Woodmont Center: Wound Care Gap Found in Inspection - VA
The gap was small in time. Whether it was small in consequence is harder to say.
Federal inspectors who visited Woodmont Center on August 27, 2025, flagged a single deficiency involving one resident, identified in the report as Resident 7. The resident was elderly, cognitively impaired, incontinent, and at risk for skin breakdown. That risk had already materialized. A baseline care plan initiated August 11 documented bruising to the right outer forearm, right outer wrist, both inner elbows, and the left hand, along with a Stage 2 pressure ulcer to the right ischial tuberosity, the bony prominence at the base of the pelvis that bears weight when a person sits.
A Stage 2 pressure ulcer means the skin has broken open. It is not a warning sign. It is an injury.
The physician's order, also dated August 11, was specific: clean the wound with normal saline, pat dry, apply calcium alginate, cover with a dressing. Every day shift. The order was clear. The care plan backed it up.
Four days later, on August 15, there was nothing.
The electronic treatment administration record for August showed no entry for wound care that day. The progress notes offered no explanation. There was no documentation that Resident 7 had refused the treatment, no note that the wound nurse was unavailable, no record of any staff member attempting and failing to complete the task. The day simply passed without a trace.
A licensed practical nurse interviewed the afternoon before inspectors completed their visit described how the system was supposed to work. The wound nurse handled treatments on weekdays. Floor staff covered when she was absent and on weekends. Staff were supposed to mark dressings with the date before applying them and sign off in the electronic record when finished. The LPN said the care plan existed to document what the team had identified and put in place, to set goals, to prevent anything from happening.
August 15 fell on a Friday.
The LPN did not offer an explanation for the missing entry. The report notes that no further information was provided before inspectors left the building.
The nursing admission assessment, completed when Resident 7 arrived, had recorded no skin issues. By August 11, the care plan was documenting multiple bruises and an open wound. The MDS assessment, the standardized federal form that captures a resident's clinical status and drives care planning, had not been completed by the time inspectors arrived on August 27.
Inspectors classified the violation under a tag that addresses baseline care plans, specifically the requirement that facilities develop and implement individualized plans within 48 hours of admission. The harm level was rated minimal or potential for actual harm. Few residents were affected.
Those classifications reflect the regulatory framework. They do not resolve the question of what happened to Resident 7's wound on August 15.
Wound care for a Stage 2 pressure ulcer is not optional maintenance. Calcium alginate dressings manage moisture and support healing in open wounds. Missing a treatment on a pressure ulcer in a resident who is incontinent, cognitively impaired, and at elevated risk for skin breakdown is not a paperwork problem. It is a gap in the physical care of an open wound on a person who cannot reliably advocate for themselves.
The interim director of nursing and another administrative staff member were notified of the finding at 3:11 p.m. on August 27, the final day of the inspection. The report does not indicate what, if anything, they said in response.
Woodmont Center sits on Dairy Lane in Fredericksburg, a short-term and long-term care facility operating under a CMS provider number that places it within Virginia's network of federally certified nursing homes. The inspection was complaint-driven, meaning someone prompted regulators to look.
The report does not say who complained, or why.
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: August 5, 2026 · Our methodology
WOODMONT CENTER in FREDERICKSBURG, VA was cited for violations during a health inspection on August 27, 2025.
Whether it was small in consequence is harder to say.
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.