Woodmont Center: MDS Coding Error Hides Catheter - VA
The resident, identified in inspection records only as Resident 105, was admitted to Woodmont Center, an 11 Dairy Lane nursing facility, with muscle wasting, a sacral pressure ulcer, and atrial fibrillation. Hospital records showed an active urethral catheter, a 16 French with a 10cc balloon, placed specifically to protect severe wounds in the trunk and perineal area from urine exposure. The care plan dated October 20 listed the foley catheter as a focus of care, with instructions to provide skin care and encourage fluids.
None of that made it into the Medicare 5-day assessment filed with an assessment reference date of October 25. The indwelling catheter box was checked no. A second assessment, filed October 27, checked no again.
The MDS coordinator, identified in the inspection report as RN #2, reviewed the discrepancy with inspectors on November 13. Her response was direct. "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," she told them.
She offered no explanation for why it hadn't been.
The treatment administration record showed catheter care being documented starting November 11, the evening shift. A physician order entered that same day spelled out the catheter's purpose and care instructions: empty the drainage bag at least once every eight hours, or when it reached one-third to two-thirds full.
When inspectors interviewed Resident 105 on November 12, the resident said the catheter had been in place for several weeks.
The gap between what the assessments said and what the resident's body reflected wasn't subtle. The MDS assessments are the mechanism Medicare uses to determine how much a facility gets paid for a resident's care, and they're the foundation for care planning at the federal level. A catheter placed because of necrotizing infection and stage III and IV pressure ulcers isn't an incidental detail. It's a condition that shapes wound care, infection monitoring, fluid management, and nursing workload.
The same 5-day assessment that omitted the catheter recorded Resident 105 as requiring maximum assistance for bathing, transfers, dressing, and toileting, and scored the resident at 15 out of 15 on the cognitive assessment, indicating no impairment. That cognitive score meant the resident was considered capable of answering questions accurately, which made the resident's own statement to inspectors, that the catheter had been in for several weeks, carry particular weight against the paperwork.
On the afternoon of November 13, the facility's executive director, director of nursing, and a regional clinical regulatory nurse were notified of the findings. No further information was provided before inspectors left the building.
The inspection, a complaint survey, covered nine residents. Only Resident 105 was cited in connection with the assessment coding failure. Federal inspectors classified the harm level as minimal, the lowest tier on the scale.
What that classification doesn't capture is the condition that made the catheter necessary in the first place. The hospital discharge summary that Woodmont Center had in its possession described a urethral catheter placed because of stage III and IV pressure ulcers on the trunk, perineal wounds, and a necrotizing infection. That was the medical picture behind the checked box.
The box said no.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 22, 2026 · Our methodology
WOODMONT CENTER in FREDERICKSBURG, VA was cited for violations during a health inspection on August 27, 2025.
The care plan dated October 20 listed the foley catheter as a focus of care, with instructions to provide skin care and encourage fluids.
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.