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AUTUMN LAKE HEALTHCARE AT OAK MANOR

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AUTUMN LAKE HEALTHCARE AT OAK MANOR is a for profit - limited liability company facility in BURTONSVILLE, MD with 145 certified beds and a 4-star overall CMS rating. The facility has 36 deficiency records on file. Total penalties: $11K.

3415 GREENCASTLE ROAD, BURTONSVILLE, MD 20866

Phone: 2409705600

Overall Rating

4/5

Health Inspection

4/5

Staffing

3/5

Quality Measures

3/5

Long-Stay Quality

4/5

Facility Information

Provider Number
215315
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
Beds
145
Residents
128
In Hospital
No
County
Montgomery
Last Inspection
Feb 19, 2025

Staffing Data

RN Hours
0.58 (nat'l avg: 0.68)
LPN Hours
1.17
CNA Hours
2.00
Total Nursing Hours
3.74 (nat'l avg: 3.89)
PT Hours
0.10
Nursing Turnover
38.1%
RN Turnover
33.3%

What the CMS Record Reveals About AUTUMN LAKE HEALTHCARE AT OAK MANOR

AUTUMN LAKE HEALTHCARE AT OAK MANOR operates 145 certified beds in BURTONSVILLE, MD with approximately 128 residents currently in care, and carries a CMS overall rating of 4 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (4★), staffing levels (3★), and quality measures (3★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.

The inspection file contains 36 deficiency records from recent surveys, of which 1 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. On the enforcement side, CMS has assessed 1 penalty totaling $11K against this provider, a tangible indicator that regulators moved beyond citation into financial consequence. Staffing is reported at 3.74 total nursing hours per resident day (national average 3.89), with RN coverage at 0.58 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.

Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, AUTUMN LAKE HEALTHCARE AT OAK MANOR falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 38.1%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.

Deficiency History (36 most recent)

J — Isolated - Jeopardy Jul 1, 2025 Tag: 0689

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

Category: Quality of Life and Care Deficiencies

Corrected: Jun 30, 2025

D — Isolated - Minimal harm Feb 19, 2025 Tag: 0806

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Category: Nutrition and Dietary Deficiencies

Corrected: May 2, 2025

E — Pattern - Minimal harm Feb 19, 2025 Tag: 0710

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Category: Nursing and Physician Services Deficiencies

Corrected: May 2, 2025

D — Isolated - Minimal harm Feb 19, 2025 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: May 2, 2025

D — Isolated - Minimal harm Feb 19, 2025 Tag: 0842

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

Category: Resident Assessment and Care Planning Deficiencies

Corrected: May 2, 2025

D — Isolated - Minimal harm Feb 19, 2025 Tag: 0812

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

Category: Nutrition and Dietary Deficiencies

Corrected: May 2, 2025

D — Isolated - Minimal harm Feb 19, 2025 Tag: 0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Category: Nutrition and Dietary Deficiencies

Corrected: May 2, 2025

D — Isolated - Minimal harm Feb 19, 2025 Tag: 0711

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Category: Nursing and Physician Services Deficiencies

Corrected: May 2, 2025

D — Isolated - Minimal harm Feb 19, 2025 Tag: 0692

Provide enough food/fluids to maintain a resident's health.

Category: Quality of Life and Care Deficiencies

Corrected: May 2, 2025

D — Isolated - Minimal harm Feb 19, 2025 Tag: 0684

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

Category: Quality of Life and Care Deficiencies

Corrected: May 2, 2025

D — Isolated - Minimal harm Feb 19, 2025 Tag: 0584

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.

Category: Resident Rights Deficiencies

Corrected: May 2, 2025

D — Isolated - Minimal harm Feb 19, 2025 Tag: 0550

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Category: Resident Rights Deficiencies

Corrected: May 2, 2025

D — Isolated - Minimal harm Nov 20, 2024 Tag: 0689

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

Category: Quality of Life and Care Deficiencies

Corrected: Jan 15, 2025

D — Isolated - Minimal harm Oct 20, 2020 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Dec 4, 2020

C — Widespread - No harm Oct 20, 2020 Tag: 0812

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

Category: Nutrition and Dietary Deficiencies

Corrected: Dec 4, 2020

E — Pattern - Minimal harm Oct 20, 2020 Tag: 0758

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Category: Pharmacy Service Deficiencies

Corrected: Dec 4, 2020

D — Isolated - Minimal harm Oct 20, 2020 Tag: 0684

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

Category: Quality of Life and Care Deficiencies

Corrected: Dec 4, 2020

D — Isolated - Minimal harm Oct 20, 2020 Tag: 0658

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

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Dec 4, 2020

D — Isolated - Minimal harm Oct 20, 2020 Tag: 0657

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

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Dec 4, 2020

E — Pattern - Minimal harm Oct 20, 2020 Tag: 0656

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

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Dec 4, 2020

D — Isolated - Minimal harm Oct 20, 2020 Tag: 0582

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Category: Resident Rights Deficiencies

Corrected: Dec 4, 2020

D — Isolated - Minimal harm Oct 20, 2020 Tag: 0580

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

Category: Resident Rights Deficiencies

Corrected: Dec 4, 2020

D — Isolated - Minimal harm Oct 20, 2020 Tag: 0550

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Category: Resident Rights Deficiencies

Corrected: Dec 4, 2020

D — Isolated - Minimal harm Jan 22, 2019 Tag: 0919

Make sure that a working call system is available in each resident's bathroom and bathing area.

Category: Environmental Deficiencies

Corrected: Mar 8, 2019

D — Isolated - Minimal harm Jan 22, 2019 Tag: 0880

Provide and implement an infection prevention and control program.

Category: Infection Control Deficiencies

Corrected: Mar 8, 2019

E — Pattern - Minimal harm Jan 22, 2019 Tag: 0867

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Category: Administration Deficiencies

Corrected: Mar 8, 2019

D — Isolated - Minimal harm Jan 22, 2019 Tag: 0759

Ensure medication error rates are not 5 percent or greater.

Category: Pharmacy Service Deficiencies

Corrected: Mar 8, 2019

C — Widespread - No harm Jan 22, 2019 Tag: 0730

Observe each nurse aide's job performance and give regular training.

Category: Nursing and Physician Services Deficiencies

Corrected: Mar 8, 2019

D — Isolated - Minimal harm Jan 22, 2019 Tag: 0697

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

Category: Quality of Life and Care Deficiencies

Corrected: Mar 8, 2019

D — Isolated - Minimal harm Jan 22, 2019 Tag: 0690

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Category: Quality of Life and Care Deficiencies

Corrected: Mar 8, 2019

E — Pattern - Minimal harm Jan 22, 2019 Tag: 0684

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

Category: Quality of Life and Care Deficiencies

Corrected: Mar 8, 2019

E — Pattern - Minimal harm Jan 22, 2019 Tag: 0658

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

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Mar 8, 2019

D — Isolated - Minimal harm Jan 22, 2019 Tag: 0656

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

Category: Resident Assessment and Care Planning Deficiencies

Corrected: Mar 8, 2019

B — Pattern - No harm Jan 22, 2019 Tag: 0625

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Category: Resident Rights Deficiencies

Corrected: Mar 8, 2019

B — Pattern - No harm Jan 22, 2019 Tag: 0623

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Category: Resident Rights Deficiencies

Corrected: Mar 8, 2019

B — Pattern - No harm Jan 22, 2019 Tag: 0578

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.

Category: Resident Rights Deficiencies

Corrected: Mar 8, 2019

Quality Measures

Measure Type Score Used in Rating
Percentage of long-stay residents whose need for help with daily activities has increased Long Stay 32.3% Yes
Percentage of long-stay residents who lose too much weight Long Stay 5.7% No
Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay 0.2% Yes
Percentage of long-stay residents with a urinary tract infection Long Stay 1.1% Yes
Percentage of long-stay residents who have depressive symptoms Long Stay 7.8% No
Percentage of long-stay residents who were physically restrained Long Stay 0.0% No
Percentage of long-stay residents experiencing one or more falls with major injury Long Stay 0.0% Yes
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine Long Stay 98.7% No
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine Short Stay 82.9% No
Percentage of short-stay residents who newly received an antipsychotic medication Short Stay 1.4% Yes
Percentage of long-stay residents whose ability to walk independently worsened Long Stay 36.5% Yes
Percentage of long-stay residents who received an antianxiety or hypnotic medication Long Stay 5.2% No
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine Long Stay 100.0% No
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine Short Stay 85.1% No
Percentage of long-stay residents with pressure ulcers Long Stay 6.2% Yes
Percentage of long-stay residents with new or worsened bowel or bladder incontinence Long Stay 30.0% No
Percentage of long-stay residents who received an antipsychotic medication Long Stay 5.0% Yes

Penalty History 1 penalties totaling $11K

Date Type Amount
Jul 1, 2025 Fine $11K

Frequently Asked Questions

What is the overall CMS rating for AUTUMN LAKE HEALTHCARE AT OAK MANOR?
AUTUMN LAKE HEALTHCARE AT OAK MANOR has an overall CMS rating of 4 out of 5 stars. This rating combines health inspection results (4★), staffing levels (3★), and quality measures (3★).
What are the staffing levels at AUTUMN LAKE HEALTHCARE AT OAK MANOR?
AUTUMN LAKE HEALTHCARE AT OAK MANOR reports 3.74 total nursing hours per resident day (national average: 3.89). RN hours are 0.58 per resident day (national average: 0.68). Nursing staff turnover is 38.1%.
How many beds does AUTUMN LAKE HEALTHCARE AT OAK MANOR have?
AUTUMN LAKE HEALTHCARE AT OAK MANOR has 145 certified beds with approximately 128 residents. The facility is located at 3415 GREENCASTLE ROAD, BURTONSVILLE, MD 20866.
Does AUTUMN LAKE HEALTHCARE AT OAK MANOR have any deficiencies on record?
Yes, AUTUMN LAKE HEALTHCARE AT OAK MANOR has 36 deficiencies on record from recent inspections. Of these, 1 are classified as causing actual harm or jeopardy.
Has AUTUMN LAKE HEALTHCARE AT OAK MANOR received any fines or penalties?
Yes, AUTUMN LAKE HEALTHCARE AT OAK MANOR has received 1 penalties totaling $11K.
Who owns AUTUMN LAKE HEALTHCARE AT OAK MANOR?
AUTUMN LAKE HEALTHCARE AT OAK MANOR is classified as "For profit - Limited Liability company" ownership. The facility type is "Medicare and Medicaid".
When was AUTUMN LAKE HEALTHCARE AT OAK MANOR last inspected?
The most recent health inspection for AUTUMN LAKE HEALTHCARE AT OAK MANOR was on Feb 19, 2025. The facility received a health inspection rating of 4 out of 5 stars.
What quality measures are tracked for AUTUMN LAKE HEALTHCARE AT OAK MANOR?
AUTUMN LAKE HEALTHCARE AT OAK MANOR is evaluated on 17 quality measures, of which 8 are used in the CMS star rating calculation. These include measures for both long-stay and short-stay residents covering areas like infections, falls, pressure ulcers, and medication use.

Data Sources

Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.

Related

Data sourced from official U.S. government datasets. See our methodology for details. Retrieved and formatted by PlainNursing Editorial