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Oakwood Health and Rehab Center

1613 Oakwood Street, Bedford, VA 24523 · Bedford County · (540) 425-7800

111 certified beds, about 106 residents a day · For profit - Corporation · Medicare and Medicaid since 1967

Last standard inspection more than 2 years ago Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
1 of 5
Staffing
2 of 5
Quality measures
5 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 495046 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on July 26, 2023, inspectors cited 7 health deficiencies (the Virginia average is 14.3, the national average 9.2).

Of 41 health citations since February 2020, 4 were rated as actual harm or immediate jeopardy to residents (3 immediate jeopardy).

CMS lists no fines against this home in the last three years.

Nurses and nurse aides worked 3.28 hours per resident per day, against 3.76 across Virginia and 3.86 nationally. Registered nurses accounted for 0.56 of those hours.

57.6% of nursing staff left within the year CMS measured (Virginia average 48.1%).

CMS links it to Hill Valley Healthcare, an affiliated group of 43 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 41 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
2J
0K
1L
Actual harm
1G
0H
0I
Potential for more than minimal harm
21D
11E
4F
Potential for minimal harm
0A
0B
1C
March 18, 2026Complaint inspection · 2 citations
  1. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 10, 2026
    Inspectors wroteBased on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to complete a thorough investigation of an alleged violation (resident elopement) for one of six residents in the survey sample (Resident #1).
  2. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 10, 2026
    Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of six residents in the survey sample (Resident #2).
November 28, 2023Complaint inspection · 1 citation
  1. D
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 6, 2023
    Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to develop a baseline care plan for one of 3 residents in the survey sample. Resident #3 (R3) did not have an accurate or timely baseline care plan for immediate care. The Findings Include: Diagnoses for R3 included: Coronary artery disease, end stage renal disease with dialysis (ESRD), hypertension, anxiety, chronic pain, neuropathy, and ischemia. The most current MDS (minimum data set) was a discharge assessment with an ARD (assessment reference date) of 10/15/23. R3 was assessed with a cognitive score of 12 out of 15, indicating cognitively intact. Review of R3's clinical record indicated R3 was admitted to the facility on [DATE]. The admission Evaluation was reviewed and documented R3's full assessment was not completed until 10/14/23 (4 days after admission). [...]
October 26, 2023Complaint inspection · 4 citations
  1. J
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards of care for one of twelve residents in the survey sample (Resident #1). Facility staff failed to clarify with the provider a new order to administer 100 units of short-acting insulin at each meal, when Resident #1 was intended to receive 20 units with meals. Resident #1 received a total of 200 units of short-acting insulin in a 4-hour period leading to life-threatening hypoglycemia, requiring hospitalization in the intensive care unit for treatment of the insulin overdose (serious harm). Immediate jeopardy was identified from 10/14/23 through 10/19/23 related to this deficiency.
  2. J
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to ensure one of twelve residents in the survey sample (Resident #1) was free from a significant medication error. Facility staff entered an erroneous order to administer an 100-unit dose of short-acting insulin with meals, when Resident #1 was intended to get 20 units with meals. Resident #1 (R1) was administered a total of 200 units of short-acting insulin in a 4-hour period based upon this order, leading to life-threatening hypoglycemia (low blood sugar) requiring immediate treatment of the insulin overdose and subsequent hospitalization in the intensive care unit (serious harm). Immediate jeopardy was identified from 10/14/23 through 10/19/23 related to this deficiency.
  3. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 1, 2023
    Inspectors wroteBased upon staff interview and clinical record review, the facility staff failed to follow physician orders for one of twelve residents in the survey sample (Resident #1).
  4. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 1, 2023
    Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure medications were available for administration for one of twelve residents in the survey sample (Resident #1).
July 26, 2023Standard inspection · 7 citations
  1. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) August 31, 2023
    Inspectors wroteBased on observations, interview, record review, and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner to prevent potential foodborne illness for 93 out of 94 residents (1 resident was receiving tube feedings). Specifically, the main kitchen freezer was found to have improperly labeled foods in the freezer and three out of four-unit pantry refrigerators were found to be improperly labeled and had expired food items. This failure had the potential to expose residents to expired and/or spoiled food, unknown allergens, and food items that were not in compliance with current dietary orders.
  2. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 31, 2023
    Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review, the facility staff failed to complete an accurate minimum data set (MDS) for one of twenty-two residents in the survey sample (Resident #19).
  3. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 31, 2023
    Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to develop a comprehensive care plan for one of twenty-two residents in the survey sample (Resident #19)
  4. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 31, 2023
    Inspectors wroteBased on observation, staff interview, and clinical record review, the facility staff failed to apply a wander prevention device as required in the plan of care for one of twenty-two residents in the survey sample (Resident #25).
  5. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 31, 2023
    Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure medication was available for administration for two of four residents during the medication pass and pour observation (Resident #8 and Resident #89). 1. 2. The Findings Include: 1. Resident #8's (R8) Telmisartan 40 milligrams (given for hypertension) was unavailable for administration as ordered by the physician. During a medication pass and pour observation conducted on 7/25/22 at 8:00 AM, Resident #8 (R8) was scheduled to receive Telmisartan 40 MG at 8AM. Licensed practical nurse (LPN #2) looked into the medication cart and verbalized that the medication was not available to give. LPN #8 then called the pharmacy and relayed that it was stated that the medication would be arriving later in the day. [...]
  6. D
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 31, 2023
    Inspectors wroteBased on observation, staff interview, facility document review, and clinical record review, the facility staff failed to ensure a medication error rate of less than five percent. Medication pass observations revealed five errors out of forty-one opportunities, resulting in a 12.2% error rate The Findings Include: 1. Resident #2 (R2) was given the wrong dose of Calcium. During a medication pass and pour observation conducted on 7/25/23 at 8:00 AM, license practical nurse (LPN #2) began pulling medications out of the medication cart for R2 and handing the medications to this surveyor to document. One of the medications pulled from the medication cart was Calcium 600 MG (milligrams) with Vitamin D 5 mcg (micrograms). LPN #1 dispensed the medication into the medication cup and administered to R2. R2's physician's orders were then reviewed to verify accuracy of medications given. [...]
  7. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 31, 2023
    Inspectors wroteBased on observation, staff interview, facility document review and clinical record review, the facility staff failed to follow infection control practices regarding hand hygiene during a dressing change for one of twenty-two residents in the survey sample (Resident #25) and on one of two units during the medication pass (unit 2).
May 19, 2022Standard inspection · 24 citations
  1. L
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · Immediate jeopardy to resident health or safety, widespread · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on resident interview, family interview, staff interview, observation, and clinical record review, the facility staff failed to provide sufficient nursing staff to ensure care and services were provided to maintain the highest practicable well-being for 11 of 22 residents in the survey sample, residing on three of three floors, Residents #188, #73, #80, #238, #11, #20, #62, #51, #35, #47, and #9. Resident #188 did not receive pain medication as ordered, which was identified as harm. Call bells were not answered in a timely manner as evidenced by resident and family interviews, and as documented in the resident council meeting minutes. Eight residents did not receive skin and/or wound care evaluations, Residents #73, #80, #238, #11, #20, #62, #51, and #35. Two residents who were identified as wandering were not provided supervision, Resident #9 and #47. [...]
  2. G
    Provide safe, appropriate pain management for a resident who requires such services.
    F697 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to provide effective pain management for one of 22 residents, Resident #188. Resident #188 reported on two separate occasions, her pain medication was delayed and/or not available for administration resulting in extreme pain greater than ten (on a scale of 1-10) and through the roof. This is harm.
  3. F
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    F801 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on facility document review and staff interview, the facility staff failed to employ a qualified dietitian. There had been no registered dietitian employed since 4/15/22 in the facility with a census of 73.
  4. F
    Administer the facility in a manner that enables it to use its resources effectively and efficiently.
    F835 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on staff interviews, family interview, clinical record review, and survey findings, the facility staff failed to provide effective administration in a manner to maintain the highest practicable well-being of each resident. The census in the facility was 73. The facility staff failed to employ sufficient nursing staff which resulted in the identification of Immediate Jeopardy.
  5. F
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to implement a Legionella water management program in the facility; failed to follow infection control practices for proper PPE (personal protective equipment) when going in and out of a resident room for one of 22 residents, Resident # 73; and failed to follow infection control practices during a dressing change for one of 22 residents, Resident # 11. 1. The facility failed to implement a Legionella water management program in the facility. 2. Facility staff did not use proper PPE when entering Resident #73's room. There was also no order or care plan in place for droplet precautions for Resident #73. 3. Staff failed to follow infection control practices during a dressing change for Resident # 11.
  6. E
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on staff interview, clinical record review, resident interview, and facility document review, the facility staff failed to develop a baseline care plan for three of 22 residents in the survey sample, Resident # 238, # 188, and # 73. 1. Resident # 238 did not a care plan for NASH (non-alcoholic steatohepatitis). 2. Resident # 188 did not have a baseline care plan for pain related to a fractured ankle, and also did not receive a copy of the baseline care plan. 3. Resident # 73 did not have a baseline care plan for droplet precautions.
  7. E
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to develop a comprehensive care plan (CCP) for 5 of 22 residents in the survey sample, Residents #62 #51, #6, #70, and #76. Resident #62's CCP did not include a focus areas with goals and interventions for the use of an anticoagulant. Resident #51's CCP did not include a focus area with goals and interventions for hospice care. Resident #6's CCP did not include a focus area with goals and interventions for nutritional/dietary needs. Resident #70's CCP did not include a focus area with goals and interventions for palliative care. Resident #76's CCP did not include a focus area with goals and interventions for mood disorder and behaviors.
  8. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 2, 2022
    Inspectors wroteBased on resident interview, staff interview, and clinical record review, the facility staff failed to follow physician orders for 4 of 22 residents in the survey sample, Residents #6, #62, #188, and #33; and failed to assess and monitor a left hip hematoma for one of 22 in the survey sample, Resident #47. Resident #6 did not have Debrox drops administered as ordered. Resident #62 did not have prophylactic medications administered as ordered. Resident #188 did not have fluid intake monitored for compliance with fluid restriction as ordered. Resident #47 did not have a hematoma monitored. Resident #33 did not have the medication Abilify administered as ordered.
  9. E
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on observation, staff interview, clinical record review, and facility document review, the facility staff failed to assess and implement interventions for the treatment of pressure ulcers for eight of 22 residents, Resident #73, #80, #238, #20, #62, #51, #11, and #35. Resident #73 was admitted to the facility with a Stage IV pressure ulcer to the sacrum. There was no skin assessment, measurement, or intervention for treatment of the pressure ulcer at the time of admission. Resident #80, #238, #20, #62, and #51, all identified as being at risk for the development of pressure ulcer/skin injury, did not have weekly skin assessments completed. Resident #11 did not have weekly skin assessments completed and the facility staff failed to follow infection control practices during a dressing change. [...]
  10. E
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on observation, resident interview, family interview, staff interview, and clinical record review, the facility staff failed to ensure supervision and interventions to prevent accidents for two of 22 residents in the survey sample, Resident #47, and #9. The facility failed to provide appropriate footwear and supervision to prevent falls as per the comprehensive care plan for Resident #47. Resident #9, with a non-functioning wander prevention device, eloped from the facility without staff knowledge and/or supervision.
  11. E
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 2, 2022
    Inspectors wroteBased on staff interview, facility document review and clinical record review, the facility failed to ensure medications were available for administration for two of twenty-two residents in the survey sample, Resident #33 and #62. Resident #33's prescribed medication Abilify was not available resulting in six missed doses. Resident #62's medications for urinary health were not available for administration.
  12. E
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on medication pass and pour observation, staff interview, and clinical record review, the facility staff failed to ensure a medication error rate of less than five percent. A medication pass and pour observation conducted on 05/10/2022 with 27 opportunities and 22 errors, yielded an medication error rate of 81.48 percent.
  13. E
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 2, 2022
    Inspectors wroteBased on observation, staff interview, and facility document review, the facility staff failed to ensure expired medications were not available for administration; and also failed to date open vials of insulin and stock medications on the medication carts on three of three units. 1. Unit 3 medication carts included open vials of undated insulin and expired insulin. 2. Unit 1 and Unit 2 medication carts included a total of twenty-one house stock medications that were not dated, four vials of insulin open and not dated, and one bottle of expired insulin still in the medication cart and available for administration.
  14. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on observation, facility document review and staff interview, the facility staff failed to store resident food in a sanitary manner on three of three nursing units. Expired and/or undated food items were observed in the nourishment refrigerators on unit 1, unit 2 and unit 3.
  15. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on family interview, staff interview and clinical record review, the facility staff failed to notify the physician and resident representative of an elopement for one of twenty-two residents in the survey sample, Resident #9. Resident #9's family and physician were not notified when the resident was found out of the facility unsupervised.
  16. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on clinical record review, staff interview and facility document review, the facility staff failed to implement their abuse policy for one of 22 residents in the survey sample, Resident #51. Facility staff failed to follow the abuse policy to report and investigate an injury of unknown orgin in a timely manner.
  17. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on clinical record review, staff interview and facility document review, the facility staff failed to implement their abuse policy for one of 22 residents in the survey sample, Resident #51. Facility staff failed to report an injury of unknown origin to the state agency in a timely manner.
  18. D
    Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
    F635 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to obtain order for the immediate care of Stage IV sacral pressure ulcer for one of 22 residents, Resident #73.
  19. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on staff interview and clinical record review, the facility staff failed to ensure a complete and accurate MDS (minimum data set) assessment for two of 22 residents in the survey sample, Resident # 84 and # 76. 1. Resident # 84, was coded in the electronic medical record (EMR) as discharged to an acute hospital, when the resident actually transferred to another facility. 2. Resident # 76 did not have sections C, D, and Q completed of the MDS.
  20. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on observation, staff interview and clinical record review, the facility staff failed to review and revise a comprehensive care plan for one of 22 residents, Resident #47. Resident #47 fell at the facility on 04/01/2022 resulting in a large hematoma to her left hip. Her care plan was not revised to include treatment of the area.
  21. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 2, 2022
    Inspectors wroteBased on family interview, staff interview, facility document review and clinical record review, the facility staff failed to follow professional standards of practice for one of twenty-two residents in the survey sample, Resident #9. Resident #9 eloped from the facility without staff knowledge and/or supervision. Nursing made no record of the incident, documented no assessment of the resident when found, and made no notification to administration, the provider or family about the incident.
  22. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on resident interview, clinical record review, and staff interview, the facility staff failed to ensure a complete and accurate record for two of 22 residents in the survey sample, Resident # 80 and # 238. 1. Resident # 80 had weights inaccurately recorded. 2. Resident # 238 did not have a code status documented.
  23. D
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    F849 · Administration · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on staff interview, clinical record review, and facility document review, the facility staff failed to provide records of weekly hospice visits as required in the hospice services agreement, for one of 22 residents in the [NAME] sample, Resident #51.
  24. C
    Keep all essential equipment working safely.
    F908 · Environmental · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) June 21, 2022
    Inspectors wroteBased on observation, facility document review and staff interview, the facility staff failed to ensure proper function of the dishwasher. The rinse temperature gauge on the main kitchen's dishwasher was in disrepair.
February 6, 2020Standard inspection · 3 citations
  1. E
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 18, 2020
    Inspectors wroteBased on observations, clinical record review, resident interview, and staff interview, the facility staff failed to develop a person centered plan of care to address the residents' use of side rails for four of 21 residents in the survey sample, Residents # 14, 20, 21 and 36. The plan of care for each of the four residents had the same problem, goal, and interventions.
  2. D
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    F578 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 18, 2020
    Inspectors wroteBased on clinical record review, staff interview, and facility document review, the facility staff failed to ensure an advance directive was signed by the authorized representative for one of 21 residents, Resident #78.
  3. D
    Assure that each resident’s assessment is updated at least once every 3 months.
    F638 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 18, 2020
    Inspectors wroteBased on staff interview, and clinical record review, the facility failed to ensure a quarterly MDS (minimum data set) was completed timely for one of 21 Resident's. Resident #2 did not have a quarterly MDS completed within 92 days. The findings Include: Resident #2 was admitted to the facility on [DATE]. Diagnoses for Resident #2 included: Osteoporosis, pain, and anxiety. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/30/20. Resident #2 was assessed with a cognitive score of 15 indicating cognitively intact. Review of Resident #2's clinical record indicated Resident #2's comprehensive MDS with an ARD of 9/23/19 was completed on 10/1/19. Further review of Resident #2's MDS's indicated there was not an MDS completed within the 92 days following the comprehensive MDS. [...]

Fire safety inspections

11 fire safety citations on file: 5 on July 26, 2023, 5 on May 19, 2022, 1 on February 6, 2020.

Every fire safety citation11 citations
  1. E
    Have properly installed hallway dispensers for alcohol-based hand rub.
    K 325 · July 26, 2023 · Corrected (the home has a date of correction)
  2. E
    Provide a written emergency evacuation plan.
    K 711 · July 26, 2023 · Corrected (the home has a date of correction)
  3. E
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · July 26, 2023 · Corrected (the home has a date of correction)
  4. D
    Have elevators that firefighters can control in the event of a fire.
    K 531 · July 26, 2023 · Corrected (the home has a date of correction)
  5. D
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · July 26, 2023 · Corrected (the home has a date of correction)
  6. F
    Install corridor and hallway doors that block smoke.
    K 363 · May 19, 2022 · Corrected (the home has a date of correction)
  7. E
    Use approved construction type or materials.
    K 161 · May 19, 2022 · Corrected (the home has a date of correction)
  8. E
    Have properly located and lighted "Exit" signs.
    K 293 · May 19, 2022 · Corrected (the home has a date of correction)
  9. E
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · May 19, 2022 · Corrected (the home has a date of correction)
  10. D
    Provide a written emergency evacuation plan.
    K 711 · May 19, 2022 · Corrected (the home has a date of correction)
  11. F
    Install an approved automatic sprinkler system.
    K 351 · February 6, 2020 · Corrected (the home has a date of correction)

Fines and payment denials

CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeVirginiaUnited States
All nursing staff (RN, LPN and aides)3.283.763.86
Registered nurses0.560.690.69
All nursing staff on weekends3.043.293.42
Nurse aides1.79
Licensed practical nurses0.93
Nursing staff turnover (share who left in a year)57.6%48.1%45.8%
Registered nurse turnover52.9%48.2%42.9%
Administrators who left0

CMS expects 3.94 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.38 on weekdays and 3.04 on weekends, 10% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 19.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 2.85 in April to June 2025 to 3.28 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.280.563.383.04 19.2%0 of 90106
Oct to Dec 20253.490.703.623.17 19.3%0 of 92102
Jul to Sep 20253.440.733.613.00 23.6%0 of 9298
Apr to Jun 20252.850.762.862.82 10.7%0 of 9199
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Virginia, Jan to Mar 20263.580.563.763.125.7%0.2% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Virginia

JobMedianMiddle halfEmployed
Virginia, all employers
CNAs (nursing assistants)$20.77$17.80 to $22.5640,580
LPNs and LVNs$31.21$28.66 to $35.8415,550
Registered nurses$45.00$38.51 to $49.5377,490
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

Work here? Share your pay anonymously

For Oakwood Health and Rehab Center. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

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Mandatory overtime?
How did staffing feel on your usual shift?

Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeVirginiaUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
10.314.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.20.40.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.31.61.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
5.83.63.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
3.21.31.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
9.715.614.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
3.74.74.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
18.514.215.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
14.922.323.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
10.511.512.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
0.71.51.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.81.51.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Oakwood Health and Rehab Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (57.0% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

57.0% this home

Better than the national rate

US median of homes 51.5% · Virginia: 101 better, 22 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 287 eligible stays.

Potentially preventable readmissions

9.3% this home

No different from the national rate

US median of homes 10.7% · Virginia: 1 better, 9 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 304 eligible stays.

Infections that led to a hospital stay

6.4% this home

No different from the national rate

US median of homes 7.1% · Virginia: 2 better, 8 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 195 eligible stays.

Self-care and mobility at discharge

70.3% this home

Median of homes: Virginia60.0% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 172 residents counted.

Falls with major injury

0.8% this home

Median of homes: Virginia0.7% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 239 residents counted.

New or worsened pressure ulcers

3.7% this home

Median of homes: Virginia2.1% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 238 residents counted.

Medication list given at discharge

100.0% this home

Median of homes: Virginia97.8% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 32 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: BEDFORD SNF OPERATIONS LLC. CMS links this home to Hill Valley Healthcare, a group of 43 nursing homes averaging 1.7 stars overall.

NameRoleTypeShareSince
Bedford SNF Holdings LLC5% or greater direct ownership interestOrganization100%11/01/2021
Timberlake Operations Holdings LLC5% or greater indirect ownership interestOrganization100%11/01/2021
Wade, JoyceW-2 managing employeeIndividual11/01/2021
Idels, ShimonCorporate officerIndividual11/01/2021
Hvh Timberlake Management LLCOperational/managerial controlOrganization11/01/2021

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. When is the care plan meeting, and can family attend it?Inspectors cited 14 problems in this area, most recently on March 18, 2026: "Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards."
  2. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 7 problems in this area, most recently on October 26, 2023: "Ensure that residents are free from significant medication errors."
  3. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 6 problems in this area, most recently on October 26, 2023: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
  4. How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 3 problems in this area, most recently on March 18, 2026: "Respond appropriately to all alleged violations."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.04 hours per resident per day, below the Virginia average of 3.29.

Other nursing homes nearby

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These are the official offices in Virginia. NursingHomeClear cannot take or act on complaints.

Common questions

What is Oakwood Health and Rehab Center's Medicare star rating?
CMS rates Oakwood Health and Rehab Center 2 out of 5 stars overall, with 1 for health inspections, 2 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Oakwood Health and Rehab Center get at its last inspection?
7 health deficiencies at the standard inspection on July 26, 2023. The Virginia average is 14.3.
Has Oakwood Health and Rehab Center been fined?
CMS lists no fines in the last three years.
Does Oakwood Health and Rehab Center accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Oakwood Health and Rehab Center?
CMS lists 5 owners and managers, and links the home to Hill Valley Healthcare. Legal business name: BEDFORD SNF OPERATIONS LLC.

Sources

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