Autumn Lake Healthcare Oak Manor: Heart Rate Alert Missed - MD
No call to the physician. No call to the nurse practitioner. No record of any notification at all.
The patient, identified in the inspection report only as Resident #2, had been admitted to Autumn Lake Healthcare at Oak Manor in January 2026 with a history that made the spike especially significant: cerebral infarction, hypertension, atherosclerotic heart disease, and a condition called inappropriate sinus tachycardia, where the heart races past 100 beats per minute for no apparent reason. The resident's heart rate had stayed between 57 and 89 beats per minute for the first two months at the facility. Then, on March 5, 2026, at 9:00 in the morning, it hit 122.
That was the first time the rate had crossed 100 since admission. It was documented in the medication administration record. And then, as far as inspectors could determine from the medical record, nothing happened.
The nurse practitioner who would have expected that call described, in plain terms, what goes through a clinician's mind when a number like that comes in. "Is the patient symptomatic, is the respiratory rate up, is he/she septic," NP #11 told inspectors during an interview on May 28. "I always try to tell the nurse when you get an abnormal rate, is the patient stable, recheck it, maybe they have pain or are positioned incorrectly. Let us know what is going on."
He said he would have expected to be notified. He was not.
The unit manager, a licensed practical nurse identified as LPN #11, was equally direct when inspectors asked what she would have expected a nurse to do upon seeing a heart rate of 122 in a patient whose normal range sat in the 70s and 80s. "I would notify the doctor to let him know what the normal heart rate has been and if he wanted to do anything or just watch it," she said. "I would also recheck the heart rate after the medication was given to see if there was any improvement."
That is standard nursing practice described by the facility's own staff. The record showed it did not happen.
The inspection was triggered by a complaint, filed under case number 2997160, alleging communication concerns at the facility. Inspectors reviewed seven residents' records. The breakdown in physician notification appeared in one of them.
When the Director of Nursing and a corporate nurse were told of the findings on the afternoon of May 28, both agreed with what inspectors had found.
Autumn Lake Healthcare at Oak Manor is a nursing and rehabilitation facility located at 3415 Greencastle Road in Burtonsville. The inspection was completed May 29, 2026. CMS rated the violation as involving minimal harm or potential for actual harm, and noted it affected only a few residents.
But the nurse practitioner's own words complicate any suggestion that a 122-beat-per-minute heart rate in this particular patient was a minor concern. Sepsis was one of the first things on his mind. So was respiratory distress. So was whether the patient was stable at all. He listed them in the order a clinician lists things when the stakes are real.
Whether Resident #2 was symptomatic that morning, whether the elevated rate resolved on its own, whether anything was ultimately done — none of that appears in the inspection record. What the record shows is a number in a chart, and silence where a phone call should have been.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Lake Healthcare At Oak Manor from 2026-05-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
AUTUMN LAKE HEALTHCARE AT OAK MANOR in BURTONSVILLE, MD was cited for violations during a health inspection on May 29, 2026.
No call to the nurse practitioner.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.