Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakwood Health And Rehab Center during CMS and state inspections, most recent first.
Facility staff did not complete a thorough investigation of an elopement incident involving a resident with dementia and severely impaired cognition. Staff observed the resident exit through a door, go down a ramp, and the resident was then assisted back inside and assessed with no injuries, while the door alarm and a functional wander prevention device were in place. However, the facility’s investigation lacked documented witness names, written statements, or interviews from staff who witnessed or were working during the incident, despite facility policy requiring that witness identities and accounts be obtained and recorded on the incident/accident report.
A resident with multiple complex diagnoses, including severe COPD and acute/chronic respiratory failure, had an incomplete and inaccurate clinical record. An NP reported assessing the resident several times, but only one NP progress note appeared in the record until the DON later produced two additional NP notes that had never been scanned into the system after a transition to a new documentation platform. In addition, the resident’s discharge summary for an emergent hospital transfer contained an incorrect time, carried over from an earlier nursing note error, and no correction or addendum was made to clarify the actual time of transfer.
Failure to Thoroughly Investigate Resident Elopement Incident
Penalty
Summary
Facility staff failed to complete a thorough investigation of an alleged elopement involving Resident #1. The resident had a diagnosis of dementia and was assessed on the MDS as having severely impaired cognition. An incident form dated 2/11/2025 documented that staff witnessed the resident go out an exit door in the evening, proceed down a ramp, and be observed by staff who were spreading salt on the sidewalks. Staff in the parking lot were advised, and the resident was assisted back into the building and assessed by nursing with no injuries. The facility’s investigation, dated 2/19/2025, documented that the door alarm was sounding as the resident exited and that the resident was wearing a functional wander prevention device at the time. Review of the facility’s investigation revealed that it did not include documented witness statements or interviews from staff who witnessed the event or were working at the time of the incident. The investigation consisted only of an initial report and a summary of findings, without listing staff member names or their accounts. The Administrator confirmed that no written statements or interviews were obtained and that only a phone interview with the maintenance staff member was conducted shortly after the resident was brought back inside. Facility policies on Elopement/Missing Person and Accidents and Incidents – Investigating and Reporting required that the Report of Incident/Accident Form include names of witnesses and their accounts, but this information was not documented in the investigation of this elopement.
Incomplete and Inaccurate Clinical Record for a Resident
Penalty
Summary
Facility staff failed to maintain a complete and accurate clinical record for one resident, whose diagnoses included severe COPD, anemia, non-infectious systemic inflammatory response syndrome, hypomagnesemia, chronic pain, lung nodule, acute and chronic respiratory failure, osteoporosis, emphysema, history of thyrotoxicosis, non-ischemic myocardial injury, anxiety, and hypothyroidism. The resident was assessed as cognitively intact on the MDS. The nurse practitioner (NP) reported assessing the resident several times during the stay, but review of the clinical record initially showed only one NP progress note dated 7/3/25. During interviews, the DON later produced two additional NP progress notes dated 6/20/25 and 6/30/25 that had not been scanned or uploaded into the resident’s electronic clinical record. The administrator explained that the facility had started with new providers and transitioned to a new documentation system in June 2025, and staff had not realized that these NP progress notes were missing from the record. The resident’s discharge summary documenting an emergent transfer to the emergency department was also inaccurate. The discharge summary was recorded with a date/time of 7/8/25 at 1:43 p.m., while the resident’s change in condition and transfer from the facility were documented as occurring at 10:45 p.m. that same day. The regional nurse consultant stated that nursing had previously documented a note with the incorrect time and then made a note regarding the correction, and that the NP’s discharge summary note reflected the incorrect time based on the earlier nursing note. The regional nurse consultant acknowledged that the discharge summary date/time should have been corrected or an addendum made to indicate the error, but this was not done, resulting in an inaccurate discharge summary in the resident’s clinical record.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bedford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bedford Co Nursing Home | 2.9 mi | ★★★★★ | 0 | 0 |
| Summit Health And Rehab Center | 15.1 mi | ★★★★★ | 2 | 0 |
| Lynchburg Health & Rehabilitation Center | 18.4 mi | ★★★★★ | 5 | 0 |
| Liberty Ridge Health & Rehab | 18.7 mi | ★★★★★ | 0 | 0 |
| Seven Hills Rehabilitation And Nursing | 18.9 mi | ★★★★★ | 8 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.