Autumn Woods Residential: Call Lights Out of Reach - MI
Federal inspectors responding to complaints at Autumn Woods Residential Health found four residents whose call lights had been placed out of reach, despite their total dependence on staff for basic care. The violations occurred repeatedly over three days of observation in August.
R4 was found six separate times with the call light on the floor at the head of the bed. Inspectors documented the violations at 11:19 AM, 11:25 AM, 1:11 PM, 2:00 PM, 2:56 PM, and 4:34 PM on August 11. The pattern continued the next day, with three more observations of the same resident unable to reach emergency help.
The resident suffered from renal failure and diabetes, with medical assessments showing severely impaired cognition and complete dependence on staff for activities of daily living.
R160 was consistently found with the call light cord and button looped over a hook on the wall below the call box, making it impossible to reach from bed. Like R4, this resident had severely impaired cognition and required total assistance from staff.
R119's call light was looped over the call box and a ventilator cart, equally unreachable. Medical records showed this resident had malnutrition and respiratory failure, along with severe cognitive impairment.
R239 presented the starkest example of the facility's failures. On August 12, inspectors found the call button hanging below the bottom of the bed frame. The next morning, they watched an aide exit the room, re-enter, then exit again while the call cord and button remained on the floor at the left side of the bed.
This resident had chronic respiratory failure and diabetes, with the same pattern of severe cognitive impairment and total dependence documented in medical records.
The facility's own policy, revised in December 2023, required call lights at each resident's bedside to allow residents to call for assistance. The policy specifically mentioned special accommodations like touch pads, larger buttons, and bright colors for residents who needed them.
None of the four residents could have summoned help in an emergency.
The inspection occurred in response to complaints about the facility. Inspectors classified the violations as having potential for actual harm, though they determined the harm level was minimal.
All four residents required complete assistance with basic activities like eating, bathing, and moving. Their medical conditions included life-threatening diagnoses like respiratory failure, renal failure, and chronic diseases requiring ongoing monitoring.
The repeated nature of the violations suggests systemic problems with staff training or oversight. Inspectors found the same residents in identical situations across multiple days, indicating the issues weren't isolated incidents but ongoing care failures.
Federal regulations require nursing homes to reasonably accommodate each resident's needs and preferences. For residents with severe cognitive impairments who cannot advocate for themselves, accessible call systems represent a critical safety measure.
The facility serves residents with complex medical needs who depend entirely on staff intervention. When call lights are unreachable, these vulnerable residents have no way to signal distress, pain, or emergency medical situations.
R239's case particularly highlighted staff awareness issues. An aide entered and exited the room twice while the call system remained on the floor, suggesting either indifference to safety protocols or inadequate training about proper call light placement.
The violations occurred during a complaint investigation, meaning concerns about resident care had already been raised before inspectors arrived. The systematic nature of the call light failures suggests deeper problems with care standards at the facility.
Medical records showed each affected resident had been admitted for serious conditions requiring ongoing medical attention. R4's renal failure, R119's respiratory failure and malnutrition, R160's undisclosed conditions, and R239's chronic respiratory failure all represented situations where emergency access to help could be life-saving.
The facility's December 2023 policy revision demonstrated awareness of call light accessibility requirements. The gap between written policy and actual practice left the most vulnerable residents without basic safety protections they couldn't provide for themselves.
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.
The violations occurred repeatedly over three days of observation in August.
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.