Woodstock Valley Health: CPR, Narcan Undocumented - VA
The inspection, completed September 26, 2025, was triggered by a complaint. What investigators found when they reviewed the clinical record for the resident identified as Resident 1 was a chart with a gap where one of the most serious medical events a nursing home can experience should have been recorded.
The resident had received a narcotic medication earlier on August 10, 2025. Later that day, she became unresponsive. The nurse who had given her the medication, RN #1, recognized the possibility of an opioid-related emergency and gave Narcan, the drug used to reverse opioid effects. She gave it twice. Neither dose worked.
A second nurse tried to get the resident's vital signs. RN #1 looked at the resident and saw she wasn't breathing. The oxygen saturation monitor returned no reading. RN #1 put a non-rebreather oxygen mask on the resident's face and began chest compressions. She kept going until EMS arrived and took the resident to the hospital.
A change-in-condition form dated August 10 noted that the resident was non-responsive, that staff had called 911, and that she had been transferred to the hospital. That was the extent of what the record captured. The Narcan. The failed doses. The absent breathing. The oxygen. The chest compressions. None of it appeared in the nurses' notes.
When investigators sat down with RN #1 on September 23, more than six weeks after the incident, she walked them through everything she had done that day. Then she told them she knew she should have written it down.
The facility's executive director was notified of the documentation failure on September 25 at 4:59 p.m.
The second violation investigators documented involved a different kind of record problem, though the mechanism was similar: something was marked as done that wasn't.
A licensed practical nurse, identified as LPN #1, had signed off on a medication in the medication administration record, the document nurses use to confirm a drug was given. When investigators reviewed the record with her on September 24, LPN #1 told them it was a documentation error. The medication had not actually been given because, according to the narcotic sign-off sheets, it was not in the building at the time.
A nurse signs a medication record to show evidence of administration. Here, the signature existed. The medication did not.
The executive director and the vice president of operations were informed of that finding on September 24 at 5:32 p.m.
Federal inspectors classified both deficiencies at a level of minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory framework's assessment of the documentation failures themselves. It does not describe what happened to Resident 1 on August 10, when a nurse pressed her hands to a resident's chest in a room where the oxygen monitor had gone flat, waiting for an ambulance, while the chart in the nurses' station recorded nothing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodstock Valley Health and Rehabilitation from 2025-09-26 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Woodstock Valley Health and Rehabilitation in WOODSTOCK, VA was cited for violations during a health inspection on September 26, 2025.
The inspection, completed September 26, 2025, was triggered by a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.