
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.