Autumn Lake Healthcare At Oak Manor
AUTUMN LAKE HEALTHCARE AT OAK MANOR in BURTONSVILLE, MD — inspection on May 29, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
his or her rights.
staff failed to treat a resident with dignity and respect.
This was evident for 1 (Resident #6) of 6
Incident 3023073 was conducted on 5/27/26 regarding Physical Therapist (PT) #5 walking in on Resident #6 unclothed on 5/22/26.Review of Resident #6's medical record revealed the Resident was admitted to the facility for rehabilitation following a hospitalization in April 2026.Further review of Resident #6's medical record revealed the Resident was assessed on 4/21/26 by the facility staff to have a BIMS (Brief Interview for Mental Status) of 15 out of 15, indicating the Resident is cognitively intact.During interview with Resident #6 on 5/27/26 at 11:30 AM, Resident #6 stated last Friday (5/22/26) he/she was in the bathroom with the door closed and unclothed from the waist up.
The Resident stated a man from physical therapy (PT #5) knocked on his/her door. Resident #6 stated he/she said someone is in here but the man opened the door anyway.
The Resident stated PT #5 stated: I don't care I am from physical therapy, and I need to see (another resident's name which the Resident couldn't remember).
The Resident stated he/she told PT #5 You don't need to be in here and turned from him to cover myself'.
The Resident stated PT #5 had the door wide open and stood there for what seemed like 2-3 minutes.
The Resident stated I reported it to the staff and they had me write up a grievance.During interview with PT #5 via the phone on 5/27/26 at 12:16 PM, PT #5 stated he/she got his list of residents to see and mistakenly went to the wrong floor. PT #5 stated he knocked on the door of Resident #6 twice, but no one answered so he entered the room and was expecting to see the Resident in bed. PT #5 stated he then proceeded to look around the room and didn't see the Resident. PT #5 stated as he was leaving the room he noticed the bathroom door was closed. PT #5 stated he knocked on the door and heard someone say I am in the bathroom. PT #5 stated he should have asked the Resident if they were okay but instead cracked the door open because he stated he was worried about the Resident's safety. PT #5 stated the Resident then said to him, You shouldn't have done that. PT #5 stated he/she believed the Resident was covered but could not recall what the Resident was wearing. PT #5 stated he only opened the door a few inches.
PT #5 stated the Resident was seated in a wheelchair turned sideways. PT #5 stated he then closed the door and apologized to the Resident through the closed door.Interview with the Administrator on 5/27/26 at 12:56 PM confirmed PT #5 failed to treat Resident #6 with respect and dignity by opening the bathroom door without the Resident's consent.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
215315 05/29/2026
Autumn Lake Healthcare at Oak Manor 3415 Greencastle Road Burtonsville, MD 20866
(injury/decline/room, etc.) that affect the resident.
the facility staff failed to notify the resident's physician/nurse practitioner when the resident had a
(Resident #2) of 7 residents reviewed during a complaint survey.The findings include:On 5/28/26 at 7:47 AM a review of complaint 2997160 alleged communication concerns.Review of Resident #2's medical record revealed the resident was admitted to the facility in January 2026 with diagnoses including cerebral infarction, hypertension, atherosclerotic heart disease, and inappropriate sinus tachycardia (a heart rhythm condition where the heart beats too fast for no apparent reason, exceeding 100 beats per minute (bpm) at rest). A normal resting heart rate is 60 to 100 bpm.Review of Resident #2's heart rates from January 2026 to 3/4/26 ranged from 57 beats per minute to 89 beats per minute.Review of Resident #2's March 2026 Medication Administration Record (MAR) revealed the resident's heart rate was documented as elevated to 122 beats per minute on 3/5/26 at 9:00 AM.Continued review of Resident #2's medical record failed to produce documentation that the physician or nurse practitioner (NP) were notified of the increase in heart rate since that was the first time that the heart rate was documented over 100 bpm since the resident's admission in January 2026.On 5/28/26 an interview was conducted with Licensed Practical Nurse (LPN) #11, who was also the unit manager. LPN #11 was asked what she would expect the nurse to do if a resident's heart rate was 122 and the resident's normal range averaged in the 70s to 80s. LPN #11 stated she would expect the physician to be notified because, looking at the range of heart rates, the resident's rate was way off. LPN #11 stated, 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. I would also recheck the heart rate after the medication was given to see if there was any improvement.On 5/28/26 at 12:45 PM an interview was conducted with Nurse Practitioner (NP) #13. NP #13 was asked if he would expect to be notified about a heart rate of 122 and he said, yes, I would expect to be notified because a lot of things are going through my mind right now. Is the patient symptomatic, is the respiratory rate up, is he/she septic. 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.On 5/28/26 at 2:10 PM the Director of Nursing (DON) and the Corporate Nurse were informed of the findings.
They both agreed with the findings.
215315 05/29/2026
Autumn Lake Healthcare at Oak Manor 3415 Greencastle Road Burtonsville, MD 20866
status as there was no documentation.
The DON confirmed the surveyor's findings.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.