Autumn Woods Residential Health: Medication Left Unattended - MI
Inspectors from the Centers for Medicare and Medicaid Services documented the finding on May 27, 2026, during a complaint inspection at Autumn Woods Residential Health. The resident at the center of it, identified in records as R806, had been living at the facility since July 2024 and carried diagnoses of Type 2 diabetes, altered mental status, and muscle weakness.
When an inspector walked into R806's room at 2:56 in the afternoon, a medication cup holding four tablets was sitting on the table extended over the resident's bed, directly in front of them. R806 said the nurse usually stays to watch them take the medications before leaving. This time, the nurse had left the pills there roughly an hour earlier. R806 said they had been half asleep and wasn't totally sure what had happened.
The medications were not minor. The four tablets included two doses of Hydralazine, a blood pressure drug prescribed at 25 milligrams each, scheduled to be given at 1:00 in the afternoon. The other two were Acetaminophen, 325 milligrams each, due at noon. Both had passed their administration windows before the inspector arrived.
R806 had no order permitting self-administration of medications. No assessment had been completed by the facility's interdisciplinary team to determine whether self-administration would be safe. The electronic medical record contained neither.
That absence mattered. R806's most recent cognitive screening showed a score of 14 on the Brief Interview for Mental Status, a result that indicates intact cognition. But intact cognition is not the same as a clinical determination that a resident can safely manage their own medications, particularly a resident with altered mental status as an active diagnosis. The facility's own policy stated that a resident may only self-administer medications after the interdisciplinary team has determined which medications may be safely self-administered.
The nurse who had left the room, identified in the report as LPN B, was interviewed at 3:04 that afternoon. LPN B did not dispute what happened. The nurse admitted to leaving the medications on the table without confirming they had been taken and acknowledged that medications should not be left at a resident's bedside. LPN B added that if a resident is sleeping at the time of administration, the medications should be returned to the medication cart.
The Director of Nursing was interviewed thirty minutes later and confirmed the same: medications should not be left at a resident's bedside without a self-administration order in place.
The facility's own people, in other words, described exactly what the policy required and confirmed exactly what had not been done.
What the inspection report does not resolve is what happened to the medications in that hour. R806 was half asleep and uncertain. The pills were still in the cup when the inspector arrived, which suggests they had not been taken. But a resident with muscle weakness and altered mental status, left alone with unsupervised medication and no staff present, was in a position where no one would have known either way.
The violation was cited at the level of minimal harm or potential for actual harm, the lower end of the federal deficiency scale. CMS reviewed two residents for self-administration practices and found the failure with one.
R806 sat in that room, half asleep, with four pills in a cup and no one watching, for about an hour before an inspector walked in.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Woods Residential Health from 2026-05-27 including all violations, facility responses, and corrective action plans.
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 11, 2026 · Our methodology
Autumn Woods Residential Health in Warren, MI was cited for violations during a health inspection on May 27, 2026.
R806 said the nurse usually stays to watch them take the medications before leaving.
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.