Woodstock Valley Health: CPR Undocumented After Narcan - VA
The incident happened on August 10, 2025. Inspectors learned about it six weeks later, during a complaint investigation that concluded September 26.
The nurse, identified in inspection records only as RN #1, told inspectors what happened that morning. She had given the resident — referred to in the report as Resident 1 — a narcotic medication earlier in the day. When the resident became unresponsive, RN #1 said she immediately suspected the opioid and administered two doses of Narcan, the medication used to reverse opioid effects. Neither dose worked.
A second nurse tried to get the resident's vital signs. RN #1 said the resident looked like she wasn't breathing. Her oxygen saturation level didn't register on the monitor. RN #1 put her on a non-rebreather mask and began chest compressions. She kept going until EMS arrived and took the resident to the hospital.
RN #1 told inspectors she knew she should have documented all of this in the clinical record. She hadn't.
What inspectors found in the chart was a change-in-condition form dated August 10 that said only that the resident was non-responsive, that staff called 911, and that she was transferred to the hospital. The nurses' notes from that same date contained nothing about the unresponsiveness, nothing about the Narcan, nothing about the oxygen, nothing about the chest compressions.
The executive director was notified of the documentation failure on September 25 at 4:59 p.m. The inspection report states that no further information was presented before inspectors left the building.
The missing documentation was not the only medication concern inspectors found.
A separate review of the facility's medication administration records turned up a narcotic that a nurse had signed off as given — checked off on the MAR, the medication administration record that serves as the official log of what residents receive and when. LPN #1, the nurse whose initials appeared on the record, told inspectors that signing off on the MAR is how a nurse documents that she gave a medication.
Then she said she hadn't given it.
LPN #1 told inspectors it was an error in documentation. The drug hadn't been administered, she said, because it wasn't in the building. A review of the narcotic sign-off sheets confirmed the medication was not present at the facility when the nurse signed that it had been given.
The executive director and the vice president of operations were notified of that finding on September 24 at 5:32 p.m.
Together, the two violations describe a facility where the paper record of what residents receive — and what happens to them when something goes wrong — cannot be trusted to reflect reality. A narcotic appears as administered when it was never in the building. A medical emergency involving CPR and two doses of a reversal drug goes unrecorded entirely.
For Resident 1, the gap in documentation means that anyone reviewing her chart after August 10 — a physician, a specialist, a nurse on a later shift — would have had no way of knowing she had stopped breathing, that her oxygen saturation had dropped off the monitor, or that she had received Narcan twice without response. The chart would have told them only that she went to the hospital.
Inspectors classified both deficiencies as causing minimal harm or potential for actual harm, and noted that few residents were affected. The facility was directed to contact the nursing home or the state survey agency for information on its plan to correct the findings.
What the plan says about Resident 1, and whether she recovered, the inspection report does not say.
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 incident happened on August 10, 2025.
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.