Autumn Woods Residential Health: Call Light Failures - MI
That resident, identified in inspection records as R4, has renal failure and diabetes. Inspectors documented severely impaired cognition and total dependence on staff for every activity of daily living. The call light was not misplaced once. It was on the floor at the head of the bed at 11:19 a.m., again at 11:25 a.m., again at 1:11 p.m., at 2:00 p.m., at 2:56 p.m., and at 4:34 p.m. on August 11, 2025. The next morning, inspectors returned. It was on the floor again.
Federal inspectors from the Centers for Medicare and Medicaid Services visited Autumn Woods, at 29800 Hoover Road in Warren, on August 13, 2025, responding to complaints. What they documented over three days was not a single lapse but a pattern, repeated across multiple rooms, involving residents who shared one critical characteristic: none of them could independently summon help under any circumstances.
R4 was not alone. Down the hall, inspectors found R160 in bed with the call light cord and button looped over a hook on the wall below the call box — not within reach, but stored, as if tidied away. R119, who has malnutrition and respiratory failure and is also assessed as severely cognitively impaired with total dependence on staff, was found with the call light looped over the call box and a vent cart. The cord was there. The button was there. Neither was reachable from the bed.
On August 12, all three were observed again in the same conditions.
A fourth resident, R239, has chronic respiratory failure and diabetes, the same cognitive and functional profile as the others. On August 12 at 11:37 a.m., inspectors found R239 in bed with the call button hanging below the bottom of the bed frame. The following morning, at 8:54 a.m. on August 13, an aide entered R239's room, then left, then came back, then left again. When inspectors looked, the call cord and button were on the floor at the left side of the bed.
The aide had just been in the room. Nobody had put the call light within reach.
Autumn Woods has its own written policy on this. The document, titled "Call Lights: Accessibility and Timely Response" and revised as recently as December 28, 2023, states that the facility exists to ensure residents can call for assistance from their bedside. It acknowledges that some residents need special accommodations, larger buttons, touch pads, brighter colors, and that those accommodations should be in the care plan. None of that applied here. These residents needed only for the cord to be placed where a hand could reach it.
The inspection covered six residents. Four of them were found without a functioning means to call for help. The harm level was classified as minimal, the lowest category in the federal rating system, meaning inspectors determined no serious injury resulted from what they found. That classification reflects what was documented, not what could have happened during the hours between observations when no one was watching.
A resident with severe cognitive impairment cannot shout a coherent request. Cannot get out of bed. Cannot walk to the door. When the call light is on the floor, or looped over a hook on the wall, or hanging below the bed frame, that resident has no way to reach anyone. What happens next depends entirely on whether a staff member decides, on their own, to check.
R4 waited through six documented observations on a single day. The call light stayed on the floor.
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
Autumn Woods Residential Health in Warren, MI was cited for violations during a health inspection on August 13, 2025.
That resident, identified in inspection records as R4, has renal failure and diabetes.
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.