Woodstock Valley Health: Infection Control Failure - VA
A Centers for Disease Control poster affixed to a resident's room at Woodstock Valley Health and Rehabilitation listed, in plain language, exactly what staff were required to do before touching the person inside. Wear gloves. Wear a gown. This applied specifically, the sign noted, to wound care involving any skin opening that required a dressing.
On December 2, 2025, at 11:24 in the morning, a licensed practical nurse walked past that sign, entered the room, and performed wound care on a stage 4 pressure injury on the resident's sacrum. She did not wear a gown.
A stage 4 pressure injury is among the most severe wounds a person can develop. The damage extends through the full thickness of skin and tissue, reaching fascia, muscle, tendon, ligament, cartilage, or bone. The wound may tunnel inward. The edges may curl. Dead tissue collects at the base. For a resident with this kind of injury, infection is not a theoretical risk.
The resident, identified in inspection records only as Resident 104, had been seen by a wound care physician on November 28, 2025. The physician documented the stage 4 sacral wound and ordered daily cleansing with wound cleanser, followed by application of Medihoney and foam dressing. What the clinical record did not contain, inspectors found, was a physician's order for enhanced barrier precautions, the infection control protocol designed to reduce the spread of multidrug-resistant organisms in nursing home settings. The protocol requires gown and glove use during high-contact care activities for residents with open wounds.
The CDC sign on the door was there anyway. The facility's own written policy required gown use during wound care. Neither stopped what inspectors watched happen.
Twenty-four minutes after the wound care was completed, inspectors interviewed the nurse, identified as LPN #5. She acknowledged the sign on the door had documented that she was supposed to wear a gown. She said she did not.
That afternoon, at 3:24 p.m., inspectors notified three members of the facility's administrative leadership: the President of Operations, a traveling Director of Nursing, and an acting Director of Nursing. All three were made aware of what inspectors had observed. No additional information was provided before inspectors left the building.
Enhanced barrier precautions exist because multidrug-resistant organisms move between people through contact, and nursing home residents, many of whom have open wounds, compromised immune systems, or invasive medical devices, are among the most vulnerable to acquiring them. A gown is a barrier. Skipping it during wound care on a resident with exposed tissue is not a minor procedural lapse.
The inspection, conducted as a complaint survey on September 26, 2025, identified this as the single infection control failure in a sample of 14 residents. Inspectors classified the level of harm as minimal harm or potential for actual harm, affecting a small number of residents.
What the classification does not capture is what Resident 104 was left with: a wound deep enough to expose bone or muscle, daily dressing changes, and at least one instance of a nurse performing that care without the protective equipment the door itself said was required.
The nurse knew. She said so.
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.
This applied specifically, the sign noted, to wound care involving any skin opening that required a dressing.
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.