Autumn Woods Residential Health: Bruising Missed - MI
The resident, identified in inspection records as R50, was admitted July 22, 2025. She was severely cognitively impaired, needed one-person assistance to use the toilet and to transfer, and required supervision to eat, walk, and move in bed. She also carried diagnoses of severe protein-calorie malnutrition and diabetes. She could not tell anyone what had happened to her.
When she was discharged on July 29, someone noticed.
The facility's own Director of Nursing, interviewed by state inspectors on August 13, acknowledged she had seen the photographs of R50's bruises. She said the facility could not determine how the resident had sustained them. Then she said something more direct: something had been missed by facility staff, because it would have been impossible to provide care to this resident and not notice the bruising.
That admission is the center of this case.
On the day R50 arrived, Licensed Practical Nurse K completed a skin assessment and found nothing. No marks. No bruises. No wounds. She confirmed this to inspectors by phone on August 13. The following evening, a nurse practitioner examined R50 at bedside, reviewed her chart and nursing assessment, and documented her skin as intact with no visualized rashes.
Seven days later, on the morning of discharge, Certified Nursing Assistant N was dressing R50 for the day. She noticed redness on the resident's right arm. She reported it to a nurse. She could not remember which nurse.
There is no documentation in the medical record showing that report went anywhere.
What followed the discharge tells the story of how seriously the injuries were taken once R50 was no longer inside the building. She was first taken to a community agency that coordinates healthcare services with the facility for a skin assessment. That assessment apparently raised enough concern that she was then transferred to a hospital for further evaluation. Inspectors reviewed photographs submitted to the state agency. The bruises were visible on her neck, her left shoulder, and her hand. The images showed injuries in multiple stages of healing, meaning some were older than others, meaning at least some of them were present during her stay.
The facility submitted a Facility Reported Incident to the state. In it, staff offered a series of explanations. The bruises on R50's chest and shin appeared more advanced in healing, suggesting they may have occurred before admission. The scratches on her thigh, the report said, were self-inflicted, caused by a small area of irritation she scratched herself. The remaining bruises, the report concluded, were most likely caused by her poor trunk control, her unsteady gait, and her habit of lying on her right side in awkward positions at various times before and during her stay.
What the facility's incident report did not explain was why none of this was documented while it was happening. R50 had poor trunk control and an unsteady gait on the day she arrived. Those were known conditions. The facility's own wound care policy required CNAs to check residents' skin daily during routine care and to report any new findings to a charge nurse or unit management for immediate intervention. CNA N noticed redness on R50's arm the morning of discharge. By the facility's own account, that was not the only injury present.
The Director of Nursing did not dispute that. She said it would have been impossible to miss.
The inspection was triggered by three separate complaints filed with the state, logged under intake numbers 2578720, 2584022, and 2586062. Inspectors cited the facility for failing to thoroughly assess and document skin bruising for an injury of unknown origin. The deficiency was tagged under the federal standard protecting residents from abuse, neglect, and mistreatment, though inspectors classified the level of harm as minimal harm or potential for actual harm, the lower end of the harm scale.
That classification sits uneasily against the facts in the record. R50 had Alzheimer's disease. She was severely cognitively impaired. She could not report pain. She could not describe what had happened to her. She could not advocate for herself in any meaningful way. She was dependent on staff for every basic function of daily life. When she left the building with bruises in multiple stages of healing on her neck, her shoulder, and her hand, and when the facility's own nursing director said staff should have seen them, the question of what actually happened to her during those seven days remained, by the facility's own admission, unanswered.
The facility said it could not substantiate the causes of all the bruises except the one on her hand. The report does not explain what caused the hand bruise, or how that one was substantiated while the others were not.
R50 was taken to a hospital. What the hospital found is not in the inspection record.
The Director of Nursing's words, recorded by inspectors that afternoon, are precise: something was missed. A woman with Alzheimer's, who needed help to stand and to eat, who could not tell anyone she was hurting, spent a week in a facility's care and left with injuries that the people responsible for watching her skin every day said they did not see. After she was gone, when photographs existed and state complaints had been filed, the facility offered explanations about trunk control and awkward sleeping positions.
CNA N dressed R50 on the morning of July 29 and saw the redness on her arm. She told a nurse. She does not remember which one. There is no note in the chart that anyone responded.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
Autumn Woods Residential Health in Warren, MI was cited for violations during a health inspection on August 13, 2025.
The resident, identified in inspection records as R50, was admitted July 22, 2025.
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.