Compiled from official CMS federal data
AUTUMN LAKE HEALTHCARE AT OAK MANOR, BURTONSVILLE, MD — Violations & Inspection Reports
Does AUTUMN LAKE HEALTHCARE AT OAK MANOR have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), AUTUMN LAKE HEALTHCARE AT OAK MANOR (CCN 215315), in BURTONSVILLE, MD, has federal inspection findings.
In its current inspection cycle, CMS cited the facility for 12 deficiencies; the most severe is rated J, which CMS classifies as Immediate Jeopardy — its most serious level, for noncompliance it found likely to cause serious harm or death. The latest standard health inspection on file is dated 2025-02-19. Earlier-cycle citations appear in the dated timeline below as historical, not current. CMS has $11,381 in civil money penalties on file against the facility. This page restates the federal record and draws no conclusion of its own.
Abuse-, fall-, and care-related findings on the federal record
- 2 citations for accident hazards or inadequate supervision (F689) — the deficiency family behind fall-related findings; most recent Jul 2025.
- 1 nutrition and hydration citation (F692) — the consumer terms are "malnutrition" and "dehydration"; most recent Feb 2025.
- 4 findings on file from complaint-triggered inspections.
Every figure above restates CMS’s own dated record; this page draws no conclusion of its own. Strict state filing deadlines can apply to nursing-home injury claims — a licensed attorney in your state can review this record.
FOR FAMILIES
What brings you to this record?
The Federal Record
At its most recent federal inspection, CMS cited this facility at the Immediate Jeopardy level — the most serious category CMS uses, for situations it found likely to cause serious harm or death.
Below is this facility's federal inspection record as on file with CMS.
Scope & Severity — current cycle
CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations.
Civil money penalties on file
$11,381
Have a lawyer review this record →
About this record: Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
Deficiency timeline
Citations are listed by scope/severity (most severe first), not chronologically; each entry is labeled current-cycle or historical.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Provide enough food/fluids to maintain a resident's health.
33 more citations on file — Accidents & supervision 1 · Medication & pharmacy 2 · Resident rights 6 · Other citations 21 (expand)
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide and implement an infection prevention and control program.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Provide and implement an infection prevention and control program.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Ensure services provided by the nursing facility meet professional standards of quality.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide safe, appropriate pain management for a resident who requires such services.
Ensure medication error rates are not 5 percent or greater.
Provide and implement an infection prevention and control program.
Observe each nurse aide's job performance and give regular training.
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.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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.
Overall CMS star rating
This facility: 4 · CMS state average: 3.1
Both figures as published by CMS.
You may be reading this record for the first time.
If something happened to someone you love at this facility, this federal record may be new to you today. The company that operates a nursing home, by contrast, is rarely seeing records like this for the first time — operators like these typically retain standing legal, risk, and insurance teams whose routine work includes records exactly like the one on this page. That is not a judgment of this facility; it is how the business is structured. Because strict time limits can apply, families often find it helps to have a qualified person review the record with them sooner rather than later.
Your federal record — tap to preview
Federal record
AUTUMN LAKE HEALTHCARE AT OAK MANOR — Federal Record
Your answers below fill this section.
- —
- —
- —
- —
- —
- —
SECTION 7 — CASE CONTEXT
Add what you saw at AUTUMN LAKE HEALTHCARE AT OAK MANOR to this record
No call centers, no auctions. CareSentinel is an independent service that compiles the public CMS record and does not provide legal advice. The federal record is a point-in-time inspection record and may understate what actually occurred. CareSentinel is operated by Nodal Logics LLC.
Strict time limits can apply to taking legal action — consider consulting a qualified attorney promptly.
If you believe a resident is in immediate danger, call 911. Care concerns can also be reported at no cost to your state survey agency or the Long-Term Care Ombudsman program (ltcombudsman.org) — independent of any legal inquiry.
How to read this record
Making sense of a CMS inspection record
CMS scores every citation on a grid from A to L, combining how widespread a finding was with how serious it was. A–C is a deficiency CMS classifies as no harm; D–F as the potential for harm; G–I as actual harm that reached a resident; and J–L as immediate jeopardy, CMS’s most serious level. Later letters mark more serious findings.
Three questions to ask on a tour
- How is the home staffed on nights, weekends, and holidays?
- What happens when a resident’s condition changes suddenly?
- How, and how quickly, are families told about an incident?