Woodstock Valley Health: Missing Care Plan at Admission - VA
Not within 48 hours of admission. Not within a week. Not, as far as inspectors could determine eight months later, at any point before they arrived.
The finding emerged from a complaint inspection conducted September 26, 2025. Inspectors reviewed clinical records for 16 residents and flagged one: the woman admitted in January, identified in the report as Resident 3. Her nursing admission assessment documented each of her conditions clearly. What the record did not contain was a baseline care plan, the document that tells every nurse and aide who walks into a resident's room what that person needs and how to provide it.
On September 24, a licensed practical nurse explained to inspectors what the document was supposed to do. She said the admitting nurse would put things in the care plan like diet, mobility, behaviors, catheters, and colostomy. She described it as giving staff "a place to go to see how to take care of the residents." She said she was not sure whether a PICC line would appear on a baseline care plan, but that it should be "a quick overview of what they need to take care of the resident."
A PICC line is not a minor detail. It is a catheter inserted through a peripheral vein and advanced until its tip sits in a large vein near the heart, used to deliver medications, fluids, or nutrition over extended periods. Infections associated with PICC lines can enter the bloodstream directly. Proper maintenance, site assessment, and handling require staff to know the line is there and understand the protocol for it.
The administrator confirmed the gap the following morning. On September 25 at approximately 9:25 a.m., the administrator told inspectors that the facility did not have a baseline care plan for Resident 3 to provide. That afternoon, at 4:58 p.m., inspectors formally notified the administrator of the deficiency. No further information was provided before the inspection closed.
The facility's own policy, dated June 1, 2025, five months after Resident 3's admission, states that a baseline care plan must be developed within 48 hours of a resident's arrival and must include initial goals based on admission orders, physician orders, and dietary orders. The policy describes the document as necessary for "effective and person-centered care" meeting professional standards. The policy existed. The care plan did not.
CMS rated the violation at the lowest level of harm: minimal harm or potential for actual harm. One resident was affected.
What that classification does not capture is the specific vulnerability of this particular resident in those first days and weeks. She arrived dependent on insulin, meaning staff needed to know her dosing schedule and the signs of a glucose crisis. She arrived with a colostomy, requiring specific care to prevent skin breakdown and infection around the stoma. She arrived with wounds already present on her body, each requiring its own assessment and treatment plan. She arrived completely incontinent, a condition that, without a documented care approach, increases the risk of skin breakdown and infection. And she arrived with a central venous catheter that, if mishandled, creates a direct pathway for infection to reach her heart.
For each of those conditions, the baseline care plan is the document that answers the first question any unfamiliar staff member would ask: what do I do?
For Resident 3, for at least the eight months between her admission and the day inspectors walked in, the answer was not written down anywhere they could find.
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 12, 2026 · Our methodology
Woodstock Valley Health and Rehabilitation in WOODSTOCK, VA was cited for violations during a health inspection on September 26, 2025.
Not within 48 hours of admission.
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.