Woodmont Center

In the surveyor’s words

From the most serious findings on record at Woodmont Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 27, 2025

  Based on staff interviews, facility document review and clinical record review, the facility staff failed to implement interventions for the prevention of falls for two of 10 residents in the survey sample, Resident #3 and Resident #9. Resident #3 was assisted by one staff member on 9/24/23 at 2:00 a.m. Resident #3 was turned over in bed and rolled off the bed, suffering a right distal femoral fracture on the leg with a below the knee amputation, thus causing harm to the resident. The findings include: 1. […]

• No harm, potential for more than minimal, widespreadF814Apr 24, 2026

  Based on observation, staff interview and facility document review, the facility staff failed to maintain one of one facility dumpster area in a sanitary manner.The findings include:On 4/21/2026 at approximately 12:30 p.m., an observation of the facility's dumpster area located behind the facility was conducted with the dietary manager. The observation revealed debris scattered behind the dumpsters, which included a black egg crate, latex gloves, napkins and batteries. When asked, the dietary manager stated that kitchen oversees maintaining the area and staff had been sent out to clean the area today after the dumpster had been emptied this morning, but staff had not done a good job.A review of the facility's Dispose of Garbage and Refuse Policy, revealed, Dining Services Director… […]

• No harm, potential for more than minimal, widespreadF868Apr 24, 2026

  Based on staff interview and facility document review, it was determined that the facility staff failed to ensure attendance of the required staff for two of nine QAPI (quality assurance performance improvement) meetings reviewed.The findings include:Review of the provided facility QAPI meeting sign-in attendance sheets failed to evidence the administrator present at the Q4 (quarter 4) 2025 meeting and the medical director present at the Q1 (quarter 1) 2026 meeting. On 4/24/2026 at 11:19 AM, an interview was conducted with the administrator who stated that the QAPI team meets monthly and identifies areas for a new department to focus on. […]

• No harm, potential for more than minimal, widespreadF812Jan 25, 2023

  Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store, prepare and serve food in a sanitary manner in one of one facility kitchens and two of two facility unit pantries. The findings include: On [DATE] at 10:45 AM the kitchen tour was conducted with OSM #1 (Other Staff Member), the dietary manager. The following items were identified: 1. In the dry storage area: trash was on the floor, a plastic cup was on the floor, the floor was sticky, a dry cereal bag was open and exposed. 2. In the refrigerator: A facility generic plastic storage container of fudge was observed and expired on [DATE]. A block of cheese in a plastic bag, was not sealed. 3. […]

• No harm, potential for more than minimal, patternF550Apr 24, 2026

  Based on observation, staff interview, facility document review, and clinical record review, the facility failed to assist residents to exercise the right to vote for one of 50 residents in the survey sample. Resident #43 and one of one facility. The findings include: 1.For Resident #43 (R43), the facility failed to inform the resident about her voting rights and the voting process. A review of R43's Quarterly Minimum Data Set (MDS) completed on 3/19/26 reveals BIMS (Brief Interview for Mental Status) score13/15, indicating the resident was not cognitively impaired for making daily decisions. On 4/22/2026 at 11:30 AM an interview was conducted with R43. She stated, no one came to me about voting on Tuesday. […]