Autumn Woods: Fall Prevention Plan Ignored - MI
Federal inspectors found the facility failed to implement fall prevention measures for the resident during an August complaint investigation. The resident, identified as R8 in inspection records, was admitted in May following a cerebral infarction and bipolar disorder diagnosis.
On August 11 at 11:32 AM, inspectors observed the resident in bed with a cane positioned on the right side. The resident reported using the cane for mobility and acknowledged having "a couple falls" at the facility.
The resident's care plan explicitly required a "mat to floor next to bed left side of bed." Yet inspectors found no floor mat during three separate observations over consecutive days.
No mat appeared on August 11 at 11:32 AM. None was present on August 12 at 9:33 AM. The mat remained absent on August 13 at 10:37 AM.
The resident's medical assessment showed intact cognition with a Brief Interview for Mental Status score of 14 out of 15. However, they required assistance with bed mobility and transfers — factors that typically increase fall risk when combined with stroke history.
Unit Manager W couldn't explain the missing safety equipment during an August 13 interview. The manager suggested maintenance may have moved the mat but expressed uncertainty about why the resident lacked the required intervention.
Inspectors requested the resident's incident and accident reports to review fall history but never received the documentation by the survey's end. The facility also failed to provide its fall prevention policy despite inspector requests.
During a Quality Assurance and Improvement Plan meeting on August 13, Nursing Home Administrator acknowledged expectations that current fall interventions should be implemented. The administrator explained that the facility's interdisciplinary team meets following falls to review interventions, with appropriate measures added to care plans for immediate implementation.
The violation represents a breakdown in the facility's care plan execution. Federal regulations require nursing homes to develop and implement complete care plans with measurable actions and timetables. The missing floor mat constituted a failure to follow through on documented fall prevention strategies.
Fall prevention becomes critical for residents with stroke history, particularly those requiring mobility assistance. The resident's combination of cerebral infarction, transfer difficulties, and previous falls at the facility created multiple risk factors that the care plan was designed to address.
The inspection occurred following a complaint, though the specific nature of the complaint wasn't detailed in available records. Federal investigators classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
Autumn Woods' inability to produce basic documentation — both incident reports and fall policies — suggested broader organizational issues beyond the single resident's missing mat. Facilities typically maintain detailed records of falls and established protocols for prevention.
The administrator's acknowledgment that interventions should be followed "immediately" after interdisciplinary team review highlighted the gap between stated expectations and actual implementation. The resident went without required safety equipment for at least three consecutive days.
The missing mat represented more than administrative oversight. For a stroke survivor who reported multiple facility falls and required assistance with basic mobility, the floor mat served as a concrete barrier between safe transfers and potential injury.
The resident's intact cognition meant they likely understood their fall risk and the purpose of safety interventions. Having a care plan intervention documented but not implemented could undermine trust in the facility's commitment to resident safety.
Inspectors found the violation during routine observations, suggesting staff weren't actively monitoring compliance with individualized care plan requirements. The unit manager's uncertainty about the mat's location indicated a lack of systematic oversight for fall prevention measures.
The facility's interdisciplinary team process, while described as responsive to falls, appeared to lack follow-through mechanisms ensuring approved interventions actually reached residents' rooms. Documentation showed planning but not execution.
The resident continued using their cane and navigating transfers without the planned safety equipment, facing the same risks that prompted the care plan intervention. The mat's absence left a stroke survivor with mobility challenges and previous falls without a basic protection measure their care team had deemed necessary.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Woods Residential Health from 2025-08-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Autumn Woods Residential Health in Warren, MI was cited for violations during a health inspection on August 13, 2025.
Federal inspectors found the facility failed to implement fall prevention measures for the resident during an August complaint investigation.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.