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)
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
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
Staffing
Hours and turnover
RN hours / resident day
0.73
Registered nurse staffing
LPN hours / resident day
0.88
Licensed practical nurse staffing
Aide hours / resident day
1.82
Nurse aide staffing
Weekend hours
3.00
Weekend nurse staffing
RN turnover
45%
Annual RN turnover
Total nurse turnover
58%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Recent inspection cycles
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
Delilah 2626 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hvh Timberlake Management LLC
Operational/Managerial Control · Organization
Idels, Shimon
Corporate Officer · Individual
Lion 26 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Sabrina 1818 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Saessy Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Tatiriq Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Timberlake Operations Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Wade, Joyce
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Bedford Co Nursing Home
Bedford, VA
4-star overall rating with 4-star inspections with 6 recent health deficiencies
#2
Summit Health And Rehab Center
Lynchburg, VA
3-star overall rating with 2-star inspections with 15 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Lynchburg Health & Rehabilitation Center
Lynchburg, VA
1-star overall rating with 1-star inspections with 38 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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