Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Oak Manor during CMS and state inspections, most recent first.
A cognitively impaired resident with Alzheimer's and a high risk for wandering was able to exit the facility unsupervised due to a low-volume door alarm that was not clearly audible to staff. The resident was discovered missing after staff responded to a faint alarm and found an exit door open and unlocked. Despite a care plan and wander guard in place, the resident was not located until the following day, after an extensive search involving staff and law enforcement.
A resident experienced a significant, unaddressed weight loss over one month, with no documentation by the physician or dietitian of interventions or follow-up, despite care plan requirements to notify and act on such changes.
A resident requiring feeding assistance was left without a meal and unattended for an extended period during dinner, despite multiple staff being present in the dining room. The resident remained without food until another staff member, after serving trays elsewhere, began to assist. Staff interviews confirmed low staffing and a lack of timely feeding support for residents needing assistance.
Surveyors observed that two clean utility rooms contained dirty intravenous poles and an oxygen concentrator, all with visible solid matter and lacking labels to indicate cleanliness. Staff confirmed these items were improperly placed in clean areas and should have been in soiled utility rooms until cleaned and labeled.
A physician order for a GI consultation for a resident with poor oral intake and weight loss was not completed or scheduled as required. The DON confirmed the consultation should have been arranged, but no evidence was found in the medical record that this had occurred.
A resident with diverticulitis experienced significant, ongoing weight loss and difficulty with food intake, yet staff failed to implement new interventions or notify the physician despite multiple system alerts and an existing care plan identifying the risk. Interviews confirmed that required monitoring and follow-up actions were not carried out.
Two residents with significant weight loss did not have required physician documentation of their medical history and treatment plans. In both cases, despite ongoing monitoring and interventions by dietary staff, there was a lack of physician or nurse practitioner notes summarizing the treatment approach or relevant diagnoses in the medical records.
Surveyors found that three hot food items served in the dining area were below the required temperature of 135°F, with potatoes at 119.8°F, spinach at 109.2°F, and veal at 123.1°F. These findings were confirmed by dietary management staff.
Surveyors identified several breaches in food service sanitation, including unlabeled repoured applesauce containers on a dirty utility table, soiled linens stored in the dry storage room, food and liquid spills on the kitchen floor, a red substance spilled on refrigerator shelves, and an unkempt dish rinsing area with food particles left in the strainer. These conditions reflect a failure to follow professional standards for food safety and cleanliness.
The facility failed to document and address significant weight loss in two residents, including lack of evidence that interventions were implemented, physicians were notified, or interdisciplinary teams were informed. Medical records did not reflect required actions or monitoring, and staff interviews confirmed that documentation and notifications were not completed as per protocol.
During a dinner service, a staff member assisted a resident with feeding after picking up utensils from the floor for another resident, but failed to sanitize her hands before resuming care. The staff member believed using a napkin was sufficient and did not perform proper hand hygiene.
Surveyors found that several residents were not consistently served meals according to their food preferences, as menu slips focused on dietary restrictions rather than individual choices. Staff, including dietary aides and nursing personnel, confirmed that they did not routinely verify or accommodate resident preferences during meal service, and the dietary manager acknowledged the absence of a system to ensure preferences were honored.
A resident left the facility without a physician's order for a therapeutic leave of absence, due to a lack of supervision. The resident, assessed as low risk for elopement, left to attend a church service in the community after being unaware of its cancellation within the facility. The resident was found by police and returned without injuries. The facility's policy requires a physician's order for such absences, which was not obtained.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
A cognitively impaired resident with a diagnosis of Alzheimer's Disease and a BIMS score indicating severe cognitive impairment was identified as being at risk for wandering, with a care plan in place that included a wander guard. Despite these measures, the resident was able to exit the facility unsupervised. On the day of the incident, the resident was last seen by a charge nurse in their room. Later, a GNA arriving for her shift heard a soft alarm, which she initially mistook for a call light. Upon investigation with an LPN, they discovered an exit door slightly open and another door leading outside that was unlocked, with the alarm still sounding faintly. After realizing the resident was missing, staff initiated a head count and notified the RN supervisor, who activated the facility's missing resident protocol. The facility conducted a search of the building and surrounding neighborhood, and local law enforcement was called to assist. The resident's family was notified, and the search continued into the evening with the involvement of police and specialized search equipment. The resident was eventually found the next morning in a wooded area near the facility by a staff member. The investigation revealed that the resident was able to leave through an exit door due to a very low-volume alarm that was barely audible from the nursing station. The resident had not previously eloped. The incident highlighted a failure to prevent a resident at risk for wandering from exiting the facility unsupervised, as well as issues with the effectiveness and audibility of the door alarm system at the time of the event.
Failure to Address and Document Significant Weight Loss
Penalty
Summary
A resident experienced a significant weight loss of 13 pounds (10%) within one month, as documented in the medical record. The resident's nutrition care plan included an intervention to notify the physician and dietitian of any significant weight changes. However, there was no documentation that the significant weight loss was addressed by either the physician or the dietitian. The discharge summary from the previous provider noted the resident's morbid obesity but did not address the recent weight loss. Interviews with the Medical Director and the dietitian confirmed that the weight loss was not specifically addressed or documented. The dietitian stated that the usual process would be to discuss supplements with the resident and initiate them if desired, but could not confirm if this occurred due to lack of documentation. Both staff members indicated that significant weight loss is typically discussed in risk management meetings, but there was no evidence in the record that interventions or changes were made in response to this resident's weight loss.
Failure to Provide Dignified Dining Experience and Timely Feeding Assistance
Penalty
Summary
During a dinner observation, a resident was seated in a geri-chair at a dining table with another resident who was independently feeding themselves. The resident in the geri-chair did not have a plate of food in front of them and was left waiting to be fed, with only two cups (one containing juice) placed on the table. Staff in the dining room were observed assisting other residents, including responding to a juice spill and discarding utensils that had fallen on the floor, but did not sanitize their hands before continuing to assist with feeding. Despite four staff members being present in the dining room, none attempted to feed the resident in the geri-chair during this time. The resident remained without a meal and unattended for approximately 26 minutes until another staff member, who had been serving trays to residents in their rooms, began to feed them. Staff interviews confirmed that staffing levels were low and that many residents required assistance with feeding. It was also stated that all staff are expected to assist with feeding residents, but this expectation was not met during the observed dining period.
Failure to Maintain Sanitary Conditions in Clean Utility Rooms
Penalty
Summary
The facility failed to maintain a sanitary environment in two out of two clean utility rooms observed during the recertification survey. On the second floor, Forest View clean utility room, two intravenous poles were found with brown and gray colored solid matter covering their bases, and neither pole had a label indicating they were clean. On the first floor, Chapel Valley clean utility room, three intravenous poles with brown and white colored substances at their bases and one oxygen concentrator covered with gray solid matter were observed, with none of these items labeled as clean. During an interview, the Central Supply Clerk confirmed that these items were dirty and should not have been placed in the clean utility room, stating that they should have been placed in the soiled utility room and labeled or bagged after cleaning.
Failure to Obtain Ordered GI Consultation
Penalty
Summary
A physician order was present in the medical record for a gastrointestinal (GI) consultation for a resident experiencing poor oral intake and weight loss. Review of the resident's medical record did not show any evidence that the GI consultation had been completed or scheduled as ordered. During an interview, the Director of Nursing confirmed that the consultation should have been scheduled and indicated that she would investigate the matter. The deficiency was identified due to the facility's failure to obtain the GI consultation as requested by the physician.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
Facility staff failed to address the nutritional needs of a resident with a known history of significant weight loss. The resident, diagnosed with diverticulitis, experienced ongoing difficulty with food intake, including being unable to keep food down and having large bowel movements after eating. Medical records showed a substantial decrease in weight over several months, with the system generating multiple significant weight loss alerts. Despite these warnings, there was no documentation of new interventions or physician notification after an initial order for a nutritional supplement was made. Interviews with staff revealed that while there were processes in place for monitoring and documenting weight changes, these were not followed for this resident. The Registered Dietician was responsible for making dietary recommendations and notifying the physician, but could not explain why further actions were not taken. Nursing staff described the process for recording weights and responding to alerts, but were unable to account for the lack of response to the resident's ongoing weight loss.
Physician Documentation Lapses for Residents with Significant Weight Loss
Penalty
Summary
The facility failed to ensure that physicians documented the medical history and treatment plans for residents experiencing significant weight loss. In one case, a resident experienced a 17.5-pound (10.7%) weight loss over a three-month period, as documented by the dietician. Despite ongoing dietary interventions and regular monitoring by the dietician and staff, there was no physician or nurse practitioner note in the medical record detailing the treatment plan or summarizing the medical conditions impacting the resident's weight fluctuations. The medical director confirmed that no such progress note had been written for this resident. In another instance, a resident with a complex medical history, including edema, gout, diverticulitis, asthma, nicotine dependence, hyperlipidemia, and lack of coordination, experienced significant weight loss. The medical director acknowledged during an interview that a diagnosis of Anasarca was not documented in the resident's medical chart, despite being aware of the condition. The absence of documentation regarding the resident's medical history and treatment plan was confirmed during the survey, and the medical director admitted to the oversight.
Failure to Serve Hot Foods at Safe and Appetizing Temperatures
Penalty
Summary
Surveyor observation determined that the facility failed to provide palatable food at an appetizing and safe temperature for residents. During a test tray check at the end of food service in the Chapel Way dining area, three hot food items were measured using the facility's thermometer by a staff member. The potatoes registered at 119.8°F, the spinach at 109.2°F, and the meat (veal) at 123.1°F, all of which were below the required internal temperature of 135°F for hot foods. The Regional Dietary Manager confirmed these temperatures during an interview.
Failure to Maintain Sanitary Food Service Practices and Cleanliness
Penalty
Summary
Surveyors observed multiple lapses in sanitary practices and cleanliness within the facility's kitchen during an initial tour with the Regional Dietary Manager. Specifically, seven repoured and unlabeled applesauce containers were found on a dirty utility table, a large white laundry basket containing soiled white linens was present in the dry storage room, and food along with a liquid substance was noted on the kitchen floor near the walk-in freezer. Additionally, a red substance had spilled over metal shelves in the walk-in refrigerator, and the area designated for rinsing dirty dishes was unkempt with food particles left in the strainer. These findings indicate that the facility failed to maintain food service safety and a clean working environment in accordance with professional standards.
Failure to Document and Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to properly document and address significant weight loss in two residents, as required by accepted professional standards. For one resident, there was a documented weight loss of 13 pounds (10%) within one month, but the medical record lacked evidence that the physician or dietitian was notified, and there was no documentation of interventions or changes to the resident's care plan. The dietitian confirmed during an interview that he could not provide documentation of any actions taken in response to the weight loss and admitted that such changes and interventions were not recorded. For another resident, records showed a substantial weight fluctuation following a hospital discharge, with a notable decrease over subsequent months. Despite this, there was no documentation that the resident's weight loss was monitored, addressed, or that the physician was notified. Interviews with the registered dietitian and nurse unit manager revealed that required forms and notifications were not completed, and review of risk management meeting minutes showed no mention of the resident's weight loss. The director of nursing was unable to provide documentation of any change in condition or physician notification related to the resident's weight loss.
Failure to Perform Hand Hygiene After Handling Contaminated Items
Penalty
Summary
Facility staff failed to adhere to infection control practices during a dinner service observation. A resident spilled juice onto their plate while feeding themselves, prompting a staff member to remove the plate. Before returning to assist the resident, the staff member picked up utensils that had fallen onto the floor from another resident and discarded them, but did not perform hand hygiene before resuming assistance. The staff member acknowledged the lapse when interviewed, stating she believed using a napkin was sufficient and that she would use proper infection control practices in the future. These actions were directly observed by surveyors, who noted the lack of hand sanitization between handling potentially contaminated items and providing direct care to a resident.
Failure to Consistently Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor residents' food preferences, as evidenced by observations, interviews, and medical record reviews. During meal service, residents reported that they were often served food items that did not match their stated preferences, and the menu slips on resident trays primarily listed dietary restrictions due to diagnoses or allergies, rather than individual food preferences. Staff interviews confirmed that menu slips did not consistently include residents' preferred food items, and staff would serve meals without verifying if residents received their preferred choices. For example, one resident expressed dissatisfaction with receiving a biscuit instead of toast and a boiled egg instead of scrambled eggs, while another resident noted a preference for boiled eggs and a dislike for cream of wheat, which was not always honored. Further, the Certified Dietary Manager acknowledged that the current system focused on avoiding restricted foods but lacked a process to ensure residents' preferences were consistently met. Observations showed that most menu slips did not disclose food preferences, and staff relied on the slips for guidance without additional verification. The lack of a check and balance system contributed to residents not consistently receiving meals according to their preferences, as confirmed by both dietary and nursing staff.
Failure to Supervise Resident Leading to Unauthorized Leave
Penalty
Summary
The facility staff failed to provide adequate supervision to prevent an accident involving a resident who was assessed to be at low risk for elopement. The resident, who was admitted for rehabilitation, left the facility without a physician's order for a therapeutic leave of absence. The incident occurred when the resident, unaware of the cancellation of a church service within the facility, decided to attend a church in the community. The resident was found outside the facility by the police and returned without injuries. Upon review, it was discovered that the resident did not have a physician's order for a leave of absence at the time of the elopement. The facility's Therapeutic Leave Policy requires a physician's order and documentation in the medical record for any leave of absence. The deficiency was confirmed during an interview with a nurse consultant, who acknowledged the failure to provide supervision for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Burtonsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fairland Center | 2 mi | — | 4 | 0 |
| Autumn Lake Healthcare At Silver Spring | 2.2 mi | — | 15 | 0 |
| Riderwood Village | 3 mi | — | 17 | 0 |
| Harmony Suites Rehabilitation And Wellness Center | 3.4 mi | — | 5 | 1 |
| Autumn Lake Healthcare At Patuxent River | 3.4 mi | — | 23 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.