Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
AUTUMN LAKE HEALTHCARE AT BIRCH MANOR
SYKESVILLE, MD · 118 certified beds · Last Life Safety survey June 11, 2025
CMS Certification Number 215136 · first certified November 1981
Ownership
Operated by AUTUMN LAKE HEALTHCARE · For profit - Limited Liability company
- Ownership changed August 1, 2022 (change of ownership)to 7309 SECOND AVENUE OPCO LLC from AXIS HEALTH AT BIRCH OPCO LLC
Position within MD
20 citations — more than 42% of the 221 certified nursing homes in MD. Compared within MD rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 8 citations; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens November 2026 — about 2 months from now. This facility’s last Life Safety survey was June 2025. Facilities in MD are typically surveyed 17–59 months after the last one (median 30), measured over 283 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
5 of the 20 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
12 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 20 Life Safety citations above. The Physical Environment Index
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0906 Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers.
- F-0923 Have enough outside ventilation via a window or mechanical ventilation, or both.
- F-0908 Keep all essential equipment working safely.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
How that compares
Compared with the median facility in MD, and nationally. Surveyors differ markedly between states, so the MD figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 20 |
| Median facility in MD | 22 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 3, 2018 | 2 |
| June 9, 2021 | 10 |
| June 11, 2025 | 8 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0923 | Have proper medical gas storage and administration areas. | 3 | 2025-06-11 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2025-06-11 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2021-06-09 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2025-06-11 |
| E-0036 | Establish emergency prep training and testing. | 1 | 2021-06-09 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2025-06-11 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2025-06-11 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2021-06-09 |
What the citations cover
- Smoke Deficiencies 8
- Emergency Preparedness Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Egress Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Emergency Preparedness Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Egress Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 11, 2025 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (August 22, 2025) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (August 22, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 22, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 22, 2025) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (August 22, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 22, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 22, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (August 22, 2025) |
June 9, 2021 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (March 5, 2020) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (March 5, 2020) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (March 5, 2020) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (March 5, 2020) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (March 5, 2020) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (March 5, 2020) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 5, 2020) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (March 5, 2020) |
| K-0911 | Meet requirements for the installation and maintenance of electrical systems. | Deficient, Provider has date of correction (March 5, 2020) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (March 5, 2020) |
August 3, 2018 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 24, 2018) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (August 24, 2018) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.