Woodstock Valley Health: Medication Records Failures - VA
That omission sat in a resident's clinical record at Woodstock Valley Health and Rehabilitation for more than six weeks before federal inspectors arrived.
When a registered nurse identified in inspection records only as RN #1 spoke with inspectors on September 23, she described the events of August 10 in detail. A resident, identified as Resident 1, had received narcotic medication earlier that day. At some point, she became unresponsive. RN #1 told inspectors she administered two doses of Narcan, a drug used to reverse opioid effects, but neither dose worked. A second nurse tried to get the resident's vital signs. The resident appeared not to be breathing. Her oxygen saturation level did not register on the monitor. RN #1 put her on oxygen through 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 it.
She hadn't.
The facility did have a change-in-condition form from that day, which noted the resident was non-responsive, that staff called 911, and that she was transferred to the hospital. That was the full extent of the written record. The nurses' notes for August 10 contained nothing about what happened, nothing about Narcan, nothing about compressions, nothing about oxygen, nothing about a resident who appeared to have stopped breathing in a nursing home bed.
A medical record stripped of that information is not a clerical inconvenience. Any clinician treating Resident 1 after that hospitalization, reading through the chart, would have no way of knowing she had received opioid medication and gone unresponsive, that two reversal doses had failed, or that staff had performed CPR before help arrived. The chart offered no picture of what had happened to her body that morning.
The documentation failure was not the only problem inspectors found.
A separate issue involved a narcotic that a nurse signed off as administered when it had never actually been given. A licensed practical nurse, identified as LPN #1, told inspectors on September 24 that a colleague had initialed the medication administration record indicating the drug was given, but the narcotic sign-off sheets showed the medication was not even in the building at the time. LPN #1 called it a documentation error. The nurse had signed for a controlled substance she had not dispensed.
The executive director and the vice president of operations were told about the medication documentation problem the same afternoon, at 5:32 p.m. on September 24. The executive director was separately informed of the charting failures around Resident 1's collapse the following day.
Inspectors classified both violations as causing minimal harm or potential for actual harm, and noted that few residents were affected. The complaint inspection was completed September 26.
What the record does not contain is any account of what happened to Resident 1 after EMS took her out. The inspection report does not say whether she survived, whether she recovered, or what her condition was when inspectors arrived more than six weeks later. The nurses' notes still said nothing about the morning she stopped breathing. RN #1's acknowledgment to inspectors, that she should have written it all down, is the most complete account that exists of what happened in that room.
It is not in the chart.
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 omission sat in a resident's clinical record at Woodstock Valley Health and Rehabilitation for more than six weeks before federal inspectors arrived.
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.