Autumn Lake Healthcare at Oak Manor

Name: Autumn Lake Healthcare at Oak Manor
Address: 3415 GREENCASTLE ROAD, Burtonsville, MD, 20866, US
Telephone: 2409705600

3415 Greencastle Road, Burtonsville, MD 20866 · Montgomery County · 145 certified beds · avg 127 residents/day · certified since Dec 24, 1998

Part of chain: AUTUMN LAKE HEALTHCARE (59 facilities, chain avg rating 2.8★)

3/5

Health inspection rating (on-site)

Serious findings on record

$11,381

Fines, last 3 years

3.32

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Jul 1, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jun 30, 2025 (Past Non-Compliance)

All citations in the current public record (40)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
May 29, 2026	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint
May 29, 2026	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
May 29, 2026	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Apr 7, 2026	E · Potential for harm, repeated	The facility did not properly notify residents about the balance of money it holds for them, or failed to return those funds when a resident was discharged, evicted, or died.
Apr 7, 2026	E · Potential for harm, repeated	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Apr 7, 2026	E · Potential for harm, repeated	The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
Apr 7, 2026	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Apr 7, 2026	D · Potential for harm, one-off	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Apr 7, 2026	D · Potential for harm, one-off	The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay).
Apr 7, 2026	D · Potential for harm, one-off	The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need.
Apr 7, 2026	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Apr 7, 2026	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Apr 7, 2026	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Apr 7, 2026	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Apr 7, 2026	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Apr 7, 2026	D · Potential for harm, one-off	The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them.
Apr 7, 2026	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jul 1, 2025	▲ J · Immediate jeopardy, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Feb 19, 2025	E · Potential for harm, repeated	The facility admitted a resident without a doctor's order, or did not make sure each resident stayed under a doctor's ongoing care. · from a complaint
Feb 19, 2025	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Feb 19, 2025	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Feb 19, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Feb 19, 2025	D · Potential for harm, one-off	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Feb 19, 2025	D · Potential for harm, one-off	The facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit.
Feb 19, 2025	D · Potential for harm, one-off	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Feb 19, 2025	D · Potential for harm, one-off	The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. · from a complaint
Feb 19, 2025	D · Potential for harm, one-off	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Feb 19, 2025	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Feb 19, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Nov 20, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Oct 20, 2020	E · Potential for harm, repeated	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Oct 20, 2020	E · Potential for harm, repeated	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Oct 20, 2020	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Oct 20, 2020	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Oct 20, 2020	D · Potential for harm, one-off	The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered.
Oct 20, 2020	D · Potential for harm, one-off	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Oct 20, 2020	D · Potential for harm, one-off	The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Oct 20, 2020	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Oct 20, 2020	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Oct 20, 2020	C · Minimal risk, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (11 → 14).

Year	Citations	Serious (G–L)	Worst severity that year
2020	10	0	E
2024	1	0	D
2025	12	1	J ▲
2026	17	0	E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

1 fine totaling $11,381.

Date	Type	Amount / length
Jul 1, 2025	Fine	$11,381

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Maryland avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.32	3.83	3.95	bottom 33% in Maryland; bottom 27% in the U.S.
Registered Nurse hours	0.58	0.83	0.69	bottom 31% in Maryland; bottom 50% in the U.S.
Weekend total nurse staffing	3.04	3.43	3.50	bottom 38% in Maryland; bottom 33% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.55	0.63	0.48	top 45% in Maryland; top 28% in the U.S.
Total nursing staff turnover (%)	38.7	40.2	45.8	top 45% in Maryland; top 33% in the U.S.
RN turnover (%)	47.1	38.7	42.9	bottom 30% in Maryland; bottom 40% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.63, RN 0.64, weekend 3.33. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 4/5 · short-stay residents: 5/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
3415 Greencastle Road Holdco LLC	Organization	Direct Ownership Interest	NOT APPLICABLE	08/01/2022
As Family MD4 Holdings LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	08/01/2022
M Meisels Family Holdings LLC	Organization	Indirect Ownership Interest	NOT APPLICABLE	08/01/2022
3415 Greencastle Road Holdco LLC	Organization	ADP of the SNF	NOT APPLICABLE	08/01/2022
3415 Greencastle Road Propco LLC	Organization	5% or Greater Mortgage Interest	NOT APPLICABLE	08/01/2022
3415 Greencastle Road Propco LLC	Organization	ADP of the SNF	NOT APPLICABLE	08/01/2022
Accurate Staffing LLC	Organization	ADP of the SNF	NOT APPLICABLE	08/01/2022
As Family MD4 Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	08/01/2022
Brand Sonnenschine LLP	Organization	ADP of the SNF	NOT APPLICABLE	08/01/2022
Kyler, Benjamin	Individual	Operational/Managerial Control	NOT APPLICABLE	02/26/2024
Kyler, Benjamin	Individual	ADP of the SNF	NOT APPLICABLE	02/26/2024
M Meisels Family Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2021
Sabapathi, Ramesh	Individual	Operational/Managerial Control	NOT APPLICABLE	10/01/2023
Sabapathi, Ramesh	Individual	ADP of the SNF	NOT APPLICABLE	10/01/2023
Schwartz, Mark	Individual	Corporate Officer	NOT APPLICABLE	08/01/2022
Schwartz, Mark	Individual	Operational/Managerial Control	NOT APPLICABLE	08/01/2022

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"If my family member falls or their condition changes, exactly when and how will I be notified?"
"How do you keep residents' medical records accurate, complete, and secure?"
"If you manage my family member's personal funds, how often will we get statements and how quickly are funds returned?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"How do you handle COVID-19 vaccination for residents and staff, and what happens during an outbreak?"
"Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Fairland Center	2.0 mi	Silver Spring, MD	★★☆☆☆	2/5
Autumn Lake Healthcare at Silver Spring	2.2 mi	Silver Spring, MD	★★★☆☆	3/5
Riderwood Village	3.0 mi	Silver Spring, MD	★★★★★	5/5
Harmony Suites Rehabilitation and Wellness Center	3.4 mi	Silver Spring, MD	★★☆☆☆	1/5
Autumn Lake Healthcare at Patuxent River	3.4 mi	Laurel, MD	★★★☆☆	3/5
Complete Care at Springbrook	4.0 mi	Silver Spring, MD	★★★☆☆	3/5
Sterling Care Hillhaven	4.5 mi	Adelphi, MD	★★★★★	5/5
Autumn Lake Healthcare at Cherry Lane	4.9 mi	Laurel, MD	★★★★★	4/5
Friends Nursing Home	5.5 mi	Sandy Spring, MD	★★★★★	4/5
Autumn Lake Healthcare at Arcola	6.2 mi	Silver Spring, MD	★★★★☆	3/5
Layhill Nursing and Rehabilitation Center	6.5 mi	Silver Spring, MD	★☆☆☆☆	1/5
Brooke Grove Rehab. & Nsg Ctr	6.6 mi	Sandy Spring, MD	★★☆☆☆	2/5

Compare this facility with the 3 closest →

All facilities in Burtonsville →

Facility data as of CMS processing date 2026-08-01. CCN 215315.

The Care File

Visit checklist — Autumn Lake Healthcare at Oak Manor

3415 Greencastle Road, Burtonsville, MD 20866 · 2409705600

Health inspection rating 3/5 · CMS overall 4/5· Fines (3y): $11,381

Most serious findings on record:

▲ Jul 1, 2025 (F-0689, Immediate jeopardy, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "If my family member falls or their condition changes, exactly when and how will I be notified?"
☐ "How do you keep residents' medical records accurate, complete, and secure?"
☐ "If you manage my family member's personal funds, how often will we get statements and how quickly are funds returned?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "How do you handle COVID-19 vaccination for residents and staff, and what happens during an outbreak?"
☐ "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 215315 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)