Oakwood Health and Rehab Center
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 110 Google reviews

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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
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 detailsStrengths
- 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
Distribution · 114 analyzed
How They Respond to Reviews
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.”
“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.”
“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.”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both 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
5
measures
4
measures
8
measures
Residents whose bladder or bowel control got worse
Residents whose walking got worse
Residents needing more daily help over time
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents who lost too much weight
Residents on anti-anxiety or sleep medication
Short-stay residents vaccinated for pneumonia
Short-stay residents vaccinated for the flu
Short-stay residents newly given antipsychotics
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
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, 2026Complaint2
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
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, 2023Complaint1
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, 2023Complaint4
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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, 2023Routine12
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Smoke Deficiencies
Have properly installed hallway dispensers for alcohol-based hand rub.
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
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.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Services Deficiencies
Have elevators that firefighters can control in the event of a fire.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
May 19, 2022Routine29
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.
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
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.
Administration Deficiencies
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
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
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.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Construction Deficiencies
Use approved construction type or materials.
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Resident Assessment and Care Planning Deficiencies
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
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.
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
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.
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.
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Environmental Deficiencies
Keep all essential equipment working safely.
Feb 6, 2020Routine4
Smoke Deficiencies
Install an approved automatic sprinkler system.
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.
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.
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
Oakwood Health and Rehab Center
for profit
Chain Affiliation
Hill Valley Healthcare
44 facilities nationwide
Chain avg rating: 2.2/5 · Rank 30 of 40 (Worst)
Ownership & Management
Owners
Bedford Snf Holdings LLC
Owner · Organization
Timberlake Operations Holdings LLC
Owner (parent company) · Organization
Key personnel
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
110 reviews from families & visitors
Official Website
Visit oakwoodhrc.com
Medicare data downloads
Original nursing home datasets
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