Cycle 1
Health 2025-02-20 · Fire 2025-02-20
7 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Clinton, MD
Autumn Lake Healthcare At Bradford Oaks
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
7520 Surratts Road, Clinton, MD
(301) 856-1660
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
180
Certified beds
Average residents
169
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1987-06-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
60 facilities
Chain averages 3 overall / 3 health / 3 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
0.45
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.41
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.03
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,931
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.95% · Performance 21.55% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.41
Baseline 9.90% · Performance 7.49% · Measure score 4.41 · Achievement 1.16 · Improvement 4.41
Total nurse turnover
4.72
Baseline 57.25% · Performance 44.38% · Measure score 4.72 · Achievement 4.72 · Improvement 3.47
Adjusted total nurse staffing
0.96
Baseline 3.13 hours · Performance 3.35 hours · Measure score 0.96 · Achievement 0.96 · Improvement 0.34
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 15.37% |
10.72%
4.6 pts worse
|
Worse than the National Rate · Eligible stays 364 · Observed rate 19.51% · Lower 95% interval 12.36% |
| Discharge to community | 4.43% |
50.57%
46.1 pts worse
|
Worse than the National Rate · Eligible stays 394 · Observed rate 0.25% · Lower 95% interval 3.01% |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.66% |
95.27%
4.4 pts better
|
Numerator 290 · Denominator 291 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 291 |
| Discharge self-care score | 43.1% |
53.69%
10.6 pts worse
|
Numerator 50 · Denominator 116 |
| Discharge mobility score | 49.14% |
50.94%
1.8 pts worse
|
Numerator 57 · Denominator 116 |
| Pressure ulcers or injuries, new or worsened | 5.5% |
2.29%
3.2 pts worse
|
Numerator 16 · Denominator 291 · Adjusted rate 3.49% |
| Healthcare-associated infections requiring hospitalization | 7.49% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 238 · Observed rate 8.82% · Lower 95% interval 4.97% |
| Staff COVID-19 vaccination coverage | 96.55% |
8.2%
88.3 pts better
|
Numerator 140 · Denominator 145 |
| Staff flu vaccination coverage | 54.5% |
42%
12.5 pts better
|
Numerator 115 · Denominator 211 |
| Discharge function score | 57.76% |
56.45%
1.3 pts better
|
Numerator 67 · Denominator 116 |
| Transfer of health information to provider | 87.25% |
95.95%
8.7 pts worse
|
Numerator 89 · Denominator 102 |
| Transfer of health information to patient | 96.24% |
96.28%
About the same
|
Numerator 128 · Denominator 133 |
| Resident COVID-19 vaccinations up to date | 8.55% |
25.2%
16.6 pts worse
|
Numerator 13 · Denominator 152 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.8% |
91.9%
0.1 pts worse
|
93.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 85.2% · Q3 87.8% · Q4 96.4% · 4Q avg 91.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.7% |
96.6%
6.9 pts worse
|
95.5%
5.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 89.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
2.3%
1 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.4% · Q4 2.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
21.4%
18.6 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.3% · Q3 3.0% · Q4 3.4% · 4Q avg 2.8% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.7%
0.4 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 0.8% · Q3 3.3% · Q4 4.9% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.1% |
16.1%
6 pts better
|
19.6%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 9.8% · Q3 10.3% · Q4 12.9% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.7% |
15.3%
9.6 pts better
|
16.7%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 7.1% · Q3 4.8% · Q4 5.3% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
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 | 24.9% |
26.6%
1.7 pts better
|
16.3%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.0% · Q2 12.2% · Q3 11.1% · Q4 43.5% · 4Q avg 24.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.8% |
22.9%
7.1 pts better
|
14.9%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 20.5% · Q3 11.7% · Q4 16.8% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.7%
0.2 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.5%
0.2 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.5% · Q3 0.7% · Q4 2.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
25.4%
3.4 pts better
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 22.0% · Q3 23.8% · Q4 21.8% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
6.3%
0.2 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 7.2% · Q3 7.3% · Q4 4.3% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.8% |
78.4%
4.6 pts worse
|
81.7%
7.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 64.7% · Q2 63.5% · Q3 77.2% · Q4 89.4% · 4Q avg 73.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
9.9%
2.8 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 7.5% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.7% · Q3 0.8% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 53.5% |
80.6%
27.1 pts worse
|
79.7%
26.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 53.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.9% |
21.2%
2.7 pts worse
|
23.9%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 23.9% · Observed 27.4% · Expected 27.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-12-10 · Fire 2019-12-10
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-07-11 · Fire 2018-07-11
14 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-02-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-02-20
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-02-20
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-02-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-02-20
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-04-03
E · Potential for more than minimal harm
2025-02-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-03
E · Potential for more than minimal harm
2025-02-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-03
E · Potential for more than minimal harm
2025-02-20
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-04-03
E · Potential for more than minimal harm
2025-02-20
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-04-03
D · Potential for more than minimal harm
2019-12-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-13
D · Potential for more than minimal harm
2019-12-10
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-01-13
D · Potential for more than minimal harm
2019-12-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-01-13
D · Potential for more than minimal harm
2019-12-10
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2020-01-13
D · Potential for more than minimal harm
2019-12-10
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2020-01-13
D · Potential for more than minimal harm
2019-12-10
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-01-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-08
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-02-04
D · Potential for more than minimal harm
2026-01-08
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 2026-02-04
D · Potential for more than minimal harm
2026-01-08
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 2026-02-04
D · Potential for more than minimal harm
2026-01-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-04
D · Potential for more than minimal harm
2025-10-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-11-21
E · Potential for more than minimal harm
2025-02-20
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-20
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 2025-03-28
D · Potential for more than minimal harm
2025-02-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-20
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 2025-03-28
D · Potential for more than minimal harm
2025-02-20
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 2025-03-28
D · Potential for more than minimal harm
2025-02-20
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 2025-03-28
D · Potential for more than minimal harm
2025-02-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-28
G · Actual harm
2019-12-10
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 2020-01-22
E · Potential for more than minimal harm
2019-12-10
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 2020-02-17
D · Potential for more than minimal harm
2019-12-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-01-22
D · Potential for more than minimal harm
2019-12-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-01-22
D · Potential for more than minimal harm
2019-12-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-01-22
E · Potential for more than minimal harm
2018-07-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2018-08-25
E · Potential for more than minimal harm
2018-07-11
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 2018-08-25
E · Potential for more than minimal harm
2018-07-11
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2018-08-25
E · Potential for more than minimal harm
2018-07-11
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2018-08-25
E · Potential for more than minimal harm
2018-07-11
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2018-08-25
D · Potential for more than minimal harm
2018-07-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2018-08-25
D · Potential for more than minimal harm
2018-07-11
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2018-08-25
D · Potential for more than minimal harm
2018-07-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2018-08-25
D · Potential for more than minimal harm
2018-07-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-08-25
D · Potential for more than minimal harm
2018-07-11
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 2018-08-25
D · Potential for more than minimal harm
2018-07-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2018-08-25
D · Potential for more than minimal harm
2018-07-11
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 2018-08-25
D · Potential for more than minimal harm
2018-07-11
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 2018-08-25
D · Potential for more than minimal harm
2018-07-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-08-25
Penalties and ownership
What sits behind the stars
Ownership
7520 Surratts Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
A&R Stern Family Md1 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hatzlacha Rabbah LLC
5% Or Greater Indirect Ownership Interest · Organization
Accurate Staffing LLC
Operational/Managerial Control · Organization
Brand Sonnenschine Llp
Operational/Managerial Control · Organization
Muo, Ofo
Operational/Managerial Control · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
Schwartz, Mark
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Clinton Healthcare Center
Clinton, MD
2-star overall rating with 1-star inspections with abuse icon flag with $76,779 in total fines with 47 recent health deficiencies with 25 fire-safety deficiencies in the latest cycle
#2
Future Care Pineview
Clinton, MD
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Ft Washington Health Center
Fort Washington, MD
4-star overall rating with 3-star inspections with $7,443 in total fines with 18 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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