Public Record
Autumn Lake Healthcare at Birch Manor
From CMS
Facility profile
- CMS overall rating
- 4 / 5
- Certified beds
- 118
- Avg. residents per day
- 107.7
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 104
- Inspections on file
- 8
- Last inspection
- 2025-11-20
*CMS
*CMS
*CMS
Citations
104 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0925Generalpotential for harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0362Generalpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0565Generalpotential for harm
Honor the resident's right to organize and participate in resident/family groups in the facility.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0223Generalpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0679Generalpotential for harm
Provide activities to meet all resident's needs.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0004Generalpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0568Generalpotential for harm
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
- 0584Generalpotential for harm
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.
- 0628Generalpotential for harm
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0695Generalpotential for harm
Provide safe and appropriate respiratory care for a resident when needed.
- 0791Generalpotential for harm
Provide or obtain dental services for each resident.
- 0803Generalpotential for harm
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0867Generalpotential for harm
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
- 0868Generalpotential for harm
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0906Generalpotential for harm
Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers.
- 0585Generalpotential for harm
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0584Generalpotential for harm
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.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0838Generalpotential for harm
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0582Generalpotential for harm
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- 0583Generalpotential for harm
Keep residents' personal and medical records private and confidential.
- 0584Generalpotential for harm
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.
- 0622Generalpotential for harm
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0624Generalpotential for harm
Prepare residents for a safe transfer or discharge from the nursing home.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0688Generalpotential for harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0761Generalpotential for harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- 0007Generalno actual harm
Address patient/client population and determine types of services needed.
- 0025Generalno actual harm
Create arrangements with other facilities to receive patients.
- 0036Generalno actual harm
Establish emergency prep training and testing.
- 0037Generalno actual harm
Establish staff and initial training requirements.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0355Generalno actual harm
Properly select, install, inspect, or maintain portable fire extinguishes.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0741Generalpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0911Generalno actual harm
Meet requirements for the installation and maintenance of electrical systems.
- 0923Generalpotential for harm
Have enough outside ventilation via a window or mechanical ventilation, or both.
- 0806Generalpotential for harm
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0943Generalpotential for harm
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
- 0923Generalno actual harm
Have proper medical gas storage and administration areas.
- 0553Generalpotential for harm
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0559Generalpotential for harm
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
- 0568Generalpotential for harm
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
- 0580Generalpotential for harm
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- 0584Generalpotential for harm
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.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0622Generalpotential for harm
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0624Generalpotential for harm
Prepare residents for a safe transfer or discharge from the nursing home.
- 0625Generalno actual harm
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.
- 0640Generalpotential for harm
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0642Generalpotential for harm
Ensure a qualified health professional conducts resident assessments.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0679Generalpotential for harm
Provide activities to meet all resident's needs.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0688Generalpotential for harm
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0690Generalpotential for harm
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0711Generalpotential for harm
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
- 0732Generalno actual harm
Post nurse staffing information every day.
- 0744Generalpotential for harm
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0758Generalpotential for harm
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.
- 0761Generalpotential for harm
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
- 0806Generalno actual harm
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0868Generalpotential for harm
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
- 0881Generalpotential for harm
Implement a program that monitors antibiotic use.
- 0908Generalpotential for harm
Keep all essential equipment working safely.
- 0919Generalpotential for harm
Make sure that a working call system is available in each resident's bathroom and bathing area.
- 0321Generalno actual harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
FAQ
Questions and answers
- What is Autumn Lake Healthcare at Birch Manor?
- Autumn Lake Healthcare at Birch Manor is a Medicare- and Medicaid-certified nursing home in Sykesville, MD, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 215136.
- What is the CMS rating for Autumn Lake Healthcare at Birch Manor?
- Autumn Lake Healthcare at Birch Manor has a CMS overall rating of 4 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Autumn Lake Healthcare at Birch Manor have?
- Autumn Lake Healthcare at Birch Manor is certified for 118 beds. It serves an average of 107.7 residents per day.
- How many citations does Autumn Lake Healthcare at Birch Manor have?
- Autumn Lake Healthcare at Birch Manor has 104 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Autumn Lake Healthcare at Birch Manor last inspected?
- Autumn Lake Healthcare at Birch Manor was last inspected on November 20, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
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