Woodmont Center: Wound Care Skipped for Bedsore Patient - VA
The resident, identified in inspection records only as R7, was admitted with a stage 2 pressure injury to the right ischial tuberosity, the bony prominence at the base of the pelvis that bears weight when a person sits. The care plan noted the resident was over 75, had impaired cognition, was incontinent, and faced risks from shear and friction. The physician had ordered wound care since August 11: clean the area with normal saline, pat dry, apply calcium alginate, cover with a dressing. Every day shift.
The treatment did not happen on August 15. The electronic treatment administration record showed no entry for that date. The progress notes showed no entry either, not a completed treatment, not a refusal.
That gap matters. A stage 2 pressure ulcer is an open wound. Skin has already broken down. Without consistent treatment, the wound can deepen.
When inspectors interviewed a licensed practical nurse at the facility on August 26, she explained how wound care was supposed to be tracked. The wound nurse handled treatments on weekdays. Floor staff covered when she wasn't there and on weekends. Staff were supposed to prove they had done the work in two ways: by dating the dressing before they applied it, and by signing off in the electronic record when finished.
On August 15, neither happened.
The care plan for R7 had been initiated the same day as the wound care order, August 11. It listed the pressure ulcer explicitly and named "provide wound treatment as ordered" as an intervention. The nursing admission assessment, completed on admission, had documented no skin issues at all, meaning the wound developed or was identified after arrival. The minimum data set assessment had not been completed by the time inspectors finished their survey on August 27.
Inspectors also noted that R7 had bruising documented across multiple sites: the right outer forearm, right outer wrist, both inner elbow creases, and the back of the left hand. Those were noted in the care plan as existing skin impairments alongside the pressure ulcer.
Administrative staff members were informed of the wound care finding on August 27 at 3:11 in the afternoon. The interim director of nursing was present. No additional information was provided before inspectors left the building.
The deficiency was cited under federal tag F0686, which covers pressure injury prevention and treatment. Inspectors rated the level of harm as minimal harm or potential for actual harm, affecting a small number of residents.
What the record cannot answer is simpler than any regulatory category: on the day R7's wound went untreated, who was responsible for that shift's wound care, and where were they.
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 2, 2026 · Our methodology
WOODMONT CENTER in FREDERICKSBURG, VA was cited for violations during a health inspection on August 27, 2025.
The care plan noted the resident was over 75, had impaired cognition, was incontinent, and faced risks from shear and friction.
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.