Autumn Woods Residential Health
Autumn Woods Residential Health in Warren, MI — inspection on March 26, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
administer pain medication per physician order and resident preference for one (R900) of three
R900 revealed a few days ago, I was waking up in severe pain in the morning. R900 further revealed they did not think they were receiving their night-time dose of pain medication. An inquiry regarding whether they had asked the nurses not to wake them in the night for pain medication, R900 said they want to be awakened for night-time medication, even if they are asleep, so the pain does not get so bad.A review of the medical record revealed R900 was admitted to the facility on [DATE] on the hospice service with the relevant diagnoses: CREST Syndrome Scleroderma and Rheumatoid Arthritis.
The Minimum Data Set (MDS) assessment's most recent Brief Interview for Mental Status (BIMS) indicates intact cognition. A review of R900's care plan revealed the following pertinent interventions under hospice care: Administer medications as ordered and observe for effectiveness, initiated on 2/9/26, revised on 2/11/26.
Evaluate for verbal and non-verbal signs and symptoms relating to pain.
Provide care based on resident preferences related to end-of-life comfort measures.A review of the medication orders for R900 revealed:A order by Primary Physician (PP) D, dated 2/19/26 at 6:50 PM, or Morphine 100 mg(milligrams)/5ml(milliliters), give two ml every four hours and, An order entered on 2/19/26 at 7:36 PM by the Nurse Practitioner, E for Morphine 100mg/5ml, give two ml every two hours as needed for breakthrough pain. A review of the medication administration record (MAR) for the month of March (2026) revealed seven doses (3/6/26, 3/11/26, 3/15/26, 3/16/26, 3/19/26, 3/20/26, and 3/25/26) of Morphine was to be given at 12:00 AM (midnight) but were not administered.
Further review revealed the medication was not given because R900 was sleeping as indicated by number 7 documented by Registered Nurse (RN) E on the MAR.On 3/26/26 at 3:30 PM, an interview with the Unit Manager (UM), C confirmed the Morphine doses were not given according to both the electronic medical record and the narcotic sign-out sheets. UM C indicated the medication should have been given (adminstered) unless the resident requested not to be awakened. On 3/26/26 at 4:00 PM, an interview with the Director of Nursing (DON) indicated medications should be given as ordered.A review of the policy Pain Management last reviewed on 10/26/23 revealed The facility will ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.A review of the policy Hospice last reviewed 10/26/2023 revealed The plan of care will include directives for managing pain and other uncomfortable symptoms and will be revised and updated as necessary.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.