Bedford, VA

Oakwood Health And Rehab Center

1-star overall rating with 1-star inspections with $15,593 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

1613 Oakwood Street, Bedford, VA

(540) 425-7800

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

111

Certified beds

Average residents

98

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Hill Valley Healthcare

Operator or chain grouping

Approved since

1967-05-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

40 facilities

Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.73

Registered nurse staffing · state 0.69 · national 0.68

LPN hours / resident day

0.88

Licensed practical nurse staffing · state 1.00 · national 0.87

Aide hours / resident day

1.82

Nurse aide staffing · state 2.12 · national 2.35

Total nurse hours

3.44

All reported nurse hours · state 3.81 · national 3.89

Licensed hours

1.61

RN + LPN hours · state 1.68 · national 1.54

Weekend hours

3.00

Weekend nurse staffing · state 3.31 · national 3.43

Weekend RN hours

0.53

Weekend registered nurse coverage · state 0.46 · national 0.47

Physical therapist

0.10

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.70

CMS adjusted RN staffing hours

Adjusted total hours

3.29

CMS adjusted total nurse staffing hours

Case-mix index

1.43

Higher values indicate more complex resident acuity

RN turnover

45%

Annual RN turnover · state 49% · national 45%

Total nurse turnover

58%

Annual nurse turnover · state 48% · national 46%

SNF VBP

Value-based purchasing

Program rank

6,204

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

33.64

Composite VBP score used to determine payment impact.

Payment multiplier

0.9878

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

6.03

Baseline 22.78% · Performance 19.02% · Measure score 6.03 · Achievement 5.2 · Improvement 6.03

Healthcare-associated infections

4.89

Baseline 7.22% · Performance 6.37% · Measure score 4.89 · Achievement 4.89 · Improvement 3.30

Total nurse turnover

2.53

Performance 53.33% · Measure score 2.53 · Achievement 2.53 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

0

Baseline 3.48 hours · Performance 3 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 9.34%
10.72%
1.4 pts better
No Different than the National Rate · Eligible stays 304 · Observed rate 7.24% · Lower 95% interval 6.95%
Discharge to community 57.03%
50.57%
6.5 pts better
Better than the National Rate · Eligible stays 287 · Observed rate 55.75% · Lower 95% interval 50.84%
Medicare spending per beneficiary 0.96
1.02
0.1 pts better
Drug regimen review with follow-up 98.65%
95.27%
3.4 pts better
Numerator 220 · Denominator 223
Falls with major injury 0.9%
0.77%
0.1 pts worse
Numerator 2 · Denominator 223
Discharge self-care score 69.54%
53.69%
15.9 pts better
Numerator 121 · Denominator 174
Discharge mobility score 66.09%
50.94%
15.2 pts better
Numerator 115 · Denominator 174
Pressure ulcers or injuries, new or worsened 4.05%
2.29%
1.8 pts worse
Numerator 9 · Denominator 222 · Adjusted rate 4.87%
Healthcare-associated infections requiring hospitalization 6.37%
7.12%
0.8 pts better
No Different than the National Rate · Eligible stays 195 · Observed rate 4.62% · Lower 95% interval 3.88%
Staff COVID-19 vaccination coverage 1.77%
8.2%
6.4 pts worse
Numerator 2 · Denominator 113
Staff flu vaccination coverage 15.61%
42%
26.4 pts worse
Numerator 27 · Denominator 173
Discharge function score 67.24%
56.45%
10.8 pts better
Numerator 117 · Denominator 174
Transfer of health information to provider 85.39%
95.95%
10.6 pts worse
Numerator 152 · Denominator 178
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date 20.83%
25.2%
4.4 pts worse
Numerator 25 · Denominator 120

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.4
1.5
0.1 pts better
1.9
0.5 pts better
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 2.0 · Expected 2.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 1.9
1.4
0.5 pts worse
1.8
0.1 pts worse
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.1 · Expected 1.9 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 95.9%
91.2%
4.7 pts better
93.4%
2.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 98.5% · Q3 92.3% · Q4 94.1% · 4Q avg 95.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 97.4%
94.0%
3.4 pts better
95.5%
1.9 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4%
Percentage of long-stay residents experiencing one or more falls with major injury 7.8%
3.6%
4.2 pts worse
3.3%
4.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 7.5% · Q3 10.8% · Q4 5.9% · 4Q avg 7.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 19.3%
15.7%
3.6 pts worse
11.4%
7.9 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 23.0% · Q3 15.3% · Q4 18.8% · 4Q avg 19.3%
Percentage of long-stay residents who lose too much weight 12.8%
5.7%
7.1 pts worse
5.4%
7.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 17.9% · Q3 14.3% · Q4 8.3% · 4Q avg 12.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 22.3%
20.2%
2.1 pts worse
19.6%
2.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 19.6% · Q3 22.8% · Q4 27.4% · 4Q avg 22.3%
Percentage of long-stay residents who received an antipsychotic medication 17.5%
15.0%
2.5 pts worse
16.7%
0.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 17.0% · Q2 12.5% · Q3 19.6% · Q4 20.0% · 4Q avg 17.5% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.0%
0.2%
0.2 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened 14.4%
17.5%
3.1 pts better
16.3%
1.9 pts better
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.4% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 8.9%
15.7%
6.8 pts better
14.9%
6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 11.3% · Q3 5.4% · Q4 6.7% · 4Q avg 8.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.3%
0.5%
0.2 pts better
1.0%
0.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 0.0%
1.6%
1.6 pts better
1.7%
1.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 14.4%
22.2%
7.8 pts better
19.8%
5.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 15.5% · Q3 15.0% · Q4 6.7% · 4Q avg 14.4%
Percentage of long-stay residents with pressure ulcers 7.1%
5.2%
1.9 pts worse
5.1%
2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 8.8% · Q3 7.7% · Q4 3.3% · 4Q avg 7.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 79.7%
74.6%
5.1 pts better
81.7%
2 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 83.2% · Q2 79.1% · Q3 78.4% · Q4 78.2% · 4Q avg 79.7%
Percentage of short-stay residents who had an outpatient emergency department visit 11.1%
11.7%
0.6 pts better
12.0%
0.9 pts better
Short Stay · 20240701-20250630 · Adjusted 11.1% · Observed 10.0% · Expected 10.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 2.0%
1.2%
0.8 pts worse
1.6%
0.4 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.7% · Q3 0.7% · Q4 5.0% · 4Q avg 2.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 74.8%
73.6%
1.2 pts better
79.7%
4.9 pts worse
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.8%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 13.8%
22.0%
8.2 pts better
23.9%
10.1 pts better
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 10.9% · Expected 18.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2023-07-26 · Fire 2023-07-26

7 health deficiencies

Top issue: Pharmacy Service (2 deficiencies)

5 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Cycle 2 Health 2022-05-19 · Fire 2022-05-19

24 health deficiencies

Top issue: Resident Assessment and Care Planning (7 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2020-02-06 · Fire 2020-02-06

8 health deficiencies

Top issue: Resident Assessment and Care Planning (4 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2023-07-26

K325 · Smoke Deficiencies

Fire Safety

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

Corrected 2023-09-11

E · Potential for more than minimal harm 2023-07-26

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2023-09-11

E · Potential for more than minimal harm 2023-07-26

K761 · Miscellaneous Deficiencies

Fire Safety

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

Corrected 2023-10-24

D · Potential for more than minimal harm 2023-07-26

K531 · Services Deficiencies

Fire Safety

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

Corrected 2023-09-11

D · Potential for more than minimal harm 2023-07-26

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

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

Corrected 2023-09-11

F · Potential for more than minimal harm 2022-05-19

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-07-15

E · Potential for more than minimal harm 2022-05-19

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2022-07-15

E · Potential for more than minimal harm 2022-05-19

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2022-07-15

E · Potential for more than minimal harm 2022-05-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-07-15

D · Potential for more than minimal harm 2022-05-19

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2022-07-15

F · Potential for more than minimal harm 2020-02-06

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2020-11-12

Inspection history

Recent health citations

D · Potential for more than minimal harm 2023-11-28

F655 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-12-06

J · Immediate jeopardy 2023-10-26

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-10-19

J · Immediate jeopardy 2023-10-26

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-10-19

E · Potential for more than minimal harm 2023-10-26

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-12-01

D · Potential for more than minimal harm 2023-10-26

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2023-12-01

F · Potential for more than minimal harm 2023-07-26

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2023-08-31

D · Potential for more than minimal harm 2023-07-26

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-08-31

D · Potential for more than minimal harm 2023-07-26

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2023-08-31

D · Potential for more than minimal harm 2023-07-26

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-08-31

D · Potential for more than minimal harm 2023-07-26

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2023-08-31

D · Potential for more than minimal harm 2023-07-26

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2023-08-31

D · Potential for more than minimal harm 2023-07-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-08-31

L · Immediate jeopardy 2022-05-19

F725 · Nursing and Physician Services Deficiencies

Health

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

Corrected 2022-06-21

G · Actual harm 2022-05-19

F697 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-06-21

F · Potential for more than minimal harm 2022-05-19

F801 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2022-06-21

F · Potential for more than minimal harm 2022-05-19

F835 · Administration Deficiencies

Health

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

Corrected 2022-06-21

F · Potential for more than minimal harm 2022-05-19

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-06-21

E · Potential for more than minimal harm 2022-05-19

F655 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2022-06-21

E · Potential for more than minimal harm 2022-05-19

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2022-06-21

E · Potential for more than minimal harm 2022-05-19

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-08-02

E · Potential for more than minimal harm 2022-05-19

F686 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-06-21

E · Potential for more than minimal harm 2022-05-19

F689 · Quality of Life and Care Deficiencies

Health

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

Corrected 2022-06-21

E · Potential for more than minimal harm 2022-05-19

F755 · Pharmacy Service Deficiencies

Health

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

Corrected 2022-08-02

E · Potential for more than minimal harm 2022-05-19

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-06-21

E · Potential for more than minimal harm 2022-05-19

F761 · Pharmacy Service Deficiencies

Health

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.

Corrected 2022-08-02

E · Potential for more than minimal harm 2022-05-19

F812 · Nutrition and Dietary Deficiencies

Health

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

Corrected 2022-06-21

D · Potential for more than minimal harm 2022-05-19

F580 · Resident Rights Deficiencies

Health

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

Corrected 2022-06-21

D · Potential for more than minimal harm 2022-05-19

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2022-06-21

D · Potential for more than minimal harm 2022-05-19

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

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

Corrected 2022-06-21

D · Potential for more than minimal harm 2022-05-19

F635 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2022-06-21

D · Potential for more than minimal harm 2022-05-19

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2022-06-21

D · Potential for more than minimal harm 2022-05-19

F657 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2022-06-21

D · Potential for more than minimal harm 2022-05-19

F658 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2022-08-02

D · Potential for more than minimal harm 2022-05-19

F842 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2022-06-21

D · Potential for more than minimal harm 2022-05-19

F849 · Administration Deficiencies

Health

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.

Corrected 2022-06-21

C · Minimal harm 2022-05-19

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2022-06-21

E · Potential for more than minimal harm 2020-02-06

F656 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2020-03-18

D · Potential for more than minimal harm 2020-02-06

F578 · Resident Rights Deficiencies

Health

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.

Corrected 2020-03-18

D · Potential for more than minimal harm 2020-02-06

F638 · Resident Assessment and Care Planning Deficiencies

Health

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

Corrected 2020-03-18

Penalties and ownership

What sits behind the stars

$7,796 2023-07-26

Fine

Fine · fine $7,796

Fine

$7,797 2023-07-26

Fine

Fine · fine $7,797

Fine

Ownership

Bedford SNF Holdings LLC

5% Or Greater Direct Ownership Interest · Organization

100% 1 facilities 2021-11-01
Delilah 2626 Holdings LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 11 facilities 2021-11-01
Hvh Timberlake Management LLC

Operational/Managerial Control · Organization

0% 4 facilities 2021-11-01
Idels, Shimon

Corporate Officer · Individual

0% 42 facilities 2021-11-01
Lion 26 Holdings LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 43 facilities 2021-11-01
Sabrina 1818 Holdings LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 44 facilities 2021-11-01
Saessy Irrevocable Trust

5% Or Greater Indirect Ownership Interest · Organization

0% 44 facilities 2021-11-01
Tatiriq Irrevocable Trust

5% Or Greater Indirect Ownership Interest · Organization

0% 44 facilities 2021-11-01
Timberlake Operations Holdings LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 4 facilities 2021-11-01
Wade, Joyce

W-2 Managing Employee · Individual

0% 1 facilities 2021-11-01

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