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Nursing HomeMedicaid Investigative

Oakwood Health and Rehab Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

1613 Oakwood Street, Bedford, VA 24523111 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
4.4/5

based on 110 Google reviews

5
4
3
2
1
Oakwood Health and Rehab Center Nursing Home in Bedford, VA — Street View
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4/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (2/5 stars)
  • High staff turnover (58%)

Bottom 25% in VA · Below recommended RN staffing · Worst in HILL VALLEY HEALTHCARE chain · $15,593 in fines

Source: Medicare data

What this means for your family

While the facility has a welcoming atmosphere and a strong activities program, the recurring reports of poor administrative communication and weekend staffing issues are significant red flags. We strongly recommend that you visit on a weekend to observe staffing levels firsthand and insist on a clear, written plan for how the facility will communicate medical changes to your family.

Google Reviews

Google Reviews

110 reviews on Google
Oakwood Health and Rehab Center receives polarized feedback, with many reviewers praising the staff's kindness and the facility's recent renovations. However, significant concerns persist regarding administrative responsiveness, inconsistent communication with families, and staffing shortages that impact patient care, particularly on weekends and during the 3-11 shift.

Quality Themes

Tap a score for details
FoodN/AStaff7.0Clean8.0Activities9.0Meds3.0MemoryN/AComms2.0ValueN/A

Strengths

  • Warm, attentive nursing and therapy staff
  • Clean, recently renovated facility
  • Engaging activities department
  • Helpful admissions and administrative support

Concerns

  • Poor communication and lack of responsiveness from management (mentioned by 6 reviewers)
  • Understaffing, particularly on weekends and evening shifts (mentioned by 4 reviewers)
  • Inconsistent medication management and medical follow-up (mentioned by 4 reviewers)
  • Issues with patient transport to medical appointments (mentioned by 2 reviewers)

Rating Trends

Tap a year to see what changed

2344.0'17(1)2.52.0'21(1)4.85.0'23(19)4.53.8'25(25)4.3'26(10)

Distribution · 114 analyzed

5
91
4
5
3
3
2
3
1
12
21 reviews posted between Dec 13, 2022Dec 17, 2022 · 21 were 5-star
13 reviews posted between Aug 8, 2023Aug 9, 2023 · 13 were 5-star

How They Respond to Reviews

80%response rate

This facility actively engages with reviewer feedback.

Questions for Your Tour

  • 1I noticed the facility has undergone recent renovations; how have these updates impacted the daily environment and comfort for residents?
  • 2Since the activities department is often highlighted as a strength, could you walk me through a typical week of programming and how you encourage residents to participate?
  • 3How does your leadership team ensure consistent communication with families regarding changes in a resident's care plan or health status?
  • 4Given that staffing levels can fluctuate, what steps are taken to ensure consistent care and supervision during weekend and evening shifts?
  • 5Could you explain your process for managing medications and ensuring that medical follow-ups are handled promptly and accurately?
  • 6I see that you are active in responding to feedback online; how do you incorporate that family input into your daily operations and staff training?

Personalized based on this facility's data


Key Review Excerpts

My mom had a drs appt with the surgeon who did her hip surgery and she missed her appt because they couldn’t get transport to take her. So they rescheduled for the next day and they dropped the ball that day too.

Long-term resident's family · 2026☆☆☆☆

Mostly good staff except for the weekends. My Dad got an infection and I wasn't contacted! Found out when I visited on Sunday and saw the IV antibiotics. Not very good about returning calls.

Long-term resident's family · 2024★★★★

There is no management at all, the place isn’t clean, patients wait as much as 45 minutes to an hour after ringing for help. Things are promised, but never addressed.

Visitor · 2025☆☆☆☆
Source: 110 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.70hrs
94%
Registered nurses for medical care
Total Nursing
3.49hrs
85%
All nurses + aides combined
Staff Turnover
59%
Lower is better (< 30% = good)
RN Turnover
44%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
5/ 5
Better Than Avg

5

measures

Worse Than Avg

4

measures

Mixed Results

8

measures

Long-Stay Residents
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility11.0%
Better than Avg
Here
11.0%
US
19.4%
VA
22.0%
Bedford
21.5%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility8.7%
Better than Avg
Here
8.7%
US
15.3%
VA
16.4%
Bedford
12.2%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility7.8%
Better than Avg
Here
7.8%
US
14.4%
VA
15.3%
Bedford
13.1%
😔

Residents with depression symptoms

↓ Lower is better
This Facility16.9%
Mixed vs Avgs
Here
16.9%
US
12.1%
VA
16.9%
Bedford
22.9%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

⚖️

Residents who lost too much weight

↓ Lower is better
This Facility10.1%
Worse than Avg
Here
10.1%
US
5.3%
VA
5.6%
Bedford
4.6%
💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility23.6%
Mixed vs Avgs
Here
23.6%
US
19.5%
VA
20.4%
Bedford
28.0%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility79.3%
Mixed vs Avgs
Here
79.3%
US
81.8%
VA
73.9%
Bedford
82.0%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility74.8%
Mixed vs Avgs
Here
74.8%
US
79.8%
VA
73.6%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.7%
Worse than Avg
Here
2.7%
US
1.6%
VA
1.2%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

9deficiencies
2penalties
Near state avg (14.5)
7 complaint-triggered
$15,593 in fines

Oakwood Health and Rehab Center has significant ongoing issues, with families filing complaints that triggered inspection deficiencies in 2023. The facility repeatedly struggles with medication management, care planning, and nursing staffing across multiple surveys from 2020-2023. While most deficiencies show correction dates, the persistence of similar problems and recent complaint-triggered violations raise concerns about sustained quality improvement.

Mar 18, 2026Complaint
2
0610Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Nov 28, 2023Complaint
1
0655Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Oct 26, 2023Complaint
4
0658Immediate jeopardy · IsolatedResolved (past non-compliance)

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0760Immediate jeopardy · IsolatedResolved (past non-compliance)

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

0684Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Jul 26, 2023Routine
12
0812Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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

0325Potential for harm · PatternCorrected

Smoke Deficiencies

Have properly installed hallway dispensers for alcohol-based hand rub.

0711Potential for harm · PatternCorrected

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

0761Potential for harm · PatternCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0689Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0755Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0759Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0880Potential for harm · IsolatedCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0531Potential for harm · IsolatedCorrected

Services Deficiencies

Have elevators that firefighters can control in the event of a fire.

0918Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

May 19, 2022Routine
29
0725Immediate jeopardy · WidespreadCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0697Actual harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

0801Potential for harm · WidespreadCorrected

Nutrition and Dietary Deficiencies

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.

0835Potential for harm · WidespreadCorrected

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0363Potential for harm · WidespreadCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0759Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

0655Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

0656Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0684Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0686Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0689Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

0755Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

0761Potential for harm · PatternCorrected

Pharmacy Service Deficiencies

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.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

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

0161Potential for harm · PatternCorrected

Construction Deficiencies

Use approved construction type or materials.

0293Potential for harm · PatternCorrected

Egress Deficiencies

Have properly located and lighted "Exit" signs.

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0580Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

0607Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

0609Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

0635Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0658Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0849Potential for harm · IsolatedCorrected

Administration Deficiencies

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.

0711Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

0908Minimal · WidespreadCorrected

Environmental Deficiencies

Keep all essential equipment working safely.

Feb 6, 2020Routine
4
0351Potential for harm · WidespreadCorrected

Smoke Deficiencies

Install an approved automatic sprinkler system.

0656Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0578Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

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.

0638Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Assure that each resident’s assessment is updated at least once every 3 months.

Federal Penalties

Fine

Jul 26, 2023

$7,796

Fine

Jul 26, 2023

$7,797

Ownership & Operations

Who Operates This Facility

Owner / Operator

Oakwood Health and Rehab Center

Organization Type

for profit

Chain Affiliation

Chain Name

Hill Valley Healthcare

Chain Size

44 facilities nationwide

Chain avg rating: 2.2/5 · Rank 30 of 40 (Worst)

Ownership & Management

Owners

Bedford Snf Holdings LLC

Owner · Organization

100%

Timberlake Operations Holdings LLC

Owner (parent company) · Organization

100%

Key personnel

Wade, JoyceW-2 Managing EmployeeIdels, ShimonOfficer / DirectorHvh Timberlake Management LLCManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 4 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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