Woodstock Valley Health: Respiratory Device Left Unsanitary - VA
The device was an incentive spirometer, a tool used after surgery or during lung illness to help patients take slow, deep breaths and keep their lungs clear. At Woodstock Valley Health and Rehabilitation, this resident, identified in inspection records only as Resident 110, had one. She told inspectors she used it regularly. What she did not have was a physician's order authorizing the device, or a plastic bag to keep the mouthpiece from collecting whatever drifted through the air of a nursing home room.
State inspectors observed the uncovered spirometer on December 1, 2025, at 1:44 in the afternoon. Resident 110 confirmed she used it. She also told them that staff had never given her a cover for it.
Less than two hours later, inspectors sat down with a licensed practical nurse at the facility. The nurse was direct about what should have happened. Nurses need a physician's order for an incentive spirometer, she said, and that order should specify how often the resident is supposed to use it. Without an order, she explained, nurses would have no way of even knowing a resident was supposed to be using one. On storage, she was equally plain: the spirometer should be kept in a plastic bag for infection control.
No such order existed in Resident 110's clinical record. No bag had been provided.
Resident 110's admission records showed she was alert and oriented to person, place, time, and situation. She knew where she was and what was happening around her. She used the device because someone had apparently given it to her, even if no physician had signed off on it and no staff member had thought to hand her a bag.
The inspection was a complaint survey, meaning someone had flagged concerns about the facility before inspectors arrived. Of the 14 residents reviewed during the survey, Resident 110 was the one whose respiratory care fell short.
On December 2, the day after the spirometer was found sitting uncovered on the nightstand, inspectors briefed three facility administrators: the President of Operations, a traveling Director of Nursing, and an acting Director of Nursing. The facility did not produce a policy on incentive spirometer use before inspectors left.
The gap here is not complicated. A breathing device requires a physician's order. The order tells staff the device exists, tells them how often the resident should use it, and creates a record that connects the patient's lungs to a plan of care. Without it, nobody in a position of clinical authority had formally evaluated whether this resident needed the spirometer, how she should be using it, or whether she was using it correctly. She was simply doing it on her own, with a mouthpiece open to the air.
The infection control piece is its own concern. Nursing homes are environments where respiratory illnesses move quickly. An uncovered mouthpiece on a device that goes into a resident's mouth is not a minor oversight in that setting. The nurse who spoke with inspectors understood this. She named the plastic bag without being prompted. It is standard. It had not happened.
CMS rated the violation at the minimal harm level, meaning inspectors did not find evidence that Resident 110 had been injured. Whether her lungs benefited from the spirometer, suffered from the lack of oversight, or were affected in any way by the uncovered mouthpiece, the inspection record does not say. What it says is that she sat in her bed and breathed through a device that, as far as her clinical record was concerned, did not exist.
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 13, 2026 · Our methodology
Woodstock Valley Health and Rehabilitation in WOODSTOCK, VA was cited for violations during a health inspection on September 26, 2025.
The device was an incentive spirometer, a tool used after surgery or during lung illness to help patients take slow, deep breaths and keep their lungs clear.
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.