Cycle 1
Health 2025-02-19 · Fire 2025-02-19
12 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Burtonsville, MD
Autumn Lake Healthcare At Oak Manor
4-star overall rating with 4-star inspections with $11,381 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3415 Greencastle Road, Burtonsville, MD
(240) 970-5600
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
145
Certified beds
Average residents
128
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1998-12-24
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing
LPN hours / resident day
1.17
Licensed practical nurse staffing
Aide hours / resident day
2.00
Nurse aide staffing
Weekend hours
3.51
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
38%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.3
0.3 pts worse
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.2
0.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
91.9%
6.8 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.6%
3.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.3%
2.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 7.8% |
21.4%
13.6 pts better
|
11.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.7% |
5.7%
About the same
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.2% |
16.1%
10.9 pts better
|
19.6%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 5.0% |
15.3%
10.3 pts better
|
16.7%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 36.5% |
26.6%
9.9 pts worse
|
16.3%
20.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.3% |
22.9%
9.4 pts worse
|
14.9%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.7%
0.5 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.5%
0.4 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.0% |
25.4%
4.6 pts worse
|
19.8%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
6.3%
0.1 pts better
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.9% |
78.4%
4.5 pts better
|
81.7%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
9.9%
2.1 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.1% |
80.6%
4.5 pts better
|
79.7%
5.4 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.8% |
21.2%
8.6 pts worse
|
23.9%
5.9 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-10-20 · Fire 2020-10-20
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-01-22 · Fire 2019-01-22
13 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-22
F · Potential for more than minimal harm
2025-02-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-22
E · Potential for more than minimal harm
2025-02-19
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-04-22
E · Potential for more than minimal harm
2020-10-20
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2020-12-04
E · Potential for more than minimal harm
2020-10-20
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2020-12-04
D · Potential for more than minimal harm
2020-10-20
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2020-12-04
C · Minimal harm
2020-10-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-12-04
D · Potential for more than minimal harm
2019-01-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-03-08
C · Minimal harm
2019-01-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-03-08
C · Minimal harm
2019-01-22
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-03-08
C · Minimal harm
2019-01-22
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-03-08
C · Minimal harm
2019-01-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-03-08
Inspection history
Recent health citations
J · Immediate jeopardy
2025-07-01
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 2025-06-30
E · Potential for more than minimal harm
2025-02-19
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-02-19
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 2025-05-02
D · Potential for more than minimal harm
2025-02-19
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 2025-05-02
D · Potential for more than minimal harm
2025-02-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-02-19
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-02-19
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-02-19
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-02-19
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-02-19
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 2025-05-02
D · Potential for more than minimal harm
2025-02-19
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 2025-05-02
D · Potential for more than minimal harm
2025-02-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-02
D · Potential for more than minimal harm
2024-11-20
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 2025-01-15
E · Potential for more than minimal harm
2020-10-20
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 2020-12-04
E · Potential for more than minimal harm
2020-10-20
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2020-12-04
D · Potential for more than minimal harm
2020-10-20
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 2020-12-04
D · Potential for more than minimal harm
2020-10-20
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 2020-12-04
D · Potential for more than minimal harm
2020-10-20
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2020-12-04
D · Potential for more than minimal harm
2020-10-20
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 2020-12-04
D · Potential for more than minimal harm
2020-10-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-12-04
D · Potential for more than minimal harm
2020-10-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-12-04
D · Potential for more than minimal harm
2020-10-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-12-04
C · Minimal harm
2020-10-20
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 2020-12-04
E · Potential for more than minimal harm
2019-01-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-03-08
E · Potential for more than minimal harm
2019-01-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-03-08
E · Potential for more than minimal harm
2019-01-22
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-01-22
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 2019-03-08
D · Potential for more than minimal harm
2019-01-22
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-01-22
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-01-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-01-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-01-22
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2019-03-08
C · Minimal harm
2019-01-22
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-03-08
B · Minimal harm
2019-01-22
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 2019-03-08
B · Minimal harm
2019-01-22
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-03-08
B · Minimal harm
2019-01-22
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2019-03-08
Penalties and ownership
What sits behind the stars
$11,381
2025-07-01
Fine
Fine · fine $11,381
Fine
Ownership
3415 Greencastle Road Propco LLC
5% Or Greater Mortgage Interest · Organization
Kyler, Benjamin
Operational/Managerial Control · Individual
Sabapathi, Ramesh
Operational/Managerial Control · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
Schwartz, Mark
Corporate Officer · Individual
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#2
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Silver Spring, MD
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
Riderwood Village
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5-star overall rating with 5-star inspections with 5 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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