Autumnwood of Deckerville

Inspectors wroteBased on observation, interview and record review, the facility failed to fulfill residents' rights by ensuring that 1) Call lights were in reach, 2) Vital signs and medications were administered/performed during the lunch time meal in the dining area with care plans not individualized, 3) Nail care was performed routinely, 4) Sanitary storage of urinals, and 5) Personal medical records were protected for 4 residents (10, 18, 56, and 58) of 8 residents reviewed for dignity, activities of daily living and residents observed during dining observation.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent prior to providing a psychotropic medication for one resident (Resident #71) of 5 residents reviewed for medications. Findings Include: Resident #71: A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #71 was admitted to the facility on [DATE] with diagnoses: Alzheimer's dementia, history of a stroke, psychosis and adjustment disorder. The MDS assessment dated [DATE] revealed the resident had severe cognitive loss with a Brief Interview for Mental Status/BIMS score of 0/15 and needed some assistance with care. A review of the Care Plans for Resident #71 identified the following: (Resident #71) has an actual behavior problem r/t (related to): [...]

Inspectors wroteBased on interview and record review, the facility failed to revise care plans regarding advance directives for three residents (R5, R82, R83) of three residents reviewed for advance directives.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that assessment, monitoring and treatments were completed/administered for two wounds on the left forearm and one wound on the right forearm for one resident (Resident #10) of one resident reviewed for wound care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary management and care of an indwelling urinary catheter for 1 resident (Resident #47) of 3 residents reviewed for urinary catheters. Findings Include: Urinary CatheterResident #47: A review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #47 was admitted to the facility on [DATE] with diagnoses: Dementia, heart disease, diabetes, chronic kidney disease, anxiety, history of bladder inflammation with bleeding, surgically placed supra pubic urinary catheter (a catheter inserted through the abdomen into the bladder). The MDS assessment 3/30/2026 revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status/BIMS score of 8/15 and the resident needed assistance with care. On 4/21/2026 at 9:34 AM, Resident #47 was observed lying in bed awake. [...]

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to date 5 of 7 bottles of liquor, liqueurs, and cocktail additives, used for Happy Hour for the residents, were opened, 2) Failed to label and date 2 of 2 clear containers of yogurt left in Resident #15's room and 3) Failed to ensure that Freezer and Refrigerator temperatures in the A-Wing Nourishment room were within an acceptable range for 1 of 2 Nourishment rooms . Findings Include: Kitchen: On 4/20/2026 at 9:55 AM, during a tour of the kitchen storage room with Dietary Aide B and [NAME] D a crate with opened liquor bottles, liqueurs and cocktail additives was stored on a shelf. A bottle of opened Grenadine (a red, sweet syrup used in cocktail mix) was opened and not dated when opened; a 1/2 gallon bottle of Rum was 3/4's empty and was not dated when opened; [...]

Inspectors wroteThis Citation Pertains to Intake Number 1316000. Based on observation, interview and record review, the facility failed to provide adequate supervision, ensure comprehensive investigations of falls, and implement meaningful interventions to prevent falls for two residents (# 701 and #702) of three residents reviewed, resulting in falls with injury including nasal bone fractures, the necessity for emergency medical treatment, and unnecessary pain.

Inspectors wroteBased on interview and record review the facility failed to notify three residents' (#42, #68 & #75) responsible parties of initiation and changes to their medication regime of five residents reviewed for unnecessary medications. Findings Include: Resident #42: On 3/5/2025 at 9:00 AM, a review was conducted of Resident #42's clinical records and it indicated the resident admitted to the facility on [DATE] with diagnoses that included, Dementia, Adjustment Disorder, Delusional Disorder, Depression, Anxiety and Schizophrenia. Resident #42 was deemed incapable of making decision for herself and a guardian was appointed. Further review was completed of Resident #42's Cymbalta (antidepressant medication) and Buspirone (antianxiety medication) orders and changes since admission which yielded the following: Physician Orders: Buspirone: Started on 2/12/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to initiate a change in condition/PASSAR follow up for one resident (Resident #3) of five residents reviewed for PASSAR's.

Inspectors wroteBased on observation, interview and record review, the facility failed to initiate a restorative therapy program to provide services to maintain or improve range of motion and mobility for one resident (Resident #76) of one resident reviewed for therapy and restorative services.

Inspectors wroteThis Citation pertains to Intake Number MI00145606. Based on observations, interviews and record review, the facility failed to protect Resident #2's right to be free from sexual abuse by Resident #1 for one resident (Resident #2) of four residents reviewed for abuse, resulting in Resident #1 being observed to make non-consensual contact with Resident #2's perineal area, with a finger in Resident #2's brief, while Resident #2 was lying in bed, resulting in psychosocial harm, trauma and/or fear using the reasonable person concept and the potential for injury.

Inspectors wroteThis Citation Pertains to Intake Number MI00137710. This Citation has two Deficient Practice Statements (DPS). DPS #1: Based on observation, interview and record review, the facility failed to ensure that appropriate interventions were in place to secure a resident in a van during a transport to prevent a fall with serious injury for one resident (Resident #8) of 5 residents reviewed for falls and accidents, resulting in Resident #8 falling out of a wheelchair in a facility van and sustaining two right leg fractures. Findings Include: Resident #8: Accidents A record review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #8 revealed the resident was admitted to the facility on [DATE] with diagnoses: history of a brain tumor, morbid obesity, heart disease, fibromyalgia, depression, chronic pain, and neuropathy. [...]

Inspectors wroteThis Citation pertains to Intake Number MI00138266. Based on observation, interview and record review, the facility failed to ensure the provision of residents' rights and dignified living conditions for three residents (Resident #11, Resident #12, and Resident #39), out of a sample of 18 residents, resulting in Resident #11 and Resident #12 having strong offensive odors in their room and bathroom and potential lack of availability of the phone for Resident #39 and feelings of embarrassment, shame, frustration, isolation, and loneliness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure monitoring of blood glucose levels for one resident (Resident #46), who was admitted back to the facility with a tube feeding of enteral nutrition, and who did not receive the ordered enteral nutrition formulated for a diagnosis of diabetes of one resident reviewed for tube feeding, resulting in blood glucose levels not being monitored and the potential for elevated blood glucose levels to be left untreated which could adversely impact health and well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain respiratory equipment in a sanitary manner for one resident (Resident #35) of one resident reviewed for respiratory care, resulting in the potential for exposure to infectious organisms and respiratory decline. Findings Include: Resident #35: Respiratory Care A review of the Face sheet and Minimum Data Set (MDS) assessment for Resident #35 indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Diabetes, chronic kidney disease, end stage renal disease, heart failure, gout, respiratory failure, COPD, morbid obesity, and chronic pain. The MDS assessment dated , 1/23/2024 indicated Resident #35 had full cognitive abilities with a Brief Interview for Mental Status (BIMS) score of 15/15 and the resident needed assistance with care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed complete timely assessments after the installment of enabler bar, continue monitoring for the appropriateness of bedrails, and obtain consent prior to use for two residents (Resident #21 and Resident #43) of two residents reviewed for bed mobility resulting in the potential for entrapment and a decline in mobility. Findings Include: Resident #21: During initial tour on 3/18/2024, Resident #21 was observed watching television and enjoying her lunch. She was not able to hold a conversation due to her disease process but did appear to be in good spirits. Observed on her bed was a right sided enabler bar. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to collaboratively review mental health documentation, code a Minimum Date Set (MDS) accurately, and add a mental health diagnosis for one resident (Resident #52) of one resident reviewed for behavioral health care, resulting in Resident #52's diagnosis of Schizophrenia not being addressed by the facility until 15 months after admission. Findings Include: Resident #52: During initial tour on 3/18/2024, Resident #52 was observed watching the news in bed. He began to speak about specifics regarding his early adulthood and without hesitation reported he was kidnapped by the facility, and is being kept here against his will. He continued with tangential/hyperverbal speech as this writer listened. He expressed his brother who resided in down state committed suicide but he does not believe that to be true. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper communication and collaboration with hospice services was provided to three residents (Resident #13, Resident #46 and Resident #63) of three residents reviewed for hospice services, resulting in facility staff and residents being unaware of their hospice schedule, specific hospice services, delays in receipt of progress notes and the timely uploads of documentation to resident medical records. Findings Include: Resident #63: During initial tour on 3/18/2024, Resident #63 was observed visiting with his wife. His wife share he recently signed onto hospice due to his decline. [...]