General Information: BRADFORD OAKS CENTER
Nursing home name BRADFORD OAKS CENTER
Address7520 SURRATTS ROAD
CLINTON, MD 20735
Phone number (301) 856-1660
Located within a hospital No
Type of ownership For profit - Corporation
Owner operates multiple homesYes
Accept Medicare or Medicaid Medicare and Medicaid
Continue Care Retirement CommunityNo
Resident and family councils Both
Certified number of beds 180
Total number of residents 168
Perc of occupied beds 93
Sprinkler status Yes
Number of Facility Reported Incidents3
Number of Substantiated Complaints24
Number of Fines0
Total Amount of Fines$0
Total Number of Penalties0
Total Number of Penalties0
Ratings Summary: BRADFORD OAKS CENTER
Overall rating 2
2
Nursing Home Staffing 3
3
Registered Nurses only 3
3
Health Inspections 1
1
Quality Measures 5
5
Nursing Home Staffing Info: BRADFORD OAKS CENTER
National AverageMaryland AverageBRADFORD OAKS CENTER
Overall staff rating NA NA 3
3
Registered Nurses only rating NANA 3
3
Total Number of Residents NA NA 168
Total Number of Nurse Staff Hours per Resident per Day 4.11 hours 4.24 hours 3.53 hours
Total Number of Licensed Nurse Staff Hours per Resident per Day 1.64 hours 1.82 hours 1.44 hours
Registered Nurses Hours per Residents per Day 0.81 hours 0.9 hours 0.64 hours
Licensed Practical or Vacation Nurses Hours per Resident per Day 0.83 hours 0.91 hours 0.8 hours
Certified Nursing Assistants Hours per Residents per Day 2.47 hours 2.42 hours 2.09 hours
Physical Therapy Staffing Hours per Resident Per Day 0.1 hours 0.13 hours 0.03 hours
Health Survey: BRADFORD OAKS CENTER
Heath Survey Summary on 2013-09-09
Total Number of Health Deficiencies 14
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Heath Survey Summary on 2012-07-20
Total Number of Health Deficiencies 23
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Heath Survey Summary on 2011-07-11
Total Number of Health Deficiencies 8
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Health Survey Details: BRADFORD OAKS CENTER
Inspection Results: 09/09/2013
Corrected Deficiency Scope and Severity
11/21/2013 Keep residents' personal and medical records private and confidential. Isolated/Minimal harm or potential for actual harm
11/21/2013 Provide housekeeping and maintenance services. Isolated/Minimal harm or potential for actual harm
11/21/2013 Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated/Minimal harm or potential for actual harm
11/21/2013 Allow residents the right to participate in the planning or revision of care and treatment. Isolated/Minimal harm or potential for actual harm
11/21/2013 Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated/Minimal harm or potential for actual harm
11/21/2013 Hire sufficient dietary support personnel. Pattern/Minimal harm or potential for actual harm
11/21/2013 Store, cook, and serve food in a safe and clean way. Isolated/Minimal harm or potential for actual harm
11/21/2013 Have a program that investigates, controls and keeps infection from spreading. Isolated/Minimal harm or potential for actual harm
11/21/2013 Keep all essential equipment working safely. Isolated/Minimal harm or potential for actual harm
11/21/2013 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Isolated/Minimal harm or potential for actual harm
11/21/2013 Operate and provide services according to Federal, State, and local laws and professional standards. Isolated/Minimal harm or potential for actual harm
11/21/2013 Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Isolated/Minimal harm or potential for actual harm
11/21/2013 Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility. Isolated/Minimal harm or potential for actual harm
11/21/2013 Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated/Minimal harm or potential for actual harm
Inspection Results: 07/20/2012
Corrected Deficiency Scope and Severity
08/31/2012 Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated/Minimal harm or potential for actual harm
08/31/2012 Store, cook, and serve food in a safe and clean way. Isolated/Minimal harm or potential for actual harm
08/31/2012 Post nurse staffing information/data on a daily basis. Pattern/Potential for minimal harm
08/31/2012 Ensure that residents are safe from serious medication errors. Isolated/Minimal harm or potential for actual harm
08/31/2012 Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern/Minimal harm or potential for actual harm
08/31/2012 Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated/Minimal harm or potential for actual harm
08/31/2012 Give each resident enough fluids to keep them healthy and prevent dehydration. Isolated/Minimal harm or potential for actual harm
08/31/2012 Ensure residents maintain acceptable nutritional status. Isolated/Minimal harm or potential for actual harm
08/31/2012 At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated/Minimal harm or potential for actual harm
08/31/2012 Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated/Minimal harm or potential for actual harm
08/31/2012 Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated/Minimal harm or potential for actual harm
08/31/2012 Allow residents the right to participate in the planning or revision of care and treatment. Isolated/Minimal harm or potential for actual harm
08/31/2012 Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated/Minimal harm or potential for actual harm
08/31/2012 Conduct initial and periodic assessments of each resident's functional capacity. Isolated/Minimal harm or potential for actual harm
08/31/2012 Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. Widespread/Potential for minimal harm
08/31/2012 Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated/Minimal harm or potential for actual harm
08/31/2012 Send unopened mail from residents and promptly deliver unopened mail to residents. Widespread/Potential for minimal harm
08/31/2012 Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern/Minimal harm or potential for actual harm
08/31/2012 Have a program that investigates, controls and keeps infection from spreading. Isolated/Minimal harm or potential for actual harm
08/31/2012 Keep all essential equipment working safely. Isolated/Minimal harm or potential for actual harm
08/31/2012 Put firmly secured handrails on each side of hallways. Isolated/Minimal harm or potential for actual harm
08/31/2012 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Isolated/Minimal harm or potential for actual harm
08/31/2012 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated/Minimal harm or potential for actual harm
Inspection Results: 07/11/2011
Corrected Deficiency Scope and Severity
08/22/2011 Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated/Minimal harm or potential for actual harm
08/22/2011 Allow residents the right to participate in the planning or revision of care and treatment. Isolated/Minimal harm or potential for actual harm
08/22/2011 Provide care by qualified persons according to each resident's written plan of care. Isolated/Minimal harm or potential for actual harm
08/22/2011 Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated/Minimal harm or potential for actual harm
08/22/2011 Develop policies and procedures for influenza and pneumococcal immunizations. Isolated/Minimal harm or potential for actual harm
08/22/2011 Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Pattern/Minimal harm or potential for actual harm
08/22/2011 Store, cook, and serve food in a safe and clean way. Pattern/Minimal harm or potential for actual harm
08/22/2011 Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. Isolated/Minimal harm or potential for actual harm

Fire Safety Survey: BRADFORD OAKS CENTER
Fire Safety Survey Summary on 2013-08-26
Total Number of Fire SafetyDeficiencies 9
Scope and Severity of most Severe Health Deficiency Widespread /Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2012-07-10
Total Number of Fire SafetyDeficiencies 1
Scope and Severity of most Severe Health Deficiency Widespread /Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2011-02-17
Total Number of Fire SafetyDeficiencies 3
Scope and Severity of most Severe Health Deficiency Isolated/Minimal harm or potential for actual harm
Fire Safety Survey: BRADFORD OAKS CENTER
Fire Safety Survey Results: 08/26/2013
Corrected Deficiency Severity
10/22/2013 Walls that prevent smoke from passing through and would resist fire for at least one hour. Isolated/Minimal harm or potential for actual harm
10/22/2013 Smoke barrier doors that can resist smoke for at least 20 minutes. Widespread /Minimal harm or potential for actual harm
10/22/2013 Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. Isolated/Minimal harm or potential for actual harm
10/22/2013 An approved automatic sprinkler system connected to the fire alarm system. Widespread /Minimal harm or potential for actual harm
10/22/2013 Properly installed electrical wiring and equipment. Pattern/Potential for minimal harm
10/22/2013 Weekly inspections and monthly testing of generators. Pattern/Potential for minimal harm
10/22/2013 Properly protected cooking facilities. Isolated/Minimal harm or potential for actual harm
10/22/2013 Exits that are free from obstructions and can be used at all times. Widespread /Minimal harm or potential for actual harm
10/22/2013 Proper medical gas storage and administration areas. Widespread /Minimal harm or potential for actual harm
Fire Safety Survey Results: 07/10/2012
Corrected Deficiency Severity
08/10/2012 An approved automatic sprinkler system connected to the fire alarm system. Widespread /Minimal harm or potential for actual harm
Fire Safety Survey Results: 02/17/2011
Corrected Deficiency Severity
04/04/2011 Corridor and hallway doors that block smoke. Pattern/Potential for minimal harm
04/04/2011 Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. Isolated/Minimal harm or potential for actual harm
04/04/2011 Proper medical gas storage and administration areas. Isolated/Minimal harm or potential for actual harm

Resident Complaints: BRADFORD OAKS CENTER
Date Complaint Substantiated: 03/25/2014
CorrectedCategoryDeficiencySeverity
04/21/2014Ensure residents maintain acceptable nutritional status. D
04/21/2014Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. G
04/21/2014Provide necessary care and services to maintain or improve the highest well being of each resident . D
04/21/2014Ensure that residents are safe from serious medication errors. D
Date Complaint Substantiated: 01/22/2014
CorrectedCategoryDeficiencySeverity
03/08/2014Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. D
03/08/2014Give notice to the resident before a room or roommate change. D
03/08/2014Allow residents to easily view the results of the nursing home's most recent inspection. B
03/08/2014Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. D
Date Complaint Substantiated: 08/28/2013
CorrectedCategoryDeficiencySeverity
09/19/2013Ensure residents maintain acceptable nutritional status. D
Date Complaint Substantiated: 05/10/2013
CorrectedCategoryDeficiencySeverity
06/14/2013Provide necessary care and services to maintain or improve the highest well being of each resident . D
Date Complaint Substantiated: 04/17/2013
CorrectedCategoryDeficiencySeverity
05/15/2013Provide necessary care and services to maintain or improve the highest well being of each resident . D
05/15/2013Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. B
Date Complaint Substantiated: 12/07/2012
CorrectedCategoryDeficiencySeverity
01/22/2013Provide necessary care and services to maintain or improve the highest well being of each resident . D
Date Complaint Substantiated: 06/04/2012
CorrectedCategoryDeficiencySeverity
07/17/2012Provide adequate and comfortable lighting levels in all areas. C
07/17/2012Provide housekeeping and maintenance services. C
07/17/2012Train all employees on what to do in an emergency, and carry out unannounced staff drills. C
07/17/2012Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. C
07/17/2012Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. C
07/17/2012Store, cook, and serve food in a safe and clean way. C
07/17/2012Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. D
07/17/2012Have enough outside ventilation via a window or mechanical ventilation, or both. C
07/17/2012Have a program that investigates, controls and keeps infection from spreading. C
Date Complaint Substantiated: 05/10/2012
CorrectedCategoryDeficiencySeverity
06/15/2012Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. D
Date Complaint Substantiated: 03/12/2012
CorrectedCategoryDeficiencySeverity
05/04/2012Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. D
05/04/2012Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. D

Quality Measures: BRADFORD OAKS CENTER
Quality Measures National Average Maryland Average BRADFORD OAKS CENTER
Overall quality rating NA NA 5
5
Long-Stay Residents
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased 15.4% 18.1% 29.5%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain 8.3% 5.2% 0.5%
Percent of High Risk Long Stay Residents With Pressure Ulcers 6.1% 7.1% 8.1%
Percent of Long Stay Residents Who Lose Too Much Weight 7.2% 6.2% 3.6%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder 43.9% 53.2% 68.0%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder 3.2% 2.6% 1.9%
Percent of Long Stay Residents With a Urinary Tract Infection 6.2% 5.2% 4.5%
Percent of Long Stay Residents Who Have Depressive Symptoms 6.3% 3.8% 0.8%
Percent of Long Stay Residents Who Were Physically Restrained 1.4% 0.9% 0.0%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury 3.2% 2.6% 1.0%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine 92.7% 92.8% 87.5%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 94.3% 94.8% 90.7%
Percent of Long Stay Residents Who Received an Antipsychotic Medication 20.7% 16.4% 6.7%
Short-Stay Residents
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain 19.2% 14.5% 7.6%
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened 1.2% 1.1% 3.1%
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine 83.4% 82.9% 60.7%
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 82.4% 83.1% 58.0%
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication 2.6% 2.3% 0.8%

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