Woodstock Valley Health: Medication Records Falsified - VA
That finding emerged during a complaint inspection completed September 26, 2025, at the facility on South Main Street. Inspectors identified two separate documentation failures, both involving narcotics, both involving residents whose safety depended on accurate records.
The first came to light when inspectors reviewed a medication administration record with LPN #1. The nurse acknowledged her signature was on the record, indicating she had given the medication. She hadn't. The narcotic sign-off sheets confirmed it was never in the building. LPN #1 told inspectors it was "an error in documentation."
A nurse signing off on a controlled substance she never gave is not a paperwork technicality. Narcotic administration records exist precisely because opioids are dangerous, tracked, and their effects on patients need to be known by every clinician who touches that patient afterward.
The executive director and the vice president of operations were informed of the finding the same afternoon.
The second violation is harder to read.
On August 10, 2025, a resident identified in the inspection report as Resident 1 became unresponsive. The registered nurse on duty, RN #1, told inspectors she had given Resident 1 a narcotic medication earlier that day. When the resident stopped responding, RN #1 administered two doses of Narcan, the medication used to reverse opioid effects. Neither dose worked.
Another nurse tried to get the resident's vital signs. They couldn't. Resident 1 wasn't visibly breathing. Her oxygen saturation level didn't register on the monitor.
RN #1 put an oxygen mask on her, a non-rebreather mask that delivers the highest concentration of oxygen possible outside of intubation, and began chest compressions. She kept doing compressions until EMS arrived and took Resident 1 to the hospital.
None of that was in the nursing notes.
The change-in-condition form from that day noted that Resident 1 was non-responsive, that staff called 911, and that she was transferred to the hospital. That was the extent of the documentation. The nurses' notes for August 10 contained nothing about what had actually happened in that room: no mention of the narcotic, no mention of the Narcan doses that failed, no mention of the oxygen mask, no mention of the chest compressions.
RN #1, when interviewed by inspectors on September 23, did not dispute any of it. She confirmed every detail and said she should have documented it.
What a nurse documents after a medical emergency is not a formality. It is the record that tells the next shift what happened, tells the physician what interventions were tried, tells anyone reviewing the case what the patient's body went through. When a resident receives two doses of Narcan that don't reverse an opioid effect and then requires CPR, that information belongs in the chart. It didn't make it there.
The executive director was notified of the documentation failure on September 25.
Inspectors classified both deficiencies as causing minimal harm or potential for actual harm, and noted that few residents were affected. The facility's plan of correction is available through the nursing home or the Virginia state survey agency.
What the records don't show is what happened to Resident 1 after the ambulance left.
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.
That finding emerged during a complaint inspection completed September 26, 2025, at the facility on South Main Street.
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.