Autumn Woods: Unexplained Bruises on Respite Patient - MI
Staff at Autumn Woods Residential Health admitted they missed the injuries entirely during the resident's seven-day stay in July, despite daily care requirements and facility policies mandating skin checks during routine care.
The 78-year-old resident, identified in inspection records as R50, was admitted July 22 for respite care with severe cognitive impairment, malnutrition and diabetes. They required one-person assistance for toileting and transfers, plus supervision for eating, walking and bed mobility.
Licensed Practical Nurse K, who admitted the resident, told state inspectors she completed a skin assessment and "did not identify any marks, bruises or wounds on the resident's body." A nursing evaluation summary from the admission date noted "no skin integrity issues."
The next evening, a nurse practitioner examined the resident at bedside and documented: "Skin: Intact with no visualized rashes."
But when the resident was discharged July 29, family members discovered bruising and took them to a community healthcare agency for assessment. The resident was subsequently transferred to a hospital for further evaluation.
Photographs taken after discharge showed bruises in multiple stages of healing on the resident's neck, left shoulder and hand. The facility's own incident report acknowledged "multiple bruises of various stages of healing" but claimed staff "could not substantiate the causes of all the bruises, except the hand."
Certified Nursing Assistant N, who was assigned to care for the resident on both admission and discharge days, told inspectors she noticed redness on the resident's right arm the morning of discharge while dressing them. She reported the skin issue to a nurse but couldn't remember which one.
The facility's incident report speculated the bruises were "most likely caused by poor trunk control, unsteady gait, laying on right side in awkward positions at various times prior to and during stay." It suggested some bruises on the chest and shin appeared more advanced in healing than injuries to the hands, arms and shoulders, "indicating that they possibly occurred prior to the hand, arm and shoulder."
The report attributed scratches on the resident's thigh to "a small area of irritation which R50 scratched themselves."
Director of Nursing acknowledged during her interview with inspectors that she had seen the photographs showing the various stages of bruising. She admitted the facility could not determine how the resident sustained the injuries.
More significantly, she conceded that "something was missed by facility staff as it would have been impossible to have provided care to the resident and not have noticed the bruising."
The admission contradicts the facility's own wound care policy, which requires all certified nursing assistants to "check the resident's skin daily during routine care for evidence of skin injuries" and bring "any new findings to the attention of charge nurse and/or Unit Management for immediate intervention."
The resident's vulnerability made the oversight particularly concerning. Medical records show they had severe protein-calorie malnutrition alongside Alzheimer's disease, conditions that can affect skin integrity and healing. Their need for assistance with basic activities meant multiple staff members would have had direct physical contact during the week-long stay.
The case raises questions about how extensively injured residents can receive daily care without staff noticing obvious bruising, particularly when policies specifically require skin monitoring during routine tasks like dressing, bathing and transfers.
Federal inspectors determined the facility failed to thoroughly assess and document the skin bruising for what they classified as an "injury of unknown origin." The citation was issued under regulations requiring nursing homes to protect residents from abuse and neglect.
The resident's case involved three separate complaint intakes to state authorities, suggesting multiple concerns were raised about the incident beyond the undocumented injuries.
State inspectors found the facility's explanation insufficient, particularly given that multiple staff members provided hands-on care to a resident who required assistance with basic activities yet somehow missed bruising visible enough to prompt immediate medical evaluation after discharge.
The facility's incident report attempted to explain away most injuries as self-inflicted due to the resident's mobility issues and positioning, but offered no documentation or witness accounts to support these theories. The speculation came only after family members discovered the bruising and sought outside medical assessment.
The timing of the bruises, described as being in various stages of healing, suggests some injuries occurred before admission while others developed during the stay. However, the facility's failure to document any bruising at admission makes it impossible to determine which injuries were pre-existing and which occurred under their care.
The resident's severe cognitive impairment would have made them unable to report pain or injuries, making staff vigilance even more critical for their safety and wellbeing.
The case highlights broader concerns about respite care oversight, where residents may stay for shorter periods but still require the same level of monitoring and documentation as long-term residents. The seven-day stay should have included multiple opportunities for staff to identify and document any skin issues.
The facility's acknowledgment that staff missed obvious injuries during routine care calls into question the adequacy of their monitoring systems and staff training on recognizing potential abuse or neglect indicators.
The resident was ultimately transferred to a hospital for evaluation of injuries that went unnoticed and undocumented during their entire nursing home stay, despite daily contact with multiple caregivers who were specifically trained and required to monitor for such conditions.
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.
They required one-person assistance for toileting and transfers, plus supervision for eating, walking and bed mobility.
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.