All citations for Autumn Lake Healthcare at Birch Manor

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Autumn Lake Healthcare at Birch Manor

Last standard health inspection on record

June 11, 2025

Showing 1 to 25 of 105 citations

  1. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Widespread (many residents). CMS level F.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of June 11, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (July 15, 2025).

  2. No harm, with potential for more than minimal harm

    Develop and maintain an Emergency Preparedness Program (EP).

    Widespread (many residents). CMS level F.

    Emergency preparedness citation E-0004, Emergency Preparedness Deficiencies. Inspection of June 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 22, 2025).

  3. No harm, with potential for more than minimal harm

    Have approved installation, maintenance and testing program for fire alarm systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0345, Smoke Deficiencies. Inspection of June 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 22, 2025).

  4. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of June 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 22, 2025).

  5. No harm, with potential for more than minimal harm

    Have generator or other power source capable of supplying service within 10 seconds.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0918, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of June 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 22, 2025).

  6. No harm, with potential for more than minimal harm

    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0321, Smoke Deficiencies. Inspection of June 9, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (March 5, 2020).

  7. No harm, with potential for more than minimal harm

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

    Widespread (many residents). CMS level F.

    Health citation F-0655, Resident Assessment and Care Planning Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  8. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Widespread (many residents). CMS level F.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  9. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Widespread (many residents). CMS level F.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  10. No harm, with potential for more than minimal harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Widespread (many residents). CMS level F.

    Health citation F-0842, Resident Assessment and Care Planning Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  11. No harm, with potential for more than minimal harm

    Keep all essential equipment working safely.

    Widespread (many residents). CMS level F.

    Health citation F-0908, Environmental Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  12. No harm, with potential for more than minimal harm

    Honor the resident's right to organize and participate in resident/family groups in the facility.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0565, Resident Rights Deficiencies. Inspection of June 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2025).

  13. No harm, with potential for more than minimal harm

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0656, Resident Assessment and Care Planning Deficiencies. Inspection of June 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2025).

  14. No harm, with potential for more than minimal harm

    Provide activities to meet all resident's needs.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0679, Quality of Life and Care Deficiencies. Inspection of June 11, 2025. Found during a standard inspection and a complaint inspection.

    The home gave a date the problem would be corrected (July 15, 2025).

  15. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of June 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (July 15, 2025).

  16. No harm, with potential for more than minimal harm

    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0223, Egress Deficiencies. Inspection of June 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 22, 2025).

  17. No harm, with potential for more than minimal harm

    Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0362, Smoke Deficiencies. Inspection of June 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 22, 2025).

  18. No harm, with potential for more than minimal harm

    Install corridor and hallway doors that block smoke.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0363, Smoke Deficiencies. Inspection of June 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 22, 2025).

  19. No harm, with potential for more than minimal harm

    Have proper medical gas storage and administration areas.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0923, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of June 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 22, 2025).

  20. No harm, with potential for more than minimal 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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of November 4, 2024. Found during a complaint inspection.

    The home gave a date the problem would be corrected (December 6, 2024).

  21. No harm, with potential for more than minimal harm

    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

    Pattern (more than a few residents). CMS level E.

    Health citation F-0655, Resident Assessment and Care Planning Deficiencies. Inspection of June 9, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 6, 2021).

  22. No harm, with potential for more than minimal harm

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0657, Resident Assessment and Care Planning Deficiencies. Inspection of June 9, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 6, 2021).

  23. No harm, with potential for more than minimal harm

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0842, Resident Assessment and Care Planning Deficiencies. Inspection of June 9, 2021. Found during a standard inspection.

    The home gave a date the problem would be corrected (August 6, 2021).

  24. No harm, with potential for more than minimal harm

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0580, Resident Rights Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

  25. No harm, with potential for more than minimal 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.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0584, Resident Rights Deficiencies. Inspection of August 3, 2018. Found during a standard inspection.

    The home gave a date the problem would be corrected (October 8, 2018).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.