Woodmont Center: Oral Hygiene Neglect Four Days - VA
The resident, identified in inspection records only as R2, was admitted to the facility with muscle weakness and scored a perfect 15 out of 15 on a standard cognitive assessment, meaning they were fully alert and capable of making their own daily decisions. Their care plan called for staff to provide setup or cleanup assistance with oral hygiene. That assistance didn't come, reliably, for the better part of a week in February 2024.
The gaps ran across shifts and days. On February 9, the evening shift was logged under a code for "personal hygiene," a different category entirely, and the night shift was marked "not applicable." On February 10, both the day shift and evening shift entries were left completely blank. The night shift that night was coded with the number for oral hygiene, suggesting the care was provided once, but not twice. February 11 looked similar: day and evening shifts blank, night shift coded as "reason for activity not occurring," though no reason was ever documented. February 12 followed the same pattern, with the night shift coded for personal hygiene and the day and evening shifts empty.
Four days. Twelve shifts. A handful of blank cells and miscoded entries where documentation of basic mouth care should have been.
An inspector reviewed those records with a certified nursing assistant on the morning of August 27, 2025, more than a year after the February 2024 entries were made. The CNA, identified as CNA #4, said without hesitation that residents should receive oral hygiene twice a day. Then she looked at R2's tracking sheet and confirmed what the records showed: R2 did not receive oral hygiene twice a day on February 9, February 10, February 11, or February 12.
That afternoon, the facility's administrator and interim director of nursing were told what inspectors had found. No further information was provided before the inspection team left the building.
The deficiency was cited at a level of minimal harm or potential for actual harm. For a resident with muscle weakness who needed staff assistance to complete oral hygiene at all, the gap wasn't a matter of preference. Oral hygiene prevents infection, reduces bacteria that can travel to the lungs, and is one of the basic daily routines a nursing home is responsible for providing when a resident cannot fully manage it alone.
What the records don't show is whether R2 knew what they were missing, whether they asked for help, or whether anyone noticed during those four days that the care wasn't being given. R2 scored a perfect cognitive score. They were aware of their surroundings and capable of making decisions. Whether that awareness extended to knowing they could push back, or to whom, the inspection report doesn't say.
The tracking sheet itself captures the problem in miniature. It existed to document care. Staff filled it in, shift after shift, with codes that didn't match, categories that didn't apply, and spaces left blank where a record of completed care should have been. The legend was there. The codes were defined. Nobody filled them in correctly for four days running, and nobody flagged it.
Woodmont Center sits on Dairy Lane in Fredericksburg. The inspection was conducted as a complaint investigation. The plan of correction, if one was submitted, was not included in the materials reviewed.
R2's four days without oral hygiene are now part of the federal record. Whether the care improved after February 12, 2024, or whether R2 is still a resident at Woodmont Center, the report does not say.
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: July 15, 2026 · Our methodology
WOODMONT CENTER in FREDERICKSBURG, VA was cited for neglect violations during a health inspection on August 27, 2025.
Their care plan called for staff to provide setup or cleanup assistance with oral hygiene.
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.