Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Woodmont Center during CMS and state inspections, most recent first.
Staff failed to consistently develop and implement comprehensive care plans for multiple residents, resulting in undocumented or omitted interventions for pain management, catheter care, fluid restriction, transfers, activities, dialysis communication, mobility, and bathing. Cognitively intact and impaired residents with pain did not have non-pharmacological interventions documented as required. Residents with indwelling catheters and ESRD lacked complete intake/output, catheter care, and fluid restriction monitoring despite physician orders and care plan directives. Other residents who required maximal assist or mechanical lifts for transfers were not consistently documented as being transferred, and one resident reported not being offered to get out of bed daily. A resident who valued voting and religious practice was not assisted to vote and had to request chaplain visits, while another on dialysis lacked consistent dialysis communication documentation. One resident with an OT-ordered hand splint had no corresponding care plan entry, and another dependent resident received fewer showers than the twice-weekly schedule specified in the care plan and described by staff. Staff interviews confirmed that care plans are intended to guide care, that missing documentation means care was not provided, and that the interdisciplinary team is responsible for updating and implementing care plans.
Staff failed to consistently provide and document ADL care, including bathing, transfers, and grooming, for several dependent residents. One resident who required assistance with bathing received far fewer showers than the twice-weekly schedule, despite being in the facility most days. Another cognitively intact resident who depended on a mechanical lift was rarely transferred out of bed over several months, while documentation often showed "not applicable" or no transfer entries. A third resident needing maximal assist for transfers had numerous days across all shifts with missing transfer documentation, which a CNA acknowledged meant the care likely did not occur. A dependent resident with advanced MS and keloids was observed with significant facial hair and reported waiting for a family member to bring an electric shaver, while therapy notes and staff interviews showed ongoing distress and lack of grooming assistance. Another severely cognitively impaired, fully dependent resident was observed in bed throughout multiple survey observations and was not transferred to a wheelchair, with the assigned CNA citing time constraints and a mistaken belief that therapy had said the resident did not need to get up.
Facility staff failed to follow professional standards for food storage, preparation, and sanitation in the kitchen and on a resident hallway. Surveyors observed dirty food-contact equipment, improperly stored dry goods, and wet pans stacked and dripping in clean storage areas. Hot foods were held and served below the facility’s stated minimum of 135°F. Expired milk cartons were placed on breakfast trays and in the milk supply on a hallway, with both dietary and nursing staff not identifying the out-of-date product. In the kitchen, a pizza cutter that had fallen to the floor and other utensils, trays, and dome lids were inadequately sanitized, with submersion times far below the one-minute contact time required by the sanitizer manufacturer, and some items not fully submerged. A dietary staff member also used a soiled utility cart and contaminated gloves to handle both dirty and clean dishware without cleaning the cart between uses, contrary to facility policy.
Facility staff failed to provide or offer scheduled showers or bed baths to a cognitively intact resident who required partial/moderate assistance with bathing. Although the shower schedule listed bathing on specific weekdays during the day shift, ADL documentation over multiple days showed entries coded as not applicable or not attempted, with some shifts left blank, and no evidence that bathing was provided or offered. A CNA who routinely cared for the resident confirmed the scheduled shower days and, upon review of the ADL records, acknowledged not knowing why the resident did not receive showers or bed baths and that there was no documentation that these were offered.
A resident with DM, Parkinson’s disease, dementia, adult FTT, severe cognitive impairment, and dependence for bed mobility and transfers was care planned as at risk for falls, with interventions including bed rails as an enabler and two-staff assistance for repositioning in bed. An agency CNA who had been at the facility about a week provided care without ensuring the low air loss mattress was in static mode, and the resident subsequently fell from bed and complained of left knee pain. Imaging showed a possible subtle distal femoral fracture. The DON described the resident as a one-person assist who held onto the bedrail and was alert but confused, and the facility’s falls policy required individualized interventions based on risk factors, which were not properly implemented in this instance.
Facility staff failed to follow care plans requiring a two-person assist for a resident with a below-the-knee amputation, resulting in a fall and serious injury. Additionally, after two separate falls involving another resident, staff did not update care plans or implement new interventions to prevent future incidents. Documentation and investigation procedures were not followed as required by facility policy.
Facility staff did not consistently implement or document comprehensive care plans for three residents, resulting in unmet care needs such as inadequate assistance with bed mobility leading to a fall and fracture, missed incontinence and wound care, lack of contracture management, and improper handling of a urinary catheter. Staff interviews and documentation reviews confirmed that care plans and physician orders were not followed as required.
Facility staff did not review or revise the comprehensive care plans for multiple residents after documented falls, despite clinical records and staff interviews confirming that care plans should be updated following such incidents. The care plans remained unchanged after each fall, contrary to facility policy and standard practice, as confirmed by staff and documentation review.
Staff failed to provide and document required ADL care for two residents, including incontinence care for a dependent, cognitively impaired resident and twice-daily oral hygiene for another resident needing assistance. Documentation was incomplete or incorrectly marked as 'not applicable,' and staff interviews confirmed that care was not provided as required.
Staff failed to maintain sanitary food service practices, including using a dirty floor fan that blew air onto clean dishware, not covering facial hair during food preparation, and not changing gloves between tasks such as handling food and touching unclean surfaces. Management acknowledged these lapses did not meet facility policy.
Facility staff did not ensure privacy for a resident with an indwelling catheter, as the catheter collection bag was repeatedly left uncovered and visible to anyone entering the room. The resident, who was alert with some forgetfulness and had a diagnosis of urinary retention, reported being bothered by the lack of privacy. This action was inconsistent with the facility's policy to treat residents with dignity and respect.
A resident was found lying in bed with the call bell on the floor and out of reach, and reported that staff only respond when the call bell is accessible. An LPN confirmed the call bell should be within reach and acknowledged it was not at the time of observation. The issue was reported to administrative staff, with no further information provided before survey exit.
Facility staff did not notify a resident's responsible party when a physician-ordered IV antibiotic for a serious foot infection was unavailable for administration. Although the nurse practitioner was informed and the pharmacy was contacted, there was no documentation that the responsible party was notified, as required by facility policy.
Staff did not maintain a clean and comfortable environment for a resident, as fall mats and floors in the resident's room were observed to have spilled liquids, debris, and dirt. Environmental services staff confirmed the cleaning protocols were not followed, resulting in unsanitary conditions despite facility policy requiring a clean and homelike environment.
Facility staff did not document or resolve a written grievance submitted by a resident's responsible party concerning wound care and other care issues. Despite being told the concerns were under review, the responsible party received no follow-up or resolution, and the grievance was not found in facility records. The resident was severely cognitively impaired and dependent on staff for ADLs, with a family member as their health care representative. Staff interviews confirmed a lack of documentation and uncertainty about the grievance process for this incident.
Facility staff did not submit a required admission MDS assessment within the federally mandated timeframe for a resident. The assessment was marked as in progress without a documented completion or submission date, and the MDS coordinator confirmed that some assessments had fallen behind due to staffing issues.
Facility staff did not develop a baseline care plan for oral hygiene for one resident and failed to implement ordered wound care for another, despite both needs being identified in their baseline care plans. Interviews and record reviews confirmed that required care planning and interventions were not completed or documented as per facility policy.
The facility did not ensure that a resident received proper care for pressure ulcers and failed to implement adequate preventive measures, resulting in the development or worsening of pressure ulcers.
A resident with an indwelling catheter for urinary retention was observed with their catheter collection bag lying on the floor, despite care plan interventions and physician orders requiring the bag to be kept off the floor. This failure to maintain proper catheter care was identified during a survey and reported to facility administration.
Staff failed to maintain an accurate medical record for a resident by documenting a progress note after the resident had expired and was no longer in the facility. The note, which described an advanced care planning discussion with the responsible party and DON, was not properly identified as a late entry, resulting in an inaccurate record.
Failure to Develop and Implement Comprehensive Care Plans Across Multiple Care Areas
Penalty
Summary
Facility staff failed to develop and/or implement comprehensive care plans for multiple residents across pain management, catheter care, fluid restriction, transfers, activities, dialysis communication, mobility, and bathing. For two residents with pain, staff did not follow care plan directions for non-pharmacological interventions. One cognitively intact resident with frequent severe back pain received PRN acetaminophen and oxycodone, but nursing progress notes from early April showed no documentation of non-pharmacological pain interventions in numerous opportunities, despite the care plan requiring evaluation of pain characteristics and use of such measures. Another resident with chronic pain and moderate cognitive impairment received PRN hydromorphone for moderate to severe pain, but the eMAR and nursing notes lacked evidence of non-pharmacological interventions at multiple documented administration times, contrary to the pain-focused care plan. For residents with urinary catheters and renal conditions, staff did not consistently implement care plan interventions or related physician orders. One resident with an indwelling catheter and an order for daily intake and output monitoring, with instructions to report urinary output below a specified amount, had multiple shifts with no recorded urinary output on the TAR, despite a care plan directive to monitor catheter output for odor, color, consistency, and amount. Another resident with ESRD and a neurogenic bladder had a care plan requiring catheter care twice daily and recording of output, and physician orders for catheter care every shift and regular emptying of the drainage bag; the TAR showed missing documentation of catheter care and output on several day and night shifts. The same ESRD resident also had physician orders for a specific daily fluid restriction total, divided between dietary and nursing-provided fluids, but there was no evidence on the MAR/TAR of fluid restriction monitoring, and the care plan for impaired renal function did not include fluid restriction monitoring as an intervention. Staff also failed to implement care plans related to transfers, activities, dialysis communication, mobility, and bathing. One resident requiring maximal assistance of one to two staff for transfers had numerous missing entries in ADL documentation for transfers across multiple dates and shifts, with a CNA stating that if care was not documented, it did not happen. Another resident, cognitively intact and dependent for mobility, had a care plan stating it was important to engage in meaningful routines, including voting and religious activities; the resident reported no one approached her about voting in a recent election and that she had to ask to see the chaplain more often, despite care plan interventions noting the importance of voting and religious engagement. A resident with a left-hand splint ordered by OT had no corresponding care plan update addressing limited range of motion or the splint, and the same resident on hemodialysis had a care plan intervention to send and review a dialysis communication book each treatment, but dialysis communication records were missing for several dialysis dates. Additional failures involved assistance out of bed and bathing frequency. One cognitively intact resident, dependent on staff for transfers and requiring a total mechanical lift with two-person assist, reported not getting out of bed every day and only being offered to get up when enough staff were available; ADL documentation over several months showed the resident was transferred out of bed only a small number of times, with many days marked as not applicable or not attempted, even though staff interviews indicated residents should be offered to get out of bed daily and refusals documented and reported. Another resident, severely impaired for decision-making and dependent for ADLs, had a care plan stating it was important to choose between a shower or bed bath and that extensive assistance for bathing would be provided, with showers scheduled twice weekly. ADL records showed this resident received only one shower in one month and five showers in the following month, despite the stated expectation of twice-weekly showers, and staff confirmed showers were scheduled twice weekly and refusals should be documented and reported. Throughout the report, multiple LPNs, a CNA, and the MDS Coordinator acknowledged that the purpose of the care plan is to guide and assist staff in providing appropriate care and that the interdisciplinary team is responsible for implementing and updating care plans. They also confirmed that missing documentation indicates care was not provided and that specific interventions, such as fluid restriction monitoring, dialysis communication, and daily transfer offers, should be reflected in and carried out according to the care plans. The Administrator and DON were notified of each set of findings, and no additional information was provided prior to exit.
Failure to Provide and Document Required ADL Care for Multiple Dependent Residents
Penalty
Summary
Facility staff failed to provide required ADL care, including bathing, transfers, and grooming, to multiple dependent residents as documented in clinical records, observations, and interviews. One resident who was severely cognitively impaired and required partial/moderate assistance for showering was care planned to receive assistance with bathing and to choose between a shower or bed bath. ADL documentation over two separate months showed this resident received only one shower in one month and five showers in the following month, despite facility staff stating that showers are scheduled twice weekly and refusals are to be documented and reported. Census records showed the resident was out of the facility on only one day during this period, and the facility’s ADL policy required necessary care and services to maintain grooming and personal hygiene. Another resident, cognitively intact and dependent on staff for transfers using a total mechanical lift, reported not getting out of bed every day and stated staff only offered to get them up when enough staff were available. Observations over multiple days showed this resident in bed, and ADL documentation over three months reflected very limited transfers out of bed, with many days coded as not applicable or not attempted due to medical condition or safety concerns. Staff interviews indicated that not applicable should only be used when a resident is not in the building or is not allowed to get out of bed, and that all residents should be offered to get out of bed daily with refusals documented and reported to the physician and responsible party. A third resident, cognitively intact and requiring maximal assistance for mobility, transfers, bathing, dressing, and hygiene per MDS and care plan, had numerous dates across all three shifts with missing ADL transfer documentation. A CNA confirmed that transfers are documented in the electronic record and that if there is no documentation, it means the care did not occur. Another resident, dependent on staff for transfers, mobility, and requiring maximum assistance with hygiene and bathing, was observed with a large amount of facial hair and reported waiting for a family member to bring an electric shaver due to keloids and an inability to use facility razors. Therapy notes documented the resident’s repeated statements about waiting for a shaver, her distress about her appearance, and her refusal to participate in certain therapy activities because of her unshaven face, while a CNA described her as totally dependent and stated she believed the resident was waiting for someone to come and shave her and that the resident refused a lot. A fifth resident, severely cognitively impaired and completely dependent on staff for transfers from bed to wheelchair, was observed lying in bed multiple times over two survey days and was never seen out of bed during surveyor presence. The resident’s representative expressed concerns about whether staff were assisting the resident out of bed. The CNA assigned to the resident on one of those days stated the resident was completely dependent for all ADLs and admitted she did not transfer the resident out of bed because she arrived late to the unit as a float CNA, had other residents to care for, and believed, based on what she said a therapy staff member told her, that the resident did not need to get up that day. The therapy assistant later stated she had not instructed any CNA that the resident did not need to get out of bed and explained that it was beneficial for the resident to be up in the wheelchair as much as tolerated each day and that he had previously been up much of the time each day before his most recent readmission. Across these five residents, the survey findings showed failures to provide scheduled showers, to consistently offer and perform transfers out of bed, to document transfers as required, and to assist with grooming needs such as shaving, despite care plan directives, MDS assessments indicating dependence for ADLs, and facility policy requiring provision of necessary ADL care to maintain grooming and personal hygiene. Staff interviews repeatedly confirmed that care should be offered and documented, that refusals should be recorded and reported, and that lack of documentation indicates care was not provided, yet the records and observations did not support that these ADL services were consistently delivered.
Food Storage, Sanitation, and Temperature Control Deficiencies in Dietary Services
Penalty
Summary
Facility staff failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen and on one resident hallway. During a kitchen observation, surveyors noted multiple soiled or improperly cleaned food-contact items, including a cutting board with dried red debris, ladles with yellow debris and a noodle attached, baking sheets with thick white debris, and a cake mixer guard and stand with white debris and the electrical cord stored inside the mixing bowl. Clean dish storage was also deficient: steam pans were stacked while still wet, and baking sheets on a rack were dripping water onto the floor. In the refrigerator, an unlabelled, undated 2‑quart container with a thick yellow substance identified by the dietary manager as butter was found. In dry storage, an open, undated bag of potato chips was not closed after opening, a blue bag of parboiled rice was left open inside a 25‑lb box, and a container of chicken base was found with the lid off on a cart. These conditions were inconsistent with the facility’s written policies requiring utensils and food-contact surfaces to be clean and sanitized after each use and dry goods to be properly sealed and date marked. Hot food holding and service temperatures were also not maintained according to professional standards and facility policy. Immediately prior to lunch tray preparation, surveyors measured five hot food items below the facility’s stated acceptable serving temperature of 135°F: mashed potatoes at 123.5°F, puréed peas at 133.3°F, gravy at 134.4°F, puréed burger at 110.0°F, and ground beef hamburger at 127.0°F. Despite these readings, staff proceeded to serve the lunch meal with the temperatures as recorded. The facility’s Dining Services policy specified that all foods would be held at appropriate temperatures greater than 135°F for hot holding, but this was not followed during the observed meal service. On a resident hallway, staff distributed expired milk and failed to ensure proper sanitization of utensils and warewashing. During breakfast tray distribution, 12 individual milk cartons on resident trays and in the ready-to-distribute supply were observed with an expiration date of the previous day. A CNA reported that dietary staff place milk in an ice-filled container on the tray cart and CNAs add milk to trays per resident request, and that dietary staff are responsible for checking expiration dates, while nursing staff are responsible for double-checking before serving. The Dining Services Director later confirmed that she and dietary aides are responsible for checking milk dates and acknowledged that expired milk had been placed in the hallway milk bucket and not identified by dietary or nursing staff. Surveyors also observed improper sanitization of a pizza cutter and other utensils and equipment at the three-compartment sink. After a pizza cutter fell to the floor, a dietary district manager briefly dipped it in the wash, rinse, and sanitizer sinks, leaving it in the sanitizer for less than three seconds before returning it for use in lunch service, contrary to the Dining Services Director’s statement that utensils should be immersed in sanitizer for at least 60 seconds. Additional observations showed a dietary staff member washing plastic tongs and submerging them in sanitizer for only 2–3 seconds before placing them in a drying rack. Later, corporate and facility dietary staff washed trays and dome covers, with observed sanitizer contact times ranging from approximately 3.38 to 40.83 seconds, and some dome covers not fully submerged in the sanitizer solution. Manufacturer instructions for the Oasis 146 Multi‑Quat sanitizer required exposure of food-contact surfaces to the sanitizing solution for at least one minute. Further, staff did not maintain separation between soiled and clean items and did not follow glove-use and cart-cleaning practices described in facility policy. A dietary staff member collected used plates and dome covers from meal carts onto a black utility cart while wearing one glove, picked up a plastic juice cup from the floor with the gloved hand, and then moved all items to the sink area. Without cleaning the cart, the staff member then used the same cart to receive washed dome lids from the sanitizer sink and stacked them on the visibly wet and debris-contaminated cart surface before transporting them to a storage rack in the kitchen. The dietary manager later stated that carts were supposed to be cleaned daily and after dirty items were placed on them, and that dishes had to go into sanitizer and then air dry, but she also stated there was no required time they had to sit in the sanitizer, which conflicted with the manufacturer’s instructions and the facility’s manual warewashing policy.
Failure to Provide Scheduled Showers/Bed Baths and ADL Support
Penalty
Summary
Facility staff failed to ensure that a resident did not lose the ability to perform activities of daily living (ADLs) by not providing or offering showers or bed baths as scheduled. The resident was admitted with diagnoses including muscle weakness and, on the most recent MDS admission assessment with an ARD of 03/19/2026, scored 15/15 on the BIMS, indicating intact cognition for daily decision-making. Section GG of the MDS coded the resident as requiring partial/moderate assistance for showering/bathing. The facility’s 200 Wing Shower List showed the resident was scheduled for showers on Mondays and Thursdays during the 7:00 a.m. – 3:00 p.m. shift. However, review of the ADL documentation for March and April 2026 revealed multiple dates on which showering/bathing was coded as not applicable or not attempted, and there was no documentation that the resident received or was offered a shower or bed bath on those days. Specifically, the March 2026 ADL sheet showed that on 03/06/2026 the day shift was coded “09” (not applicable – not attempted and the resident did not perform this activity prior to the current illness), the evening shift “88” (not attempted due to medical condition or safety concerns), and the night shift “09.” On 03/23/2026, the day shift entry was left blank, and the evening and night shifts were both coded “09.” The April 2026 ADL sheet showed that on 04/13/2026 the day shift was coded “98,” the evening shift “88,” and the night shift “09,” and on 04/20/2026 all three shifts were coded “09.” During an interview on 04/23/2026, CNA #5, who provided care and showers to the resident and confirmed the scheduled Monday/Thursday shower days, stated she did not know why the resident did not receive showers or bed baths on the identified dates and acknowledged the resident should have been offered them. Upon review of the ADL sheets, CNA #5 confirmed there was no evidence that showers or bed baths were offered on those dates.
Failure to Ensure Safe Bed Environment Resulting in Resident Fall and Injury
Penalty
Summary
Facility staff failed to provide a safe environment and adequate supervision for a resident with significant cognitive and functional impairments, resulting in a fall from bed. The resident had diagnoses including DM, Parkinson’s disease, dementia, and adult FTT, and was assessed on the most recent MDS as severely cognitively impaired with a BIMS score of 04/15. The MDS Section GG documented that the resident was dependent for bed mobility, transfers, hygiene, and bathing, and required supervision for eating. The comprehensive care plan identified the resident as at risk for falls due to Parkinson’s disease, dementia, poor safety awareness, and general weakness, and included interventions such as use of bed rails as an enabler and requiring two staff to assist with repositioning/turning in bed. Despite these identified risks and interventions, the resident experienced a fall from bed. On the date of the incident, a CNA reported that the resident fell out of bed, after which the resident complained of left knee pain. The resident was unable to verbalize what occurred other than stating she fell out of bed. Subsequent evaluation and imaging showed a possible subtle distal femoral fracture of the left knee. A root cause analysis documented that the CNA, an agency staff member who had been working at the facility for about a week, failed to ensure that the low air loss mattress was placed in static mode prior to providing care. The DON stated that the resident was considered a one-person assist who would hold onto the bedrail and was described as alert but confused. The facility’s Falls Management policy required implementation and documentation of patient-centered interventions according to individual risk factors and adjustment of interventions as the patient’s condition changed, but the failure to properly set the mattress contributed to the unsafe environment and the resulting fall.
Failure to Implement Fall Prevention Interventions and Inadequate Post-Fall Response
Penalty
Summary
Facility staff failed to implement required interventions for fall prevention for two residents, resulting in deficiencies related to accident hazards and supervision. In one case, a resident with a right below-the-knee amputation and multiple comorbidities, including heart failure, diabetes, and muscle weakness, was assessed as requiring a two-person assist for all activities of daily living (ADLs), including bed mobility. Despite this, only one staff member assisted the resident during incontinence care, leading to the resident rolling off the bed and sustaining a right distal femoral fracture. Documentation confirmed that the care plan and CNA Kardex both specified a two-person assist, but this was not followed. Additionally, there was no evidence of a thorough investigation into the fall with serious injury, as required by facility policy. Staff interviews revealed inconsistent communication and understanding of care requirements for new admissions and readmissions. While some staff stated that care plans and Kardexes are used to inform CNAs of resident needs, the involved CNA did not follow the two-person assist directive. Witness statements and interviews indicated that the incident was not properly documented in the risk management system, and the required accident report was not completed. The facility's fall management policy mandates assessment, documentation, and implementation of individualized interventions, but these steps were not adequately performed in this case. In a separate incident, another resident experienced two falls within a four-month period. After each fall, there was no evidence in the clinical record or care plan that staff addressed or implemented new interventions to prevent future falls. Interviews with staff confirmed that interventions such as increased monitoring and toileting should be implemented post-fall, but the records did not reflect any such actions. The lack of follow-up and failure to update care plans or implement preventive measures contributed to the ongoing risk of falls for this resident.
Failure to Implement and Document Comprehensive Care Plans
Penalty
Summary
Facility staff failed to develop and/or implement comprehensive care plans for three residents, resulting in unmet care needs and adverse outcomes. For one resident with a right below-knee amputation, the care plan and CNA Kardex specified a two-person assist for bed mobility. Despite this, only one staff member assisted the resident during incontinence care, leading to a fall from bed and a fracture of the distal right femur. Documentation and staff interviews confirmed that the care plan was in effect at the time of the incident and should have been followed. Another resident, assessed as severely cognitively impaired and fully dependent for ADLs, did not receive incontinence care and wound treatments as outlined in their care plan and physician orders. Multiple dates showed missing or inappropriate documentation for incontinence care, with staff confirming that such care should always be documented for a resident who is always incontinent. Additionally, wound care treatments were not administered or documented on several dates, and there was no evidence of resident refusal. The care plan also failed to address contracture management, despite the resident having a diagnosis and orders for splints and braces, as well as therapy recommendations for contracture prevention. A third resident with an indwelling urinary catheter had a care plan intervention to keep the catheter bag off the floor. However, observation revealed the catheter collection bag lying flat on the floor next to the bed. Staff interviews confirmed that the care plan should be implemented for resident safety. In all cases, the facility's own policies required timely development and implementation of individualized, measurable care plans, but these were not consistently followed or documented.
Failure to Review and Revise Care Plans After Resident Falls
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for four residents following documented falls. For one resident, after a fall was observed and documented by nursing staff, there was no evidence that the care plan, which had been created months prior, was reviewed or updated to address the incident. Interviews with staff confirmed that care plans are expected to be updated after such events, but this was not done in these cases. Another resident experienced multiple falls, each documented in the clinical record, but the care plan remained unchanged after each event. Staff interviews reiterated the expectation that care plans should be updated after falls, but documentation did not support that this occurred. The facility's own policy requires care plans to be reviewed and revised after assessments and as needed to reflect changes in the resident's condition or response to care. Additional residents also experienced falls, with clinical records and fall investigations documenting the incidents and subsequent assessments, but without evidence of care plan review or revision. In each case, staff interviews confirmed the expectation for care plan updates following such events, and facility policies supported this requirement. Despite this, the care plans did not reflect the necessary reviews or changes after the falls, as confirmed by both documentation review and staff statements.
Failure to Provide and Document Required ADL Care for Dependent Residents
Penalty
Summary
Facility staff failed to provide required activities of daily living (ADL) care for two residents who were dependent on staff assistance. For one resident with severe cognitive impairment and total incontinence of bowel and bladder, documentation showed multiple instances across several months where incontinence care was not provided or not documented as provided on various shifts. The resident's care plan specified the need for incontinence care to maintain dignity and prevent complications, yet ADL records were either left blank or marked as 'not applicable' on days when care should have been given. Staff interviews confirmed that such documentation was inappropriate for a resident who was always incontinent and dependent on staff. For another resident, who was cognitively intact but required set-up or clean-up assistance with oral hygiene, the facility failed to provide oral care twice daily as required. Review of the ADL tracking sheets for this resident revealed missed oral hygiene care on several consecutive days, with documentation either left blank, marked as 'not applicable,' or coded without explanation for why care was not provided. Staff interviews confirmed that the resident did not receive oral hygiene care as required during these periods. Facility policy required that ADL care, including hygiene and elimination, be documented accurately and reflect the care provided by nursing staff. The deficiencies were identified through clinical record review, staff interviews, and examination of facility documentation, which consistently failed to show evidence of required care being provided or properly documented for these dependent residents.
Sanitary Food Service Deficiencies in Kitchen Operations
Penalty
Summary
Facility staff failed to maintain sanitary food service practices in the kitchen, as observed during multiple site visits. A floor fan was found on the dish room floor, blowing air across clean plate bases and covers, with visible debris and grease on the fan guard. The dietary manager acknowledged the fan was dirty and removed it after the observation. Additionally, a kitchen aide was seen plating pureed cake and assembling dinner trays without a cover over his mustache and facial hair, contrary to facility policy requiring facial hair to be restrained. The aide confirmed that his mustache should have been covered during food preparation. Further observations revealed a cook wearing gloves while performing multiple tasks, including opening and closing the walk-in refrigerator, wiping hands on a dirty apron, handling resident sandwiches, stacking dinner plates, and plating food, without changing gloves between tasks. The dietary manager confirmed that gloves should be changed between tasks to maintain sanitation. Interviews with dietary management staff indicated awareness of these issues and acknowledged that the observed practices were not sanitary and did not align with facility policy.
Failure to Provide Privacy for Catheter Collection Bag
Penalty
Summary
Facility staff failed to promote the dignity of a resident with urinary retention who had an indwelling catheter. On two separate occasions, surveyors observed the resident's catheter collection bag hanging uncovered on the lower portion of the bed, with the contents clearly visible. The resident was alert with some forgetfulness, as documented in the facility's clinical admission assessment. The physician's order specified the use of an indwelling catheter with straight drainage due to urinary retention. During an interview, the resident expressed discomfort and stated that it bothered him that anyone entering the room could see the urine in the collection bag. The facility's policy on resident rights requires that each resident be treated with respect and dignity, and that care be provided in a manner that promotes or enhances quality of life. Despite this policy, the lack of privacy for the catheter collection bag was not addressed prior to the survey exit.
Failure to Maintain Call Bell Within Resident's Reach
Penalty
Summary
Facility staff failed to accommodate the needs of a resident by not ensuring the call bell was within the resident's reach. The resident was observed lying in bed with the call bell on the floor, out of reach, and reported that staff only respond to the call bell when it is accessible. During an interview, an LPN confirmed that the call bell should be placed next to or clipped on the resident when in bed, and acknowledged that the call bell was not within reach at the time of observation. The issue was brought to the attention of the administrator and interim director of nursing, but no additional information was provided before the survey exit. The deficiency was identified through direct observation, resident interview, and staff interview, specifically noting the failure to maintain the call bell within reach for the resident while in bed.
Failure to Notify Responsible Party of Unavailable Medication
Penalty
Summary
Facility staff failed to notify the responsible party when a physician-ordered medication, Daptomycin, was not available for administration to a resident with a left foot infection and gangrene. The resident was alert with some forgetfulness, and the medication was ordered to be given intravenously every other day for 23 days. On the scheduled administration date, the medication was not available, and the nurse's note indicated that the pharmacy would deliver it during the next run and that the nurse practitioner was aware. However, there was no documentation that the responsible party was informed of the missed dose. Staff interviews confirmed that the facility's procedure requires notifying the responsible party when a medication is unavailable, and this notification should be documented in the progress notes. Review of the clinical record and facility documentation did not show evidence that the responsible party was notified as required. The facility's policy also mandates immediate notification of the patient's representative when there is a need to alter treatment significantly, such as when a medication is not available.
Failure to Maintain Clean and Comfortable Resident Environment
Penalty
Summary
Facility staff failed to maintain a clean and comfortable environment for one resident, as evidenced by observations of the resident's room. During two separate visits, surveyors noted that the fall mats on both sides of the resident's bed had visible evidence of spilled liquids, causing the surveyor's shoes to stick to the mats. Additionally, there were bits of paper on both sides of the bed and dirt and debris behind the bed and nightstand. These conditions were present despite the facility's stated cleaning protocols. Interviews with the director of environmental services and another environmental services staff member confirmed that all resident rooms are supposed to be cleaned daily, including lifting and cleaning fall mats. However, both staff members acknowledged that the fall mats in this resident's room were in need of cleaning at the time of observation. The facility's own policy requires a safe, clean, and comfortable environment for residents, but this standard was not met for the resident in question.
Failure to Document and Resolve Family Grievance Regarding Resident Care
Penalty
Summary
Facility staff failed to demonstrate efforts to resolve a written grievance submitted by a resident's responsible party in November 2024. The grievance, which was related to wound care procedures and other care concerns, was sent to the former administrator. Although the responsible party was informed that the administration was investigating the concerns, there was no documented follow-up or resolution provided to the responsible party. Review of facility grievance records from January 2024 onward did not show any documentation of the November 2024 grievance, and staff interviews revealed uncertainty about whether an official grievance was completed or properly tracked. The resident involved was assessed as being severely impaired in making daily decisions and was dependent on staff for activities of daily living, with a family member designated as the responsible party and health care representative. Interviews with current and former administrative staff indicated a lack of clear documentation and follow-up regarding the grievance, and the facility's grievance log did not reflect the reported concern. The facility's policy required the administrator to oversee and track grievances through to their conclusion, but this process was not followed in this instance.
Failure to Submit Timely Admission MDS Assessment
Penalty
Summary
Facility staff failed to submit a required Minimum Data Set (MDS) admission assessment within the federally mandated timeframe for one resident. Clinical record review showed that the resident was admitted on a specific date, but the admission MDS assessment, while marked as in progress, did not have a documented completion or submission date within the required 14 days. This omission was confirmed through review of the resident's facesheet and MDS records. During an interview, the MDS coordinator, an LPN, acknowledged that the admission MDS was completed and submitted before the fourteenth day, but also stated that some MDS assessments had fallen behind due to staffing issues. The deficiency was brought to the attention of the administrator and acting DON, and no further information was provided prior to the survey exit.
Failure to Develop and Implement Baseline Care Plans for New Admissions
Penalty
Summary
Facility staff failed to develop and implement baseline care plans for two residents within 48 hours of admission, as required by facility policy. For one resident, who was admitted with muscle weakness and was cognitively intact, the baseline care plan did not address oral hygiene needs. The MDS coordinator confirmed that a baseline care plan for this resident was not developed, despite the facility's policy mandating a person-centered care plan be created within 48 hours of admission. For another resident, staff failed to implement the baseline care plan intervention for pressure injury treatment as ordered by the physician. The baseline care plan identified the resident as being at risk for skin breakdown and included an intervention to provide wound treatment as ordered. However, review of the electronic treatment administration record did not show evidence that the wound care was completed on a specified date, and there was no documentation of treatment refusal. Staff interviews confirmed that wound care should have been provided and documented according to the care plan.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that residents at risk for pressure ulcers did not consistently receive necessary interventions such as regular repositioning, skin assessments, or timely wound care. As a result, some residents developed new pressure ulcers or experienced worsening of existing wounds due to inadequate preventive and treatment practices.
Failure to Maintain Proper Catheter Care
Penalty
Summary
Facility staff failed to provide appropriate care and services for an indwelling catheter for one resident. Specifically, the staff did not keep the resident's catheter collection bag off the floor, as observed during the survey. The collection bag was found lying flat on the floor next to the resident's bed, contrary to the care plan intervention that required the catheter to be kept off the floor. The resident had a diagnosis of urinary retention and was alert with some forgetfulness at the time of admission. The physician's order specified the use of a 16FR indwelling catheter with a 10cc balloon to bedside straight drainage for urinary retention. The comprehensive care plan, initiated upon admission, included an intervention to keep the catheter off the floor. Despite these documented requirements, the deficiency was observed and brought to the attention of administrative staff, with no additional information provided prior to the survey team's exit.
Failure to Maintain Accurate Medical Record Documentation
Penalty
Summary
Facility staff failed to maintain a complete and accurate medical record for one resident. The clinical record for this resident documented a discharge date, but a progress note was entered with a date after the resident had already expired and was no longer in the facility. The note described an advanced care planning discussion with the resident's responsible party and the DON, referencing the resident's ongoing decline, multiple hospitalizations, and poor prognosis. However, the nurse practitioner who authored the note confirmed in an interview that the entry was made after the resident's death and should have been documented as a late entry, which it was not. The administrator reviewed the progress note and confirmed that the resident was not present in the facility on the date indicated in the documentation, acknowledging the inaccuracy of the medical record. Facility policy requires that documentation be completed at the time of service or during the shift in which care occurred, and that any late entries be clearly indicated as such. The failure to properly document the timing and nature of the entry resulted in an incomplete and inaccurate medical record for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 18 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fredericksburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fredericksburg Health And Rehab | 4.3 mi | — | 2 | 0 |
| Carriage Hill Health & Rehab Center | 5.4 mi | — | 2 | 0 |
| Falls Run Nursing And Rehabilitation | 5.5 mi | — | 0 | 0 |
| Berea Health & Rehab Center | 5.6 mi | — | 14 | 0 |
| Heritage Hall King George | 13.9 mi | — | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.