Woodstock Valley Health: Documentation Failures - VA
That is what federal inspectors found when they reviewed care at Woodstock Valley Health and Rehabilitation following a complaint inspection completed September 26, 2025.
The resident, identified in inspection records only as Resident 1, collapsed on August 10, 2025. A registered nurse told inspectors she had given the resident narcotic medication earlier that day. When the resident became unresponsive, the nurse administered two doses of Narcan, the opioid-reversal drug. Neither dose worked.
Another nurse tried to get vital signs. Resident 1 appeared not to be breathing. Her oxygen saturation level did not register on the monitor. The registered nurse placed an oxygen mask on her, a non-rebreather mask, and began chest compressions. She kept going until EMS arrived and the resident was transferred to the hospital.
A change-in-condition form from that day noted that Resident 1 was non-responsive, that staff called 911, and that she was sent to the hospital. That was the extent of the written record. The nurse's notes from August 10 contained nothing about what had actually happened in that room: no mention of the Narcan, no mention of the failed vital signs, no mention of the compressions, no mention of the oxygen mask.
When inspectors interviewed the registered nurse on September 23, she confirmed all of it and acknowledged she should have written it down.
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.
That gap, more than six weeks between the emergency and the inspection, means there is no contemporaneous clinical record of what interventions were attempted, in what order, and how Resident 1 responded to each one. For any clinician treating her afterward, or reviewing her care, the record shows only that she was once non-responsive and went to the hospital.
A second violation found during the same inspection involved a different nurse and a different kind of documentation failure, one that pointed in the opposite direction.
A licensed practical nurse had signed off on a medication in the medication administration record, the standard log that tracks what drugs residents receive and when. The signature indicated the medication had been given. It had not been. According to narcotic sign-off sheets, the drug was not even in the building at the time.
The LPN told inspectors directly: it was an error in documentation. She had signed the record as though she had administered the medication, but she had not given it.
The executive director and the vice president of operations were both told about this finding on September 24 at 5:32 p.m.
Inspectors classified both violations under the same deficiency, citing the facility's failure to maintain complete and accurate clinical records. The level of harm was listed as minimal harm or potential for actual harm, affecting few residents.
What the classification does not capture is the specific nature of what was missing. A nurse performed cardiopulmonary resuscitation on a resident who had received opioids and stopped breathing, and the only way inspectors learned the details was by interviewing the nurse herself, six weeks later. Had she left the facility, retired, or simply remembered it differently, that account would not exist anywhere in the clinical record.
Resident 1's condition after the hospital transfer, and whether she recovered, is not addressed in the inspection report.
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 resident, identified in inspection records only as Resident 1, collapsed 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.