Woodstock Valley Health And Rehabilitation

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Based on observation, staff interview and clinical record review, it was determined that facility staff failed to promote a resident's dignity for one of 16 current residents in the survey sample, Residents #8 (Resident R8). The findings include:For Resident R8, facility staff stood while providing feeding assistance. Resident R8 was admitted to the facility with diagnoses that included but were not limited to swallowing difficulties. On the most recent comprehensive MDS (minimum data set), a significant change assessment with an ARD (assessment reference date) of 08/13/2025, Resident R8 scored 3 (three) out of 15 on the BIMS (brief interview for mental status), indicating Resident R8 was severely impaired of cognition for making daily decisions. GG0130 Self-Care coded Resident R8 as being dependent for eating. 09/23/2025 at approximately 8:08 a.m., an observation revealed Resident R9 in bed being fed by CNA (certified nursing assistant) #2. Further observations revealed CNA #2 standing next to

the bed while feeding Resident R8. Observation of Resident R9's meal tray revealed food was p[placed in bowls. The comprehensive care plan for Resident R8 dated 10/29/2018 documented in part, Focus. (Resident R8) has an ADL self-care performance deficit r/t (related to) Vascular dementia (1), history of CVA (cerebral vascular accident) (2), and impaired cognition. Date Initiated: 10/29/2018. Under Interventions it documented in part, EATING: (Resident R8) is dependent on staff for feeding Date Initiated: 10/29/2018. On 09/24/2025 at approximately 4:35 p.m. an

interview was conducted with CNA (certified nursing assistant) #2. When asked to describe how she positioned herself when she fed Resident R8 on 09/23/2025 during breakfast CNA #2 stated she was standing next to Resident R8 while feeding her. She further stated that it was not dignified to be standing while assisting a resident with eating/feeding. The facility's policy Resident Rights documented in part, 4. Respect and dignity. The resident has a right to be treated with respect and dignity, including: c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit. References:(1) A gradual and permanent loss of brain function. This occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior.

Vascular dementia (VaD) is caused by a series of small strokes over a long period. This information was obtained from the website: https://medlineplus.gov/ency/article/000746.htm.(2) A stroke. This information was obtained from the website: https://medlineplus.gov/ency/article/000726.htm.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, facility document review and clinical record review, the facility staff failed to maintain a resident's right to be treated with respect and dignity, including the right to retain their personal belongings for one of 16 residents in the survey sample, Resident #2. The findings include: For Resident #2 (Resident R2), the facility staff failed to maintain the resident's right to display her personal belongings.The resident was admitted to the facility on [DATE REDACTED], with diagnoses that included but were not limited to: diabetes, obesity, high blood pressure, sleep terrors, insomnia, depressive disorder, anxiety disorder, osteoarthritis, post-traumatic stress disorder, and pain. On the most recent MDS (minimum data set) assessment, an annual assessment, with an ARD (assessment reference date) of 8/3/25, the resident scored a 15 out of 15

on the BIMS (brief interview for mental status) score, indicating the resident was not cognitively impaired for making daily decisions. In Section E - Behavior, the resident was not coded as having any behaviors during

the lookback period. The nurse's note dated 3/29/25 at 3:29 p.m. documented, Resident has been agitated and verbally inappropriate to staff this shift. Resident came up to med (medication) cart crying and stated that she was going through withdrawal, and she felt like she was dying and couldn't do this anymore. DON (director of nursing), NP (nurse practitioner), Police and EMS (emergency medical services) notified.

Resident refused to cooperate with all party's (sic) involved.The Ombudsman's report dated 4/29/25, documented in part, Additionally, the DON removed the resident's personal signs from her door without her permission, and they were not an immediate harm to anyone. This both violated her right to maintain her personal possessions and escalated the mental anguish of the resident during this interaction. An interview was conducted with Resident R2 on 9/23/25 at 10:00 a.m. The resident stated on 3/29/25, the DON at that time removed her signs, that she had made, from her door without her permission. Resident R2 stated she just ripped them off the door stating it was a health department violation. Resident R2 stated she didn't ask my permission to do so. When asked how that made her feel, Resident R2 stated she was angry that she did that, they were her belongings. An interview was conducted with OSM (other staff member) #1, the social worker, on 9/24/25 at approximately 9:30 a.m. OSM #1 stated the resident was very upset that ASM (administrative staff member) #4 removed her signs off her door. She stated the resident was angry that ASM #4 did that. An

interview was conducted with ASM #4, the former DON, on 9/24/25 at 10:22 a.m. When asked if she removed the resident's handmade signs off the door or walls, ASM #4 stated she did remove them as they were a health department violation due to infection control concerns.An interview was conducted with LPN #4 on 9/24/25 at 9:03 a.m. She stated the resident had posters on her door and clothing stating that she was being mistreated and wasn't getting her medications. ASM #4 ripped the signs off the door. LPN #4 stated she didn't hear ASM #4 ask permission to remove them off the door, stating it was a fire hazard. The facility policy, Resident Rights documented in part, Resident rights. The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . Respect and dignity. The resident has a right to be treated with respect and dignity, including: The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. ASM #1, the executive director and ASM # 6, the vice president of operations, were made aware of the above concern

on 9/25/25 at 5:32 p.m. No further information was provided prior to exit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

wander guard applied, and safety checks initiated. Recommendations of Primary Clinician (if any): Wanderguard. Name of Family/Health Care Agent Notified: Resident is his own RP (responsible party).The progress notes for Resident R4 documented in part, 07/08/2024 03:47 Note Text: Resident caught outside of the front parking lot by a staff member. Resident was walked back. [Name of staff member] notified to care plan for a wander guard.On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that when a resident has a change in condition they documented everything on the change in condition form and notified the physician and responsible party. She stated that even if the resident was their own responsible party if there was an emergency, they contacted the next of kin to notify them what was happening and documented that in the medical record. LPN #2 stated that if the resident was having an emergency and a change in condition they may not be able to understand what was happening and the family needed to know. She reviewed the documentation for Resident R4 and stated that the next of kin for Resident R4 should have been made aware of the elopement and wander guard because at the time of the elopement and need for a wander guard she would question if they would be able to be their responsible party.On 9/25/2025 at 4:58 p.m., ASM (administrative staff member) #1, the administrator, was made aware of the concern.No further information was provided prior to exit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583

resident has a right to secure and confidential personal and medical records. No further information was presented prior to exit.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584

conducted.

Level of Harm - Minimal harm or potential for actual harm

An observation of the wall behind the head-of-the-bed of the A-side revealed gouges in the wall exposing

the inside of the plaster board covering an area approximately four foot wide by two feet high. Observation of the wall behind the head-of-the-bed of the A-side revealed gouges in the wall exposing the inside of the plaster board covering an area approximately four foot wide by two feet high.

Residents Affected - Some

On 09/23/2024 at approximately 9:45 a.m., an observation of resident room [ROOM NUMBER] revealed a gouged, unpainted plaster patch on the lower portion of the wall between the resident's dresser and the bathroom door covering an area approximately two feet wide by 18 inches high.

On 09/24/2024 at approximately 9:40 a.m., an observation of resident room [ROOM NUMBER] was conducted. An observation of the wall behind the head-of-the-bed of the A-side revealed gouges in the wall exposing the inside of the plaster board covering an area approximately four foot wide by two feet high.

Observation of the wall behind the head-of-the-bed of the A-side revealed gouges in the wall exposing the inside of the plaster board covering an area approximately four foot wide by two feet high.

On 09/24/2024 at approximately 9:40 a.m., an observation of resident room [ROOM NUMBER] revealed a gouged , unpainted plaster patch on the lower portion of the wall between the resident's dresser and the bathroom door covering an area approximately two feet wide by 18 inches high.

On 09/24/2025 at approximately 2:35 p.m. an interview was conducted with OSM #4, plant operator and maintenance director. When asked to describe the procedure for keeping resident rooms in good repair he stated that staff will usually tell him when something needs to be fixed in a resident's room. He also stated that each nurse's has maintenance request log that staff fill in when something in a resident's room in in need of repair. He stated he does walk-throughs checking resident rooms for repairs but that it is inconsistent. At approximately 2:55 p.m. an observation of resident rooms [ROOM NUMBERS] was conducted with OSM #4. He agreed with the findings as stated above and stated the rooms needed repair and it did not present a homelike environment.

On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings.

No further information was provided prior to exit.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

police and EMS were involved. The day after the incident she received calls from her boss asking about the commotion over the weekend. She spoke with Resident R2, and resident informed her that the police were there on 3/29/25 and ASM #4 was trying to TDO her. The resident informed ASM #1 that she could hear the conversation between the police and ASM #4 and her anxiety and PTSD were affected. It was only after the Ombudsman's visit and report that the investigation was reopened. ASM #4 was suspended, brought back for a short period of time and then terminated on the grounds of violation of resident rights and mental abuse.An interview was conducted on 9/24/25 at 3:09 p.m. with ASM #6, the vice president of operations.

ASM #6 stated she was not in the building at the time of the incident. She stated when Ombudsman's report came, we investigated it further and found that the conclusion was that there was a concern for violating Resident R2 rights and neglect. When asked if psychosocial harm was found, ASM #6 stated, It could have been also.An interview was conducted with ASM #7, the psychiatric nurse practitioner, that saw the resident on 5/22/25. ASM #7 reviewed her notes and stated the resident told her about the case with APS and it was when the facility tried to TDO her. The resident explained to her that she was afraid of police coming into the building after the 3/29/25 incident.The facility policy, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including

a caretaker, of goods or services that are necessary to attain or maintain physic

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

residents medications that they had brought in on admission to take home with them and she was not sure of the process if the prescriptions had not been signed or sent prior to discharge to ensure that medications were available when the resident got home.On 9/25/2025 at 4:05 p.m., an interview was conducted with LPN #1 who stated that the social worker notified them when a resident was being discharged . She stated that nursing filled out three sections of the discharge instructions, reviewed the medications and set up any follow up appointments as needed. LPN #1 stated that the discharging nurse should perform a skin assessment, check the vital signs and go over the discharge instructions, educating the resident on any needs and the medications. She stated that they had the resident sign the discharge instructions and copied them for their records and sent a copy with the resident. LPN #1 stated that the nurse should write a note documenting the discharge in the clinical record and this process was for continuity of care.The facility policy Discharge Planning Progress dated 6/1/25 documented in part, . The facility will assist residents and their resident representatives in choosing an appropriate post-acute care provider (i.e., another SNF (skilled nursing facility), HHA (home health agency), IRF (inpatient rehab facility), or LTCH (long term care hospital)) that will meet the resident's needs, goals, and preferences. The Social Services Director, or designee, shall compile available data on other post-acute care options to present to the resident, including, but not limited to: Data on providers within the resident's desired geographic area, where available. Quality measure data, based on standardized patient assessment data, publicly available on the CMS Care Compare website. Data on resource use to the extent the data is available, such as number of residents/patients are discharged to the community, and rates of potentially preventable hospital readmissions. The facility will ensure that the data used is relevant and applicable to the resident's goals of care and treatment preferences. The facility will present provider information to the resident and resident representative, if applicable, in an accessible and understandable format, and will answer any questions to assist in the resident's/representative's understanding. All relevant information will be provided in a discharge summary to avoid unnecessary delays in the resident's discharge or transfer, and to assist the resident in adjustment to his or her new living environment. Education needs, as identified in the discharge plan, will be provided to the resident and/or family member prior to discharge.On 9/25/2025 at 4:58 p.m., ASM #1, the administrator was made aware of the concern.No further information was provided prior to exit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on clinical record review, staff interview and facility document review, it was determined that the facility staff failed to develop a baseline care plan for one of 16 residents in the survey sample, Resident #3.The findings include:For Resident #3 (Resident R3), the facility staff failed to develop a baseline care plan.The nursing admission assessment for Resident R3 dated 1/23/2025 documented the resident admitted with a PICC (peripherally inserted central catheter) access, always being incontinent of bowel and bladder, having multiple wounds present on admission, a colostomy, and taking insulin.Review of the clinical record failed to evidence a baseline care plan developed within 48 hours of Resident R3's admission of 1/23/2025.On 9/24/2025 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2 who stated that the baseline care plan was developed by the admitting nurse. She stated that the purpose of the care plan was to give them a place to go to see how to take care of the residents. She stated that the admitting nurse would put things in the care plan like diet, ability to move, behaviors, catheters, and colostomy. LPN #2 stated that she was not sure if the PICC line would be on the baseline care plan or not, but it should be a quick overview of what they need to take care of the resident. On 9/25/2025 at approximately 9:25 a.m., ASM (administrative staff member) #1, the administrator, stated that they did not have a baseline care plan for Resident R3 to provide.The facility policy Baseline Care Plan dated 6/1/2025 documented in part, The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will: Be developed within 48 hours of a resident's admission. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: Initial goals based on admission orders. Physician orders. Dietary orders.On 9/25/2025 at 4:58 p.m., ASM #1, the administrator, was made aware of the concern.No further information was provided prior to exit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

assistants) as they were noted or communicated to them. LPN #2 stated that treatments were evidenced as completed by documentation in the eTAR. She stated that the facility formerly had a wound care nurse practitioner who came in weekly and assessed residents pressure injuries, measuring them and adjusting treatments as needed but they did not come there any longer. She stated that she had been on night shift and was not sure of the current process but if a new wound was reported to her she asked a nurse trained

in wounds to measure it and referred it to the physician for treatment.

On 9/24/2025 at 4:56 p.m., an interview was conducted with ASM (administrative staff member) #2, the director of nursing who stated that the former assistant director of nursing used to keep a log sheet where

she tracked pressure injuries and measured them weekly but had stepped down from the position. She stated that there was an assessment that they could complete in the electronic medical record to record their assessments but there had been a lapse due to the assistant director stepping down, and the wound nurse practitioner leaving. She stated that she could say that after the assistant director of nursing stepped down there was a period when there was a gap in tracking and measuring but they had a new doctor who started last week to assist them. ASM #2 stated that Resident R6 was non-compliant with repositioning and tended to lay flat on her back or on the left side.

On 9/25/2025 at 4:58 p.m., ASM #1, the administrator, was made aware of the concern.

No further information was provided prior to exit.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm

treatment plan .Patients need to know how to take medications properly and the risks associated with failing to do so .

On 9/25/2025 at 4:58 p.m., ASM (administrative staff member) #1, the administrator, was made aware of

the concern.

Residents Affected - Few No further information was provided prior to exit.

Reference: (1) Carvedilol: MedlinePlus Drug Information (2) Valsartan and Sacubitril: MedlinePlus Drug Information

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

No further information was obtained prior to exit.

Level of Harm - Minimal harm or potential for actual harm

References:

Residents Affected - Some

1. 1. Hydrofera Blue® creates a multifaceted, non-toxic environment for wound healing. Hydrofera Blue's

unique capillary action continuously pulls harmful bacteria- laden slough, exudate, and debris away from

the wound bed. This information was obtained from the following website: https://hydrofera.com/why-blue/

2. 3. For Resident #7 (Resident R7), the facility staff failed to administer the medication melatonin on multiple dates in

July 2025 and September 2025.

A review of Resident R7's clinical record revealed a physician's order dated 3/5/25 for melatonin 5mg (milligrams).

Two tablets by mouth at bedtime for insomnia. A review of Resident R7's July 2025 and September 2025 MARs (medication administration records) failed to reveal evidence that melatonin was administered on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/25/25, 7/26/25, 7/28/25, 9/15/25, 9/16/25, 9/17/25, and 9/18/25 (as evidenced by blank spaces on the MARs). A review of the in-house over-the-counter medication supply list revealed melatonin 5mg tablets were available in the facility.

On 9/24/25 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated nurses evidence the administration of medications by documenting the medications were administered on

the MAR.

On 9/25/25 at 3:51 p.m., another interview was conducted with LPN #2. LPN #2 stated that if a medication is not available in the medication cart, the nurse should obtain the medication from the facility stock of over-the-counter medications or Omnicell (a machine containing various medications) if the medication is available there.

On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of

the above concern.

No further information was presented prior to exit.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

injuries and measured them weekly but had stepped down from the position. She stated that there was an assessment that they could complete in the electronic medical record to record their assessments but there had been a lapse due to the assistant director stepping down, and the wound nurse practitioner leaving.

She stated that she could say that after the assistant director of nursing stepped down there was a period when there was a gap in tracking and measuring but they had a new doctor who started last week to assist them. ASM #2 stated that Resident R6 was non-compliant with repositioning and tended to lay flat on her back or on

the left side. On 9/25/2025 at 4:58 p.m., ASM #1, the administrator, was made aware of the concern.No further information was provided prior to exit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689

2/4/25-Wanderguard placement every shift (resolved/discontinued on 2/6/25).

Level of Harm - Immediate jeopardy to resident health or safety

Further review of Resident R7's clinical record failed to reveal any further elopement risk evaluation since 2/2/25, revealed the physician's order for a WanderGuard was discontinued on 2/6/25, and failed to reveal any documentation why the WanderGuard was discontinued or documentation of any further interventions to prevent elopement.

Residents Affected - Few

On 9/23/25 at 2:09 p.m., an observation of Resident R7 was conducted. The resident was observed ambulating with

a walker in the hall and was not wearing a WanderGuard. Also, the resident's room was not located on the locked Alzheimer's unit.

On 9/24/25 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated if a resident is at risk for elopement, the nurse should discuss this with the physician, social services, administrator, and minimum data set coordinator to determine if the resident is suitable for a WanderGuard and update the resident's care plan. LPN #2 stated an additional elopement risk assessment should be done before discontinuing an elopement intervention such as a WanderGuard to make sure the resident truly is no longer at risk for elopement.

On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of

the above concern.

The facility policy titled, Elopements and Wandering Residents documented, 4. Monitoring and Managing Residents at Risk for Elopement or Unsafe Wandering a. Residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary care plan team. b. The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. c. Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. d. Adequate supervision will be provided to help prevent accidents or elopements. e. The IDT (Interdisciplinary Team) will monitor the implementation of interventions, response to interventions, and document accordingly. f. The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff.

No further information was presented prior to exit.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695

Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, resident interview, staff interview, and clinical record review, the facility staff failed to provide respiratory care and services for one of 14 residents in the survey sample, Resident #110. The findings include:For Resident #110 (Resident R110), the facility staff failed to obtain a physician's order for the use of an incentive spirometer (1) and failed to store the incentive spirometer in a sanitary manner. Resident R110's admission minimum data set assessment was not complete. A clinical admission assessment dated [DATE REDACTED] documented Resident R110 was alert and oriented times four (to person, place, time, and situation). A review of Resident R110's clinical record failed to reveal a physician's order for an incentive spirometer. On 12/1/25 at 1:44 p.m., Resident R110 was observed sitting up in bed. An incentive spirometer was observed sitting on the resident's nightstand, with the mouthpiece uncovered. Resident R110 stated she used the incentive spirometer, and staff had not provided a cover for the device. On 12/1/25 at 3:51 p.m., an interview was conducted with LPN (Licensed Practical Nurse) #1. LPN #1 stated nurses should obtain a physician's order for an incentive spirometer and the order should include how often the resident should use it. LPN #1 stated nurses would not know that a resident is supposed to use an incentive spirometer unless there was an order. LPN #1 stated an incentive spirometer should be stored in a plastic bag for infection control purposes. On 12/2/25 at 3:24 p.m., ASM (Administrative Staff Member) #1 (the [NAME] President of Operations), ASM #2 (the traveling Director of Nursing), and ASM #3 (the acting Director of Nursing) were made aware of the above concern. The facility did not provide a policy regarding an incentive spirometer. No further information was presented prior to exit. Reference:(1) Your health care provider may recommend that you use an incentive spirometer after surgery or when you have a lung illness, such as pneumonia. The spirometer is a device used to help you keep your lungs healthy. Using the incentive spirometer helps you take slow deep breaths.

This information was obtained from the website: https://medlineplus.gov/ency/patientinstructions/000451.htm

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

nurse evidence she's given a medication by checking it off on the MAR. The above MARs, narcotic sheet and nurse's notes were reviewed with LPN #1. She verified that the resident did not receive her Fentanyl patch for 12 days in March and missed doses of Fentanyl in September per the documentation. The facility policy, Pain Management documented in part, The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. ASM (administrative staff member) #1, the executive director, and ASM #6, the vice president of operations, were made aware of the above concern on 9/24/25 at 5:32 p.m. No further information was obtained prior to exit. References:. 1. This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a601202.html

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

coordinator for sister facility. After reviewing the As Worked schedule for the dates listed above, she agreed that the facility was short staffed on the 3-11 shift for the dates listed above. The facility's policy Nursing Services and sufficient Staff documented in part, Policy: It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. The facility's census, acuity and diagnoses of the resident population will be considered based on the facility assessment. Policy Explanation and Compliance Guidelines: 3. The facility is required to provide licensed nursing staff 24 hours a day (except when waived), along with other nursing personnel, including but not limited to nurse aides. 5. Providing care includes, but is not limited to, assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on

a full time basis.

Based on staff interview, and facility document review, the facility staff failed to meet RN (registered nurse) requirements for 16 of 31 days reviewed. The findings include:1. The facility staff failed to provide RN coverage for eight consecutive hours a day on 8/25/25, 8/30/25, 8/31/25, 9/13/25, and 9/14/25. A review of nursing schedules revealed there was no RN coverage for eight consecutive hours on 8/25/25, 8/30/25, 8/31/25, 9/13/25, and 9/14/25. On 9/25/25 at 1:45 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated there had not been eight consecutive hours of RN coverage in the facility and there was only one other RN besides her working at

the facility. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. The facility policy titled, Nursing Services-Registered Nurse (RN) documented, The facility will utilize the services of a Registered Nurse for at least 8 consecutive hours per day, 7 days per week. No further information was presented prior to exit. 2. The facility staff failed to ensure

the Director of Nursing did not serve as a charge nurse on 8/25/25, 8/27/25, 8/29/25, 9/2/25, 9/8/25, 9/9/25, 9/10/25, 9/11/25, 9/12/25, 9/15/25, 9/19/25, and 9/20/25. A review of the nursing schedules revealed the Director of Nursing served as a charge nurse on 8/25/25, 8/27/25, 8/29/25, 9/2/25, 9/8/25, 9/9/25, 9/10/25, 9/11/25, 9/12/25, 9/15/25, 9/19/25, and 9/20/25. A review of nurse staffing postings revealed the resident census on all of those dates was greater than 60 residents. On 9/25/25 at 1:45 p.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated she was told

she was not supposed to work as a nurse on the floor unless there was a crisis, but if we don't have any other choice then we don't have a choice. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern.The facility policy titled, Nursing Services-Registered Nurse (RN) documented, The Director of Nursing may serve as a charge nurse only when the facility has average daily occupancy of 60 or fewer residents. No further information was presented prior to exit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730

Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or potential for actual harm

Based on staff interview, and facility document review, the facility staff failed to complete an annual performance review for four of five CNA (certified nursing assistant) reviews. The findings include:For CNA #3, CNA #4, CNA #5, and CNA #6, the facility staff failed to complete an annual performance review. CNA #3 was hired on 8/22/23. CNA #3's most recent performance review was completed on 8/27/24.CNA #4 was hired on 6/13/23. CNA #4's most recent performance review was completed on 7/23/24.CNA #5 was hired on 7/20/21. CNA #5's most recent performance review was completed on 7/22/24.CNA #6 was hired

on 2/15/23. CNA #6's most recent performance review was completed on 7/31/24. On 9/25/25 at 1:45 p.m.,

an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated she did not know who was responsible for ensuring the completion of CNA performance reviews because she had only been the director of nursing since April 2025 and had never been a director of nursing before then. ASM #2 stated she assumed CNA performance reviews should be completed every year based on the CNA's hire date. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. The facility policy titled, Nurse Aide Training Program documented, 2.b. It is the responsibility of the employee to attend/complete mandatory in-service trainings to maintain employment status with the facility. A review of the employee's attendance/completion records shall be performed at least annually, such as at time of performance review. No further information was presented prior to exit.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732

Post nurse staffing information every day.

Level of Harm - Potential for minimal harm

Based on staff interview and facility document review, the facility staff failed to meet nurse staffing information requirements for 31 of 31 days reviewed. The findings include:The facility staff failed to ensure

the total number and the actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides directly responsible for resident care per shift was documented on the nurse staffing information postings from 8/25/25 through 9/24/25, and failed to ensure accurate nurse staffing information was posted on 9/23/25. A review of nurse staffing information postings from 8/25/25 through 9/24/25 failed to reveal the total number and the actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides (the postings only documented the total number and the actual hours worked by licensed staff and unlicensed staff). On 9/23/25 at 4:05 p.m., an observation of the posted nurse staffing information was conducted. The posting was dated 9/19/25. At this time, ASM (administrative staff member) #1 (the executive director) stated the staffing coordinator resigned the previous day. On 9/25/25 at 10:45 a.m., an interview was conducted with OSM (other staff member) #8 (the staffing coordinator from a related facility). OSM #8 stated she used to manually complete the nurse staffing information postings but now the postings are generated from the online scheduling system and only document the total number and the actual hours worked by licensed staff and unlicensed staff. In regard to the posting of nurse staffing information, OSM #8 stated the information should be posted each morning, every day. On 9/25/25 at 4:59 p.m., ASM #1 was made aware of the above concern. The facility policy titled, Nurse Staffing Information Posting documented, The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information:d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides. No further information was presented prior to exit.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755

of the concern.

Level of Harm - Minimal harm or potential for actual harm

No further information was provided prior to exit.

Reference:

Residents Affected - Some (1) Daptomycin Injection: MedlinePlus Drug Information (2) Epoetin Alfa, Injection: MedlinePlus Drug Information (3) Pregabalin: MedlinePlus Drug Information

1. 2. For Resident #7 (Resident R7), the facility staff failed to ensure the medications Ziprasidone and Flomax were

available for administration on multiple dates July 2025 through September 2025.

A review of Resident R7's clinical record revealed the following physician's orders: 3/14/25-Ziprasidone 60mg (milligrams). One capsule by mouth every morning and at bedtime for schizophrenia. 5/6/25-Flomax 0.4mg. One capsule by mouth once a day for enlargement of the prostate gland.

A review of Resident R7's MARs (medication administration records) for July 2025 through September 2025 failed to reveal evidence the morning dose of Ziprasidone was administered on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/26/25, and 8/11/25, failed to reveal evidence the bedtime dose of Ziprasidone was administered on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/26/25, 7/28/25, 9/15/25, 9/16/25, 9/17/25, and 9/18/25, and failed to reveal evidence the daily dose of Flomax was administered on 7/21/25, 7/22/25, 7/23/25, 7/24/25, 7/26/25, 7/27/25, and 8/11/25.

On 9/24/25 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated nurses evidence the administration of medications by documenting the medications were administered on

the MAR.

On 9/25/25 at 3:51 p.m., another interview was conducted with LPN #2. LPN #2 stated that if a medication is not available in the medication cart, the nurse should obtain the medication from the Omnicell (a machine containing various medications) if the medication is available there or contact the pharmacy if the medication is not available in the Omnicell.

A review of the Omnicell list revealed Ziprasidone and Flomax were not available in the Omnicell.

On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of

the above concern.

No further information was presented prior to exit.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Level of Harm - Minimal harm or potential for actual harm

Based on staff interview, facility document review, and clinical record review, the facility staff failed to ensure a resident was free from unnecessary medications for one of 16 residents in the survey sample, Resident #1. The findings include:For Resident #1 (Resident R1), the facility staff failed to obtain and/or ensure a physician's order was in place prior to administering tramadol and oxycodone to the resident on 8/10/25. A

review of Resident R1's clinical record revealed the following physician's orders:5/18/25-tramadol 50mg (milligrams).

One tablet by mouth every four hours as needed for pain.6/19/25-oxycodone 5mg. One tablet every six hours as needed for pain. Resident R1 was transferred to the hospital on 7/29/25. Resident R1 returned to the facility on 8/4/25 and the orders for tramadol and oxycodone were discontinued on that date. A review of Resident R1's controlled medication utilization records revealed the resident was administered one tablet of tramadol 50mg on 8/10/25 at 9:15 a.m. and one tablet of oxycodone 5mg on 8/10/25 at 11:30 a.m. A review of Resident R1's August 2025 physician's orders and August 2025 MAR (medication administration record) revealed there were no orders on 8/10/25 for tramadol or oxycodone (until back dated orders were created in the computer system

on 8/19/25). On 9/23/25 at 11:06 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that on 8/10/25, there were no tramadol or oxycodone orders for Resident R1 in the computer system but there were tramadol and oxycodone medication cards with Resident R1's name in the medication cart. RN #1 stated

she incorrectly assumed the medications were prescribed for Resident R1, so she administered the medications. RN #1 stated she made a mistake and should have verified active orders before administering the tramadol and oxycodone to Resident R1. On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of the above concern. The facility policy titled, Medication Administration documented, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician .11. Review MAR to identify medication to be administered. No further information was presented prior to exit.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Based on observation, staff interview and facility document review, facility staff failed to provide residents with the correct amount of food according to the facility's menu in one of one facility kitchens. The findings include:On 09/22/2025 at approximately 2:00 p.m. an observation in the facility's kitchen revealed OSM (other staff member) #10, acting dietary manager plating Caesar salad into bowls using a beige/ off-white handle scoop. Further observations revealed OSM #10 placing one scoop of salad into each bowl. At approximately 4:24 p.m. an observation of the facility's kitchen tray line revealed the cook plating food for

the resident's dinner. Observations of the serving utensils being used by the cook to plate the food revealed

he was using a grey handle scoop for serving lasagna, and a red handle scoop for sliced carrots. Continued

observations revealed the cook placed one scoop of lasagna, carrots on the resident's dinner plates and one bowl of Caesar salad on each meal tray. The facility's menu for dinner on 09/22/2025 documented in part, Monday. Entree. Lasagna w/ (with) meat sauce 1 (one) square. Caesar Salad 1 Cup. Sliced Carrots 1/2 (half) Cup.The facility's Production Count dated Monday-9/22/2025 documented in part, Lasagna w/MeatSauce 8 Oz (eight ounces), Caesar Salad 1 Cup, Sliced Carrots 1/2 Cup. The kitchen's Disher Size reference sheet documented in part, SCOOP NO. (number) MENU OZ VOLUME#4 8 Oz 1 Cup#8 4 Oz 1/2 Cup#10 3 Oz 3/8 (three-eighth) Cup#16 2Oz 1/4 (quarter) Cup On 09/25/2025 at approximately 1:10 p.m.

an interview was conducted with OSM #11, district manager for dietary. When asked about the serving sizes of the grey, red and beige/ off-white handle scoops, OSM #11 showed the surveyor the scoops and stated the that the grey handle scoop holds four ounces, the red handle scoop holds two ounces and the beige/ off-white handle scoop holds three ounces. After informed of the observation of the serving utensils/scoops being used for food portions as stated above for the resident's dinner on 09/22/2025 OSM #11 stated the cook should have referenced the Production Sheet and check for the correct serving utensil/scoop to serve the correct portions of food. When asked if residents received the correct amount of food for dinner on 09/22/2025 she stated no. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or potential for actual harm

Based on observation and staff interview, it was determined that the facility staff failed to serve palatable food on one of two facility units, Rosewood Unit. The findings include:On 09/22/2025 at approximately 5:45 p.m., a test tray consisting of lasagna with meat sauce, sliced carrots, green beans and mash potatoes were placed on a food cart in the facility's kitchen and sent to the Rosewood Unit of the facility. The cart was followed by the surveyor, OSM (other staff member) #11, district manager for dietary. At approximately 6:05 p.m., the last dinner tray was served to a resident on the Rosewood Unit and OSM #11 was asked to remove cover from the test plate then proceeded to take the temperatures of the food. Two surveyors observed OSM #11 obtaining the food temperatures of the test tray. The lasagna with meat sauce was 127-degrees F (Fahrenheit), the green beans were 117-degrees F, sliced carrots were 113-degrees F and

the potatoes were 112-degrees F. The test tray was sampled by two surveyors, OSM #11 for appropriate holding temperatures and palatable taste. When asked to describe the taste of the food OSM #11 stated

the food could have been warmer. After tasting all the food on the test tray OSM #11 was asked if the food was palatable. She stated the food was not palatable and should have been 130-degree F. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0809 Level of Harm - Minimal harm or potential for actual harm

p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observations and staff interviews, the facility staff failed to serve food in a sanitary manner in one of one facility kitchens. The findings include:On 09/22/2025 at approximately 5:30 p.m. an observation in the facility kitchen revealed OSM (other staff member) #10, acting dietary manager and OSM #11 , district manager for dietary, hand drying 20 resident meal trays, placing them on the tray line. Continuing

observation revealed kitchen staff at the tray line, sliding the meal trays down the tray line, placing resident's meals on the tray and placing the tray in the food carts to be taken to the unit floors. On 09/25/2025 at approximately 1:30 p.m. an interview was conducted with OSM #11. When informed of the

observation as stated above OSM #11 stated that the meal trays should have been air dried to prevent contamination. On 9/25/2025 at approximately 4:58 p.m. ASM (administrative staff member) #1, the executive director, ASM #6, vice president of operations, and ASM #9, regional director of clinical services, were made aware of the above findings. No further information was provided prior to exit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0836 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.

Based on staff interview, and clinical record review, the facility staff failed to provide services in compliance with State code for one of 16 residents in the survey sample, Resident #1. The findings include:For Resident #1 (Resident R1), the facility staff failed to obtain a physician's order for tramadol and oxycodone prior to administering the medications on 8/10/25. The Virginia Administrative Code 12VAC5-371-300 (E).

Pharmaceutical services. documents, Excluding cannabidiol oil and THC-A oil, no drug or medication shall be administered to any resident without a valid verbal order or a written, dated and signed order from a physician, dentist, podiatrist, nurse practitioner, or physician assistant, licensed in Virginia. A review of Resident R1's clinical record revealed the following physician's orders:5/18/25-tramadol 50mg (milligrams). One tablet by mouth every four hours as needed for pain.6/19/25-oxycodone 5mg. One tablet every six hours as needed for pain. Resident R1 was transferred to the hospital on 7/29/25. Resident R1 returned to the facility on 8/4/25 and the orders for tramadol and oxycodone were discontinued on that date. A review of Resident R1's controlled medication utilization records revealed the resident was administered one tablet of tramadol 50mg on 8/10/25 at 9:15 a.m. and one tablet of oxycodone 5mg on 8/10/25 at 11:30 a.m. A review of Resident R1's August 2025 physician's orders and August 2025 MAR (medication administration record) revealed there were no orders on 8/10/25 for tramadol or oxycodone (until back dated orders were created in the computer system on 8/19/25). A physician's order dated 8/10/25 and created on 8/19/25 by RN (registered nurse) #1 documented an order for oxycodone 5mg by mouth as needed for pain. Give a one-time dose. The order documented the medication was ordered by ASM (administrative staff member) #3 (Resident R1's physician). A physician's order dated 8/10/25 and created on 8/19/25 by RN #1 documented an order for tramadol 50mg as needed by mouth times one dose. The order documented the medication was ordered by ASM (administrative staff member) #3 (Resident R1's physician). A nurse's note with an effective date of 8/10/25 and created by RN #1 on 8/19/25 documented, Received order to give resident 50 mg po (by mouth) tramadol x (times) 1 dose, if ineffective give oxycodone 5 mg x 1 dose, VTO (verbal telephone order) (name of ASM #3). On 9/23/25 at 11:06 a.m., an interview was conducted with RN (registered nurse) #1. RN #1 stated that on 8/10/25, there were no tramadol or oxycodone orders for Resident R1 in the computer system but there were tramadol and oxycodone medication cards with Resident R1's name in the medication cart. RN #1 stated she incorrectly assumed

the medications were prescribed for Resident R1, so she administered the medications. RN #1 stated she did not directly talk to ASM #3 about this matter. RN #1 stated she entered the back dated orders into the computer system because someone from nursing management told her they spoke with ASM #3 who said he approved and to go ahead and enter the orders into the system. On 9/23/25 at 12:25 p.m., an interview was conducted with ASM #3. ASM #3 stated he did not remember anyone asking, or him approving orders for Resident R1 to be administered one-time doses of tramadol or oxycodone for when the resident was administered

the medications on 8/10/25. On 9/24/25 at 3:52 p.m., an interview was conducted with LPN (licensed practical nurse) #2. LPN #2 stated nurses definitely should obtain a physician's order prior to administering medications to a resident. On 9/24/25 at 4:58 p.m., an interview was conducted with LPN #1 (the staff development coordinator). LPN #1 stated she talked to ASM #3 about Resident R1 but did not remember the conversation or recall information regarding late tramadol or oxycodone orders put into the computer system. On 9/24/25 at 5:22 p.m., an interview was conducted with ASM #2 (the director of nursing). ASM #2 stated she was not involved in Resident R1's late tramadol or oxycodone orders being put into the computer system. On 9/25/25 at 4:59 p.m., ASM #1 (the executive director) was made aware of the above concern.

No further information was presented prior to exit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0840 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Based on staff interview, and facility document review, the facility staff failed to provide evidence of an updated contract with an outside provider for one of eight contracts reviewed, potentially affecting seven residents who received respiratory equipment services. The findings include:The facility staff failed to provide an updated contract for respiratory equipment. A review of facility contracts with outside service providers revealed there was no current contractual agreement with the respiratory equipment provider. The contract was between the outside provider and the name of the previous owner of the facility, a company no longer in existence. On 9/25/25 at 1:54 p.m., an interview was conducted with ASM (administrative staff member) #1 (the executive director). ASM #1 stated that when the new company began ownership of the facility (June 2025), she had to reach out to all vendors, write up new contracts, send the contracts to the new company's legal team for review, send the contracts back to the vendors for changes, then send the contracts back to the new company's legal team. ASM #1 stated the new company bought approximately 48 or 49 facilities and this has been a slow process. On 9/25/25 at 4:59 p.m., ASM #1 was made aware of

the above concern. No further information was presented prior to exit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

3/29/25. There was no record of administration of Fentanyl on a narcotic sheet between 3/17/25 and 3/29/25, a period of 12 days.

An interview was conducted with LPN (licensed practical nurse) #1, on 9/24/25 at 11:47 a.m. LPN #1 stated

a nurse evidence that she's given a medication by checking it off on the MAR. The above MAR was reviewed with LPN #1. LPN #1 stated it is an error in documentation as the nurse signed it off and didn't give it as it wasn't in the building according to the narcotic sign off sheets.

ASM (administrative staff member) #1, the executive director, and ASM #6, the vice president of operations, were made aware of the above concern on 9/24/25 at 5:32 p.m.

No further information was obtained prior to exit.

References: 1.This information was obtained from the following website: https://medlineplus.gov/druginfo/meds/a601202.html.

1. 3. For Resident #1 (Resident R1), the facility staff failed to document complete and accurate information regarding

the resident's change in condition and interventions that were implemented on 8/10/25.

A review of Resident R1's clinical record revealed a change in condition form dated 8/10/25 that documented Resident R1 was non-responsive, staff called 911, and the resident was transferred to the hospital. A review of Resident R1's nurses' notes dated 8/10/25 failed to document information regarding the resident's change in condition or interventions that were implemented.

On 9/23/25 at 11:06 a.m., an interview was conducted with RN (registered nurse) #1 (the nurse who sent Resident R1 to the hospital). RN #1 stated that on 8/10/25, Resident R1 became unresponsive. RN #1 stated she had administered narcotic medication to Resident R1 earlier that day so when the resident became unresponsive, she administered two doses of Narcan (medication used to reduce or reverse the effects of opioids) which were not effective. RN #1 stated another nurse attempted to obtain Resident R1's vital signs. RN #1 stated Resident R1 looked like

she wasn't breathing, and the resident's oxygen saturation level did not register, so RN #1 administered oxygen via a non-rebreather mask and began chest compressions until EMS (emergency medication services) arrived. RN #1 stated she should have documented this information in Resident R1's clinical record.

On 9/25/25 at 4:59 p.m., ASM (administrative staff member) #1 (the executive director) was made aware of

the above concern.

No further information was presented prior to exit.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0843 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

Based on staff interview, and facility document review, the facility staff failed to provide evidence of an updated hospital transfer agreement for one of one agreement reviewed, potentially affecting all residents,

a census of 86. The findings include:The facility staff failed to provide an updated hospital transfer agreement. A review of the hospital transfer agreement revealed there was no current contractual agreement with the hospital. The agreement was between the hospital and the name of the previous owner of the facility, a company no longer in existence. On 9/25/25 at 1:54 p.m., an interview was conducted with ASM (administrative staff member) #1 (the executive director). ASM #1 stated that when the new company began ownership of the facility (June 2025), she had to reach out to all vendors, write up new contracts, send the contracts to the new company's legal team for review, send the contracts back to the vendors for changes, then send the contracts back to the new company's legal team. ASM #1 stated the new company bought approximately 48 or 49 facilities and this has been a slow process. On 9/25/25 at 4:59 p.m., ASM #1 was made aware of the above concern. No further information was presented prior to exit.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or potential for actual harm

Based on staff interview, and facility document review, the facility staff failed to ensure the required QAPI (Quality Assurance and Performance Improvement) committee members attended for three of three quarterly meeting reviews, (October 2024 through December 2024, January 2025 through March 2025, and April 2025 through June 2025). The findings include:The facility staff failed to ensure an Infection Preventionist attended QAPI meetings from October 2024 through June 2025. A review of QAPI meeting sign-in sheets for October 2024 through June 2025 failed to reveal the signature of an Infection Preventionist. On 9/25/25 at 1:54 p.m., an interview was conducted with ASM (administrative staff member) #1 (the executive director). ASM #1 stated an infection preventionist is supposed to attend the QAPI meetings and she could not show an infection preventionist attended the QAPI meetings from October 2025 through June 2025. On 9/25/25 at 4:59 p.m., ASM #1 was made aware of the above concern. 1. The facility policy titled, Quality Assurance and Performance Improvement (QAPI) documented, The QAA Committee shall be interdisciplinary and shall:a. Consist at a minimum of: i. The Infection Preventionist.b.

Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary. No further information was presented prior to exit.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Woodstock Valley Health and Rehabilitation

803 South Main St Woodstock, VA 22664

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to implement infection control practices for one of 14 residents in the survey sample, Resident #104.

The findings include:For Resident #104 (Resident R104), the facility staff failed to implement enhanced barrier precautions (1) during wound care. A review of Resident R104's clinical record revealed a wound care physician note dated 11/28/25 that documented Resident R104 presented with a stage four pressure injury (2) on the sacrum. A physician's order dated 12/1/25 documented, Cleanse wound with wound cleanser. Pat dry. Apply medihoney and foam to wound bed QD (every day) one time a day for Wound care. Further review of Resident R104's clinical record failed to reveal a physician's order for enhanced barrier precautions. On 12/2/25 at 11:24 a.m., LPN (Licensed Practical Nurse) #5 was observed performing wound care on Resident R104's sacral wound. LPN #5 did not wear a gown during wound care. A Centers for Disease Control sign on Resident R104's room door documented, ENHANCED BARRIER PRECAUTIONS. EVERYONE MUST Clean their hands, including before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and a gown for the following High-Contract Resident Care Activities .Wound Care: any skin opening requiring a dressing. On 12/2/25 at 11:48 a.m., an interview was conducted with LPN #5. LPN #5 stated the sign on the door documented to wear a gown during wound care and she did not. On 12/2/25 at 3:24 p.m., ASM (Administrative Staff Member) #1 (the [NAME] President of Operations), ASM #2 (the traveling Director of Nursing), and ASM #3 (the acting Director of Nursing) were made aware of the above concern.

The facility policy titled, Enhanced Barrier Precautions documented, 2.b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers) .3. Implementation of Enhanced Barrier Precautions: b. PPE (Personal Protective Equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities .4. High-contact resident care activities include: h. Wound care: any skin opening requiring a dressing . No further information was presented prior to exit. References:(1) Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). This information was obtained from the website: https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html (2) A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as

a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar (dead skin tissue) may be visible. Epibole (rolled edges), undermining and/or tunneling often occur.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet