Woodmont Center

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Based on observation, resident interview, and facility document review, it was determined that facility staff failed to promote resident's dignity for one of 10 residents in the survey sample, Resident #8 (Resident R8). The findings include:For Resident R8, the facility staff failed to provide privacy for the catheter collection bag. Resident R8 was admitted to the facility with diagnoses that included but were not limited to urinary retention (1). The admission MDS (minimum data set) was not due at the time of the survey. The facility's Clinical Admission assessment for Resident R8 dated 08/14/2025 documented in part, Level of cognitive impairment: b. alert (some forgetfulness). On 08/25/2025 at approximately 3:47 p.m. observation of the catheter collection bag hanging

on lower portion of bed uncovered. Further observation revealed the contents of the collection bag could clearly be seen. On 08/27/2025 at approximately 7:45 p.m. observation of the catheter collection bag hanging on lower portion of bed uncovered. Further observation revealed the contents of the collection bag could clearly be seen. The physician's order for Resident R8 documented, Indwelling catheter 16FR (French) with 10cc (cubic centimeter) balloon to bedside straight drainage for diagnosis/Hx (history) of urinary retention.

Order Date Date:8/14/2025. On 08/27/2025 at approximately 9:15 a.m. an interview was conducted with Resident R8. When asked how he felt about the catheter collect bag not being covered and that the urine could be seen by anyone walking into his room, he stated that it bothered him that the urine could be seen by anyone coming into his room. The facility's policy Resident Rights Under Federal Law documented in part,

1. 1. Resident Rights. The resident has a right to a dignified existence, self-determination, andcommunication

with and access to persons and services inside and outside the facility:1.1. The facility must treat each resident with respect and dignity and care for each residentin a manner and in an environment that promotes maintenance or enhancement of his/herquality of life, recognizing each resident's individuality. On 08/27/2025 at approximately 3:10 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, interim director of nursing, were made aware of the above findings. No further information was provided prior to exit. References:(1) A condition where your bladder doesn't empty all the way or at all when you urinate. This information was obtained from the website: https://my.clevelandclinic.org/health/disease/15427-urinary-retention.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodmont Center

11 Dairy Lane Fredericksburg, VA 22405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558

Reasonably accommodate the needs and preferences of each resident.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, resident interview, and staff interview, the facility staff failed to provide accommodation of needs for one of ten residents in the survey sample, Resident #6 (Resident R6). The findings include:For Resident #6 (Resident R6), the facility staff failed to maintain the resident's call bell within reach. On 8/25/25 at 3:37 p.m., Resident R6 was observed lying in bed. The resident stated staff answer the call bell, but this can only happen when the call bell is within reach. Resident R6 further stated the call bell is not always within her reach. At this time, Resident R6's call bell was observed on the floor, out of the resident's reach. On 8/25/25 at 3:41 p.m., an interview was conducted with LPN (licensed practical nurse) #1. LPN #1 stated that when a resident is in bed, the call bell should be placed next to him or her or clipped on him or her, so the call bell is within the resident's reach. Resident R6's call bell was observed with LPN #1. LPN #1 stated the call bell was not within Resident R6's reach. On 8/26/25 at 4:08 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the interim director of nursing) were made aware of the above concern. No further information was presented prior to exit.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodmont Center

11 Dairy Lane Fredericksburg, VA 22405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Based on staff interview, clinical record review and facility document review, the facility staff failed to notify

the responsible party as required for one of 10 current residents in the survey sample, Resident #8 (Resident R8).

The findings include:The findings include: For Resident R8, facility staff failed to notify the responsible party (RP) that medication, Daptomycin (1), was not available for administration on 08/15/2025. Resident R8 was admitted to the facility with diagnoses that included but were not limited to left foot infection. The admission MDS (minimum data set) was not due at the time of the survey. The facility's Clinical Admission assessment for Resident R8 dated 08/14/2025 documented in part, Level of cognitive impairment: b. alert (some forgetfulness). The physician's order for Resident R8 documented in part, Daptomycin Intravenous Solution Reconstituted 500 MG (milligram) (Daptomycin). Use 10 ml (milliliter) intravenously (into a vein) one time a day every other day for left foot gangreen [sic] (2) for 23 Days. Order Date Date:8/15/2025. The EMAR (electronic medication administration record) for Resident R8 dated August 2025 documented the physician's order as stated above. Further review of the eMAR revealed it was coded HD on 08/15/2025 for Daptomycin. The Chart Codes / Follow Up Codes on

the eMAR documented in part, HD=Hold/See Nurse Note. The facility's nurse's note for Resident R8 dated 08/15/2025 documented, Daptomycin Intravenous Solution Reconstituted 500 MG. Use 10 ml intravenously one time a day every other day for left foot gangreen [sic] for 23 days, per pharmacy it will be delivered next run np (nurse practitioner) (Name of NP) aware. Review of the facility's nurse's notes for Resident R8 dated 08/15/2025 through 08/16/2025 failed to evidence documentation of Resident R8's responsible party being notified of

the Daptomycin not being available on 08/15/2025. Review of the facility back up pharmacy system inventory list failed to evidence Daptomycin. On 08/26/2025 at approximately 1:54 p.m. LPN (licensed practical nurse) #1. When asked to describe the procedure when a physician ordered medication is not available for a resident she stated that the pharmacy is called to find out the status of the medication such as a problem with the scrip or a delay in sending the medication, notify the nurse practitioner or physician regarding the status of the medication and notify the responsible party. She further stated that the status of

the medication and notification to the nurse practitioner or physician and responsible party it is documented

in the progress notes. After reviewing the nursing progress notes for Resident R8 regarding the daptomycin she stated she could not locate the documentation. The facility's policy Change in Condition: Notification of.

Documented in part, A Center must immediately inform the patient, consult with the patient's physician, and notify,consistent with their authority, the patient's representative, where there is: A need to alter treatment significantly (that is, a need to discontinue or change an existing formof treatment due to adverse consequences, or to commence a new form of treatment) On 08/27/2025 at approximately 3:10 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, interim director of nursing, were made aware of

the above findings. No further information was provided prior to exit. References:(1) Used to treat certain blood infections or serious skin infections caused by bacteria. This information was obtained from the website: https://medlineplus.gov/druginofo/meds/a608045.html. (2) The death of tissues in your body. This information was obtained from the website: https://medlineplus.gov/gangrene.html.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodmont Center

11 Dairy Lane Fredericksburg, VA 22405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observation, staff interview, facility document review, the facility staff failed to maintain a clean and comfortable environment for one of ten residents in the survey sample, Resident #4 The findings include: For Resident #4 (Resident R4), the facility staff failed to maintain the resident's fall mats and floors in a clean and comfortable environment. Observation was made of Resident R4's room on 8/25/25 at 4:02 p.m. The resident was in bed; there were fall mats on both sides of the bed. The fall mats had evidence of liquids having been spilled and the surveyor's shoes stuck to the fall mats. There were bits of paper on both sides of the bed.

There were dirt and debris behind the bed and nightstand. On 8/26/25 at 10:59 a.m., an interview was conducted with OSM (other staff member) #5 (the director of environmental services). OSM #5 stated all resident rooms are cleaned every day. OSM #5 stated that in the morning, the cleaning consists of pulling

the trash, cleaning surfaces, sweeping, moping, cleaning the bathroom, and replacing toiletries. OSM #5 stated that later in the day, the housekeeping staff completes a walk through and the walk through consists of pulling the trash, cleaning debris on the floor, wiping the bedside tables, pulling the trash, and replacing toiletries. OSM #5 stated fall mats should be lifted up, pulled away from the bed, and cleaned every day.A second observation was made on 8/26/25 at 2:00 p.m. The resident was not in bed but both fall mats were down. There was evidence of spills on the fall mats. An interview was conducted with OSM (other staff member) #9, environmental services, on 8/26/25 at 2:03 p.m. OSM #9 observed the fall mats and stated there were in need of cleaning. The facility policy, Accommodation of Needs, documented in part, The resident/patient (hereinafter patient) has the right to a safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely.ASM (administrative staff member) #1, the administrator, and ASM #2, the acting director of nursing, were made aware of the above concern on 8/27/25 at 3:11 p.m. No further information was provided prior to exit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodmont Center

11 Dairy Lane Fredericksburg, VA 22405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

present documented resolution of concerns. Implementation of the plan of correction was verified by resident and staff interviews. There were no current concerns regarding grievance resolution or follow-up

during the survey dates.The facility policy Grievance/Concern revised 10/15/24 documented in part, .The Administrator will serve as the Grievance Officer who is responsible for overseeing the grievance process, including Civil Rights grievances/concerns, receiving and tracking grievances through to their conclusion, leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, for example, the identity of the patient for those grievances submitted anonymously, issuing written grievance decisions to the patient, and coordinating with state and federal agencies, in consultation with the National Law Department, as necessary in light of specific allegations.On 8/27/2025 at 3:11 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the interim director of nursing were made aware of the findings cited as past non-compliance.No further information was provided prior to exit.Past Non-Compliance

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodmont Center

11 Dairy Lane Fredericksburg, VA 22405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to submit an MDS (minimum data set) assessment in the required timeframe for one of ten residents in the survey sample, Resident #7.The findings include:For Resident #7 (Resident R7), the facility staff failed to submit the admission MDS assessment within fourteen days of admission.Review of the facesheet for Resident R7 documented an admission date of 8/9/2025.Review of the MDS assessments for Resident R7 documented an admission assessment with an ARD (assessment reference date) of 8/15/25 in progress. The assessment failed to show a completion or submission date.On 8/26/2025 at 2:33 p.m., an interview was conducted with LPN (licensed practical nurse) #8, MDS coordinator. LPN #8 stated that the admission MDS was completed and submitted before the fourteenth day after admission. She stated that some of the MDS assessments had gotten behind due to staffing issues.According to the RAI (Resident Assessment Instrument) 3.0 User's Manual Version 1.19.1 October 2024, documented in part, .OBRA-Required Tracking Records and Assessments are Federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes. These assessments are coded on the MDS 3.0 in items A0310A (Federal OBRA Reason for Assessment) and A0310F (Entry/discharge reporting). They include: Tracking records: Entry, Death in facility. Assessments: admission (comprehensive). Assessment Type/Item Setadmission (Comprehensive) - Assessment Reference Date (ARD) (Item A2300) No Later Than: 14th calendar day of the resident's admission (admission date + 13 calendar days).On 8/27/2025 at 3:11 p.m., ASM (administrative staff member) #1, the administrator and ASM #2, the acting director of nursing were made aware of the findings.No further information was provided prior to exit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodmont Center

11 Dairy Lane Fredericksburg, VA 22405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, staff/resident interview, clinical record review and facility document review, it was determined that the facility failed to provide an accurate MDS (minimum data set) assessment for one of nine residents

in the survey sample, Resident 105 (Resident R105).The findings include: Resident R105 was admitted to the facility on [DATE REDACTED] with diagnosis that included but were not limited to muscle wasting/atrophy, sacral pressure ulcer and atrial fibrillation. The most recent MDS (minimum data set) assessment, a Medicare 5-day assessment, with an ARD (assessment reference date) of 11/8/25, coded the resident as scoring a 15 out of 15 on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired. A review of the MDS Section GG-functional abilities and goals coded the resident as requiring max assist for bathing/transfer/dressing/toileting and supervision for eating; Section H-Bladder and Bowel, H0100.

Appliances- A. Indwelling catheter was coded as ‘yes'. A review of the Medicare 5-day assessment dated [DATE REDACTED] and the 10/27/25 discharge return anticipated assessment both coded Resident R105 as ‘Indwelling catheter-no'. A review of the comprehensive care plan dated 10/20/25 revealed, FOCUS: Resident has foley catheter. INTERVENTIONS: Provide skin care. Encourage resident to consume all fluids during meals.

Offer/encourage fluids of choice. A review of the Hospital Discharge summary dated [DATE REDACTED] revealed, Active Lines: urethral catheter.A review of the facility's physician H&P dated 10/20/25 revealed, Has a new Foley catheter and continue with outpatient nephrology follow-up as planned.A review of the Hospital admission history & physical (H&P) dated 10/27/25 revealed, Renal: Patient with Foley.A review of the Hospital Discharge summary dated [DATE REDACTED] revealed, Urethral catheter 16 FR due to stage III / IV pressure ulcers on trunk, perineal wounds, necrotizing infection. A review of the October and November TAR (treatment administration record) revealed, Perform Indwelling Catheter Care every day and evening shift with evidence of care provided starting 11/11/25 evening shift.A review of the physician orders dated 11/11/25 revealed, Indwelling catheter 16 FR with 10 cc balloon to bedside straight drainage for diagnosis/history of need wounds. Empty catheter drainage bag at least once every eight hours to when it becomes one third to two thirds full.An interview was conducted on 11/12/25 at 1:45 PM with Resident R105. During

the interview process, Resident R105 stated, my catheter has been in for several weeks.An interview was conducted

on 11/13/25 at 12:05 PM with RN (registered nurse)#2, the MDS coordinator. RN #2 was asked to review Resident R104's care plan focus of foley catheter as well as the MDS Section H- H0100. Appliances- A. Indwelling catheter dated 10/25/25 and 10/27/25. RN #2 stated, 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 stated, we follow the RAI manual as our standard. On 11/13/25 at 3:50 PM, ASM #1, the executive director, ASM #2, the director of nursing and ASM #3, the regional clinical regulatory nurse was made aware of the concerns.According to the RAI (resident assessment instrument) Steps for Assessment:1.

Examine the resident to note the presence of any urinary or bowel appliances.2. Review the medical record, including bladder and bowel records, for documentation of current or past use of urinary or bowel appliances.Coding Instructions: Check next to each appliance that was used at any time in the past 7 days.

Select none of the above if none of the appliance's A-D were used in the past 7 days. H0100A = indwelling catheter. No further information was provided prior to exit.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodmont Center

11 Dairy Lane Fredericksburg, VA 22405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655

The MDS (minimum data set) assessment was not completed at the time of the survey.

Level of Harm - Minimal harm or potential for actual harm

The nursing admission assessment dated [DATE REDACTED] documented no skin issues.

Residents Affected - Few

The baseline care plan for Resident R7 documented in part, “Resident at risk for skin breakdown related to actual pressure ulcer, Advanced age(greater than 75 years), impaired cognition, incontinence, shear/friction risks. Resident has actual skin impairment: bruises to right outer forearm, right outer wrist, right and left antecubital space and left dorsum hand, and stage 2 to right Ischial Tuberosity. Date Initiated: 08/11/2025.” Under “Interventions” it documented in part, “…Provide wound treatment as ordered. Date Initiated: 08/11/2025…”

The physician orders for Resident R7 documented in part, “Clean area to right Ischial tuberosity with NS (normal saline), pat dry, apply calcium alginate and cover with dressing. Every day shift for wound care.

Order Date: 08/11/2025.”

Review of the eTAR (electronic treatment administration record) for Resident R7 dated 8/1/25-8/31/25 failed to evidence treatment to the right ischial tuberosity wound completed on 8/15/2025.

The progress notes for Resident R7 failed to evidence refusal of the wound treatment on 8/15/2025.

On 8/26/2025 at 2:55 p.m., an interview was conducted with LPN (licensed practical nurse) #4 who stated that wound care was completed by the wound nurse during the weekdays and by the floor nursing staff when she was not there and on weekends. She stated that the staff evidenced the treatments being done by dating the dressings before they applied them and by signing them off on the eTAR when done. LPN #4 stated that the purpose of the care plan was to document the things that they identified and put in place for goals and to prevent anything from happening. She stated that the care plan should be implemented for resident safety.

On 8/27/2025 at 3:11 p.m., ASM (administrative staff member) #1 and ASM #2, the interim director of nursing were made aware of the concern.

No further information was provided prior to exit.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodmont Center

11 Dairy Lane Fredericksburg, VA 22405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm

(3) Urine drainage bags collect urine. Your bag will attach to a catheter (tube) that is inside your bladder.

This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000142.htm.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodmont Center

11 Dairy Lane Fredericksburg, VA 22405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

(respirations)17,T (temperature)98.4,HR(heart rate)75.Head to toe assessment, sustain a laceration on the left intercostal/rib, ROM (range of motion) with easy, but not on left lower leg/contracture at that limb.

Alertness at his baseline. Dr (doctor), aware and order neuro check, call back for changes. RP (responsible party), DON (director of nursing) aware.”

Review of the care plan failed to evidence documentation of the care plan being reviewed and/or revised for

the above fall.

An interview was conducted with ASM (administrative staff member) #2, the acting DON, on 8/27/25 at 10:20 a.m. All of the above falls and the care plan were reviewed. ASM #2 stated that there was no evidence that the care plan was reviewed and revised for these falls ASM #1, the administrator and ASM #2 were made aware of the above concern on 8/27/25 at 3:11 p.m.

No further information was provided prior to exit.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodmont Center

11 Dairy Lane Fredericksburg, VA 22405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

On 8/27/2025 at 3:11 p.m., ASM (administrative staff member) #1 and ASM #2, the interim director of nursing were made aware of the concerns.

No further information was provided prior to exit.

1. 2. For Resident R2, facility staff failed to provide oral hygiene twice a day on 02/09/2024, 02/10/2024, 02/11/2024

and on 02/12/2024. Resident R2 was admitted to the facility with diagnoses that included but were not limited to muscle weakness.

On the most recent MDS (minimum data set), a 5 (five)-Day assessment with an ARD (assessment reference date) of 02/12/2024, Resident R2 scored 15 out of 15 on the BIMS (brief interview for mental status), indicating the resident was cognitively intact for making daily decisions. Section GG “Functional Abilities” code Resident R2 as requiring set-up or clean-up assistance with oral hygiene.

The ADL (activities of daily living) oral hygiene tracking sheet for Resident R2 dated February 2024 was reviewed.

The ADL legend documented in part, “Oral Hygiene – The ability to use suitable items to clean teeth. Dentures (if applicable0: The ability to insert and remove dentures into and from the mouth and manage denture soaking and rinsing with the use of equipment.” On 02/09/2024 the evening shift (3:00 p.m. – 11:00 p.m.) was coded “03” (three) and the night shift (11:00 p.m. – 7:00 a.m.) was coded “97.” The ADL tracking sheet legend documented in part, “03Personal Hygiene; 97 – not applicable.” On 02/10/2024 the day shift (7:00 a.m. – 3:00 p.m.) and evening shift were blank; the night shift was coded “01” (one). The ADL tracking sheet legend documented in part, “1- Oral Hygiene.” On 02/11/2024 the day shift (7:00 a.m. – 3:00 p.m.) and evening shift were blank; the night shift was coded “02” (two). The ADL tracking sheet legend documented in part, “2-Reason for Activity Not Occurring.” Further

review of the coding on 02/11/2024 failed to evidence the reason for the activity not occurring. On 02/12/2024 the night shift was coded “03”; the day and evening shifts were blank.

On 08/27/2025 at approximately 11:10 a.m. an interview was conducted with CNA (certified nursing assistant) #4. When asked to describe how often a resident should receive oral hygiene she stated two times a day. After reviewing Resident R2’s ADL tracking sheet dated February 2024 for the coding for oral hygiene on 02/09/2024, 02/10/2024, 02/11/2024 and on 02/12/2024, CNA #4 stated Resident R2 did not receive oral hygiene twice a day on 02/09/2024, 02/10/2024, 02/11/2024 and on 02/12/2024.

On 08/27/2025 at approximately 3:10 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, interim director of nursing, were made aware of the above findings.

No further information was provided prior to exit.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodmont Center

11 Dairy Lane Fredericksburg, VA 22405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

pressure injury treatment as ordered on 8/15/2025.The MDS (minimum data set) assessment was not completed at the time of the survey.The nursing admission assessment dated [DATE REDACTED] documented no skin issues.The physician orders for Resident R7 documented in part, Clean area to right Ischial tuberosity with NS (normal saline), pat dry, apply calcium alginate and cover with dressing. Every day shift for wound care.

Order Date: 08/11/2025.Review of the eTAR (electronic treatment administration record) for Resident R7 dated 8/1/25-8/31/25 failed to evidence treatment to the right ischial tuberosity wound completed on 8/15/2025.The progress notes for Resident R7 failed to evidence refusal of the wound treatment on 8/15/2025.The baseline care plan for Resident R7 documented in part, Resident at risk for skin breakdown related to actual pressure ulcer, Advanced age(greater than 75 years), impaired cognition, incontinence, shear/friction risks.

Resident has actual skin impairment: bruises to right outer forearm, right outer wrist, right and left antecubital space and left dorsum hand, and stage 2 to right Ischial Tuberosity. Date Initiated: 08/11/2025.

Under Interventions it documented in part, .Provide wound treatment as ordered. Date Initiated: 08/11/2025.On 8/26/2025 at 2:55 p.m., an interview was conducted with LPN (licensed practical nurse) #4 who stated that wound care was completed by the wound nurse during the weekdays and by the floor nursing staff when she was not there and on weekends. She stated that the staff evidenced the treatments being done by dating the dressings before they applied them and by signing them off on the eTAR when done.On 8/27/2025 at 3:11 p.m., ASM (administrative staff member) #1 and ASM #2, the interim director of nursing were made aware of the concern.No further information was provided prior to exit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodmont Center

11 Dairy Lane Fredericksburg, VA 22405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689

(including the comprehensive care plan dated 2/12/25 and nurses' notes dated 4/30/25 through 8/3/25) failed to reveal the facility staff addressed and/or implemented interventions to prevent future falls.

Level of Harm - Actual harm Residents Affected - Few

A nurse's note dated 8/3/25 documented Resident R9 was observed sitting on the floor in front of the bed. Further

review of Resident R9's clinical record (including the comprehensive care plan dated 2/12/25 and nurses' notes dated 8/3/25 through 8/25/25) failed to reveal the facility staff addressed and/or implemented interventions to prevent future falls.

On 8/26/25 at 1:55 p.m., an interview was conducted with LPN (licensed practical nurse) #3. LPN #3 stated that after a resident falls, interventions such as monitoring, keeping the resident busy, and toileting the resident should be implemented to prevent future falls.

On 8/27/25 at 3:12 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the interim director of nursing) were made aware of the above concern.

No further information was presented prior to exit.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodmont Center

11 Dairy Lane Fredericksburg, VA 22405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Based on observation and clinical record review, facility staff failed to provide care and services for an indwelling catheter for one of ten residents in the survey sample, Resident #8 (Resident R8). The findings include:For Resident R8, the facility staff failed to keep the catheter collection bag (1) off the floor. Resident R8 was admitted to the facility with diagnoses that included but were not limited to urinary retention (2). The admission MDS (minimum data set) was not due at the time of the survey. The facility's Clinical Admission assessment for Resident R8 dated 08/14/2025 documented in part, Level of cognitive impairment: b. alert (some forgetfulness). On 08/26/2025 at approximately 8:18 a.m. observation of Resident R8's catheter collection bag revealed it was lying flat on the floor next to Resident R8's bed. The physician's order for Resident R8 documented, Indwelling catheter (3)16FR (French) with 10cc (cubic centimeter) balloon to bedside straight drainage for diagnosis/Hx (history) of urinary retention. Order Date Date:8/14/2025. The comprehensive care plan for Resident R8 dated 08/19/2025 documented in part, Focus.

Resident requires indwelling foley catheter Date Initiated: 08/19/2025. Under Interventions it documented in part, Keep catheter off floor. On 08/27/2025 at approximately 3:10 p.m., ASM (administrative staff member) # 1, administrator, ASM # 2, interim director of nursing, were made aware of the above findings. No further information was provided prior to exit. References:(1) Urine drainage bags collect urine. Your bag will attach to a catheter (tube) that is inside your bladder. This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000142.htm. (2) A condition where your bladder doesn't empty all the way or at all when you urinate. This information was obtained from the website: https://my.clevelandclinic.org/health/disease/15427-urinary-retention. (3) A tube placed in the body to drain and collect urine from the bladder. This information was obtained from the website: https://medlineplus.gov/ency/article/003981.htm

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodmont Center

11 Dairy Lane Fredericksburg, VA 22405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observation, staff interview and facility document review, the facility staff failed to serve food in a sanitary manner in one of one facility kitchens. The findings include:On 08/25/2025 at approximately 1;30 p.m. an observation of the facility's dish room located in the kitchen was conducted with OSM (other staff member) 32, dietary manager. The observation revealed a 17-inch floor fan. Observation of the fan revealed

it was sitting on the floor blowing air across the floor on to a rack of clean plate bases and covers. Further

observation of the fan revealed the back fan guard with pieces of debris and greasy to the touch. When the

observation of the fan as described above was pointed out to OSM #2, he agreed the fan was dirty immediately removed the fan from the dish room. On 08/25/0225 at approximately 4:30 p.m. an observation

in the facility's kitchen revealed OSM #3 plating pureed cake into bowls for the resident's desert.

Observation of OSM #3 revealed he sported a mustache and a tuff of hair under his lower lip. Further

observation failed to evidence a covering over OSM 3's facial hair. At approximately 4:40 p.m., OSM #3 was observed on the tray line assembling resident's dinner trays without a cover over his facial hair. On 08/25/0225 at approximately 4:45 p.m. an observation in the facility's kitchen revealed OSM #4, cook wearing a pair of plastic gloves. Observations of OSM #4 revealed he opened and closed the walk-in refrigerator, wiping his hands on a dirty apron, handling resident's sandwiches, stacking dinner plates onto

the tray line while placing fingers on the surface of the plates, plating dinner food items and placing his thumb on the surface of the plates, without changing his gloves between the tasks described. On 08/26/2025 at approximately12:49 p.m. an interview was conducted with OSM #1, district dietary manager and OSM #2, dietary manager. When asked to describe the procedure for keeping staff hair from falling into food OSM #2 stated staff wear hair nets and beard nets for facial hair. After describing the observation of OSM #3 without the mustache being covered OSM #2 stated the mustache should have been covered.

When asked to describe the purpose of kitchen staff wearing gloves OSM #2 stated that it was to prevent staff from touching raw food and ready to eat food with their bare hands. After informed of the observation of OSM #4 as stated above OSM #2 stated that it was not sanitary, and the gloves should have been changed between each task. On 08/26/2025 at approximately 1:11 p.m. an interview was conducted with OSM #3, kitchen aide. After being informed of the observation of not having his mustache covered during meal preparation he stated that his mustache should have been covered. On 08/26/2025 at approximately 12:49 p.m. an interview was conducted with OSM #2, dietary manager. He stated that he started at the facility on January 15, 2025. When asked if he was aware of any concerns regarding meals being provided

in a timely manner, providing meals according to resident preference and providing palatable food, he stated he had observations of the issues when he started based on his background of being a chef. OSM #1, district dietary manager, stated that the prior dietary manager was lacking in management that affected meals being provided in a timely manner, providing meals according to resident preference and providing palatable food. She further stated that the facility's kitchen was short staffed at that time. On 08/27/2025 at approximately 1:20 p.m. an interview was conducted with OSM #3 regarding the fan observed in the dish room. When asked why the fan should not be blowing on clean dishware he stated that it could cause contamination. The facility policy Staff Attire Procedures. 1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. On 08/26/2025 at approximately 4:00 p.m. ASM (administrative staff member) #1, administrator, and ASM #2, interim director of nursing, were informed of the above findings. No further information was provided prior to exit. Complaint deficiency

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodmont Center

11 Dairy Lane Fredericksburg, VA 22405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to maintain a complete and accurate medical record for one of ten residents in the survey sample, Resident #1.The findings include:For Resident #1 (Resident R1), the facility staff failed to maintain an accurate medical record.Review of Resident R1's clinical record documented a discharge date of [DATE REDACTED].The progress notes for Resident R1 documented in part,- [DATE REDACTED] 07:40 Note : Significant change to reflect hospice closed due to resident death on 2/21.- [DATE REDACTED] 20:15 (8:15 p.m.) Date of Service: 2025-03-12, Visit Type: Advanced care planning, Details: Chief complaint: ACP (advanced care planning) discussion w/ RP (responsible party), daughter in presence of DON (director of nursing) as res (resident) continues to decline. Res is seen for overall decline in condition and has been hospitalized 5 times this year for various issues of PVD (peripheral vascular disease), anemia, AMS (altered mental status), wound infections and PN (pneumonia).

Pt is seen today at bedside with daughter to discuss ACP. Spoke w/ RP in regards to overall decline, multiple hospitalizations. Res has become more contracted w/ poor po (by mouth) intake, continues w/ multiple nonhealing wounds. Informed RP daughter, [Name of daughter] of poor prognosis based on aforementioned. Recommended hospice at this time, suggested she speak with family about what they would like to do moving forward. Res is DNR (do not resuscitate). Answered questions in regards to current condition. Informed daughter about recommendations by vascular to not be aggressive but to continue current woud [sic] management and that surgery/amputations would hasten mortality. Daughter is still wanting to get recommendations on this from PCP (primary care physician) and is to have an appt within

the week. Discussion 20 minutes in presence of DON. RP states she will speak with sisters and get back to staff. Signed Date : 2025-03-12.On [DATE REDACTED] at 10:10 a.m., an interview was conducted with ASM (administrative staff member) #6, nurse practitioner. ASM #6 stated that she no longer worked at the facility but worked with Resident R1 when they were there. She stated that she had written the note dated [DATE REDACTED] and that it was prior to them leaving the facility and was after Resident R1 had expired. She stated that it probably should have been a late entry.On [DATE REDACTED] at 12:27 p.m., an interview was conducted with ASM #1, the administrator.

ASM #1 reviewed the progress note for Resident R1 dated [DATE REDACTED] and stated that the resident was not in the facility

on that date. She stated that the medical record was not accurate.The facility policy Clinical record: Charting and documentation dated [DATE REDACTED] documented in part, . Documentation shall be completed at the time of service, but no later than during the shift in which the assessment, observation, or care service occurred. Documentation shall be timely and in chronological order. When documentation occurs after the fact, outside the acceptable time limits, the entry shall be clearly indicated as late entry.On [DATE REDACTED] at 3:11 p.m., ASM #1, the administrator and ASM #2, the interim director of nursing were made aware of the findings.No further information was provided prior to exit.

Event ID:

Facility ID:

If continuation sheet