Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumnwood Of Deckerville during CMS and state inspections, most recent first.
The facility failed to keep a resident’s call light within reach, provide individualized care planning and privacy during med pass and VS checks in the dining area, ensure routine nail care, and store urinals sanitarily. A resident’s call light was out of reach in bed, meds and VS were performed in the dining room with resident information visible on the cart screen, two residents had long or jagged fingernails, and a resident’s urinals were left on an overbed table and on equipment with residual urine present.
Missing Informed Consent for Psychotropic Medication Change: A resident with Alzheimer’s dementia, severe cognitive impairment, psychosis, and behavioral symptoms was switched from Ativan to Xanax for shower days, but the chart contained informed consent only for Ativan and none for Xanax. The SW reviewed the record and confirmed the consent for the new psychotropic medication was missing.
Advance directive care plans were not updated or completed for three residents. Two residents had DNR orders and signed DNR documents, but their care plans still listed them as full code, while another resident had full code documentation but no advance directive care plan in the chart. SW staff acknowledged the missing and inaccurate care plans.
Failure to assess, document, and treat arm skin tears: A resident was observed with multiple bandaged wounds on both arms, including one dated dressing and two undated dressings with dried blood. The chart lacked documentation of the wounds, skin checks recorded no skin issues, and there were no treatment or monitoring criteria in the orders. An LPN later found the areas appeared to be skin tears, with the right wrist reddened and moist, and stated the wounds had not been communicated in report.
Improper Suprapubic Catheter Bag Positioning: A resident with dementia, CKD, DM, and a suprapubic catheter had the drainage bag observed on the floor and later dragging while seated in a wheelchair. The care plan addressed keeping the bag below the bladder and checking for kinks, but did not mention keeping it off the floor; prior notes also documented blood clots in the tubing and a detached bag with urine spilled.
Food storage and temperature control were deficient when opened liquor, liqueurs, and cocktail additives for resident activities were found undated, two containers of yogurt were left unlabeled and undated in a resident’s room, and the A-wing nourishment room refrigerator and freezer temperatures were outside the facility’s stated acceptable range. A resident with multiple chronic conditions and intact cognition had unmarked yogurt containers on a bedside table, and staff also found freezer and refrigerator readings that did not match policy.
The facility did not keep an area free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
The facility failed to notify the responsible parties of three residents about changes in their medication regimens. One resident received changes in antidepressant and antianxiety medications without guardian consent. Another resident was administered Haldol for severe agitation without notifying the guardian. A third resident had changes in antianxiety medications without documented consent from her daughter. The facility did not adhere to its policy requiring notification and documentation of such changes.
A facility failed to initiate a timely change in condition/PASSAR follow-up for a resident with diabetes, stroke, and mental illness, who remained in the facility beyond the 30-day hospital exemption period without a Level II OBRA assessment. The deficiency was identified through record reviews and staff interviews, revealing a delay in completing necessary documentation.
A resident with multiple health issues and moderate cognitive impairment did not receive a restorative therapy program after physical and occupational therapy ceased. Despite the resident's willingness to continue therapy, a lack of communication and documentation between the therapy and nursing departments resulted in the resident not being transitioned to restorative therapy, contrary to facility policy.
A review of facility records revealed that the required annual inspection identified a failed dry fire sprinkler system accelerator, resulting in a failed flow test. The deficiency was not corrected by the time of survey, as confirmed by the maintenance director.
A resident with a history of behavioral issues made non-consensual contact with another resident who had severely impaired cognitive skills. Despite previous warnings and room changes, the resident was found with his hand on the other resident's brief. The facility failed to adequately supervise and prevent the incident, highlighting a deficiency in implementing their abuse prevention policy.
Call lights, medication privacy, nail care, and urinal storage deficiencies
Penalty
Summary
The facility failed to ensure call lights were within residents’ reach. Resident 10 was observed lying in bed with the call light positioned on a chair next to the head of the bed and a shoe on top of it. The resident was unsure where the call light was and could not see or find the cord to reach it. Staff were directed to the room and repositioned the call light across the resident so it was within reach. The facility also failed to provide individualized care planning and privacy during medication administration and vital sign checks in the dining area during the lunchtime meal. During the meal observation, a nurse passed medications to residents seated in the dining room and took vital signs for another resident while other residents were nearby and eating. The medication cart was left in the hallway with a resident’s information displayed on the computer screen while no staff were at the cart, and residents in wheelchairs moved near and past it. The DON stated that administering medications in common areas was an automatic intervention for all residents and that there was no documentation of discussion with residents or representatives about it. The facility further failed to provide routine nail care and sanitary storage of urinals. Resident 18 had long fingernails, including a curled fifth digit that could not be visualized, and reported staff did not trim the nails during the last shower. Resident 56 had long and jagged fingernails, stated he did not like them that long, and reported staff could not find clippers; two nails had been chewed down to the skin. Resident 58 had urinals stored on an overbed table and on top of heart rhythm transmitter equipment and newspapers, with residual urine in one container and personal items and snack food nearby. The unit manager noted the urinal could be placed in a holder, and the resident said he would appreciate that.
Missing Informed Consent for Psychotropic Medication Change
Penalty
Summary
The facility failed to obtain informed consent before providing a psychotropic medication for Resident #71. The resident was admitted with diagnoses including Alzheimer’s dementia, history of stroke, psychosis, and adjustment disorder, and the MDS showed severe cognitive loss with a BIMS score of 0/15. The care plan documented worsening psychosis, delusional thought process, anger, agitation, and aggression, with interventions including administration of medication as ordered and monitoring for ineffectiveness and side effects. The record showed that Ativan had been discontinued due to ineffectiveness and the resident was switched to Xanax 0.5 mg prior to showers, with a physician order starting 2/16/2026. The psychotropic medication informed consent file contained a consent for Ativan dated 1/4/2026, but there was no informed consent document for Xanax. During interview, the Social Worker reviewed the record and confirmed there was no consent for Xanax and stated there should have been one because the medication had been changed from Ativan to Xanax.
Advance directive care plans were not updated or completed
Penalty
Summary
The facility failed to revise advance directive care plans for three residents. R5, who had diagnoses including type 2 diabetes, depression, chronic kidney disease, and congestive heart failure, had a signed DNR form and a physician order for DNR, but the care plan still identified the resident as full code and was dated before the DNR documentation. R82, an 87-year-old resident who was later discharged, had a physician order for DNR and a signed document indicating the resident had chosen DNR status, but the advance directive care plan still indicated full code and was dated before the change in code status. R83, who had diagnoses including cellulitis of the right lower limb, heart disease, depression, and COPD, had a physician order for full code and a signed document indicating full code status, but there was no advance directive care plan present in the chart. During interview, Social Work staff stated that advance directive care plans are done on admission and updated when code status changes, and acknowledged that the care plan for R83 was not completed and that the care plans for R5 and R82 were inaccurate. The policy reviewed stated that the care plan should be reviewed and revised to address refusals of care and the withholding and withdrawing of treatment, as appropriate.
Failure to Assess, Document, and Treat Arm Skin Tears
Penalty
Summary
The facility failed to ensure assessment, monitoring, and treatment were completed for three wounds on one resident’s arms. On 4/20/26, the resident was observed in bed with a large bandage on the right wrist area dated 4/15 and two undated bandages on the left arm, all with blackened areas that appeared to have bled into and dried on the dressings. The resident stated the areas kept bleeding and was unsure when the left arm bandages had been applied, indicating they were not placed that day. The resident’s record showed skin observation entries on 4/18/26 and 4/21/26 documenting no skin issues, and a skin check on 4/21/26 at 3:02 AM also indicated no skin issues and no new skin issues found. The record also lacked documentation of a wound to the right wrist area on 4/15/26 and lacked documentation of wounds to the left arm. During interview, the Unit Manager could not determine when the undated bandages had been applied and acknowledged there was no assessment or documentation regarding what occurred. Review of orders showed no treatment and monitoring criteria for the bilateral arm wounds. When the bandages were removed, the nurse observed the left arm areas appeared to be skin tears and noted the right wrist area was reddened and moist under the bandage. The nurse stated the adhesive band aids were not good for the resident’s fragile skin and that a wrapped dressing would be more appropriate. The nurse also stated she was not aware of the wounds and that the information had not been exchanged in report.
Improper Suprapubic Catheter Bag Positioning
Penalty
Summary
The facility failed to provide necessary management and care of an indwelling urinary catheter for Resident #47, who had diagnoses including dementia, heart disease, diabetes, chronic kidney disease, anxiety, a history of bladder inflammation with bleeding, and a surgically placed suprapubic urinary catheter. The resident’s MDS showed moderate cognitive loss with a BIMS score of 8/15 and need for assistance with care. Physician orders included suprapubic care every shift, cleansing with normal saline and applying a drain sponge daily, and changing the suprapubic catheter every 28 days. During observation, the resident’s catheter bag was seen sitting on the floor and partially covered with a cloth, and later the bag was again observed touching the floor while the resident sat in a wheelchair. Progress notes documented prior catheter-related concerns, including dark blood clots in the suprapubic catheter tubing and an episode in which the catheter bag was detached with urine spilled all over. The care plan identified the resident as at risk for urinary tract infection and catheter-related trauma and included positioning the catheter bag and tubing below the bladder and checking for kinks each shift, but it did not mention keeping the bag and tubing off the floor. When interviewed, a CNA stated the wheelchair was short and it was hard to keep the catheter bag off the floor, and the resident asked whether it was dragging.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to date 5 of 7 opened bottles of liquor, liqueurs, and cocktail additives stored for resident Happy Hour activities. During a kitchen storage room tour, an opened bottle of grenadine was not dated, a 1/2 gallon bottle of rum was 3/4 empty and not dated, a bottle of amaretto was opened and not dated, agave nectar was opened and not dated, and a bottle of agave silver tequila was 1/2 empty and not dated. Staff stated the items were for Activities department resident parties and should not have been there, and one bottle of vodka was the only item with a written date. The facility also failed to label and date 2 clear containers of yogurt left in Resident #15's room and failed to ensure acceptable temperatures in the A-wing Nourishment room refrigerator and freezer. Resident #15 had diagnoses including heart failure, diabetes, anxiety, depression, back pain, fibromyalgia, arthritis, epilepsy, and hypothyroidism, and had a BIMS score of 15/15 with full cognitive abilities. The yogurt containers on the resident's table were unidentifiable and were identified by staff as yogurt from meal trays, with the resident stating one was from breakfast and the other from the day before. In the nourishment room, the freezer temperatures included readings of 2 and 4 degrees Fahrenheit and the refrigerator temperatures were mostly 30 to 32 degrees Fahrenheit, while the facility policy identified the freezer as below 0 degrees Fahrenheit and the refrigerator as 38 to 41 degrees Fahrenheit.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Responsible Parties of Medication Changes
Penalty
Summary
The facility failed to notify the responsible parties of three residents regarding the initiation and changes to their medication regimens. Resident #42, who was diagnosed with Dementia, Adjustment Disorder, Delusional Disorder, Depression, Anxiety, and Schizophrenia, was deemed incapable of making decisions, and a guardian was appointed. Despite changes in her medication, including the initiation and dosage increases of Cymbalta and Buspirone, there was no documentation indicating that the guardian consented to these changes. Resident #68, diagnosed with Dementia, Adjustment Disorder, Anxiety, Depression, and Psychotic Disorder, also had a guardian appointed due to his inability to make decisions. He was administered Haldol for severe agitation without documentation of guardian consent or notification of the events leading to the administration. The resident exhibited aggressive behavior, necessitating the emergency use of Haldol, but the facility failed to inform the guardian about this medication change. Resident #75, with diagnoses including Vascular Dementia, Alzheimer's, Adjustment Disorder, Psychotic Disorder, and Depression, was also incapable of making decisions, with her daughter as the responsible party. Changes in her medication regimen, including the initiation and dosage adjustments of Lorazepam and Klonopin, were made without documented consent from her daughter. The facility's policy required notification and documentation of such changes, but these were not adhered to, leading to the deficiency.
Plan Of Correction
1. Res. #42's responsible party was notified and agreed to use of anti-depressant and anti-anxiety medications. Update was given to responsible party on all changes and adjustments that have been made. Res. #68's responsible party was contacted and consent was obtained for use of anti-psychotic medication. Responsible party was also updated on all recent changes or adjustments and behaviors. Res. #75's responsible party was notified and agreed to use of anti-anxiety medication. Update was given to responsible party on all changes and adjustments that have been made. 2. Social Service Designee reviewed other residents in the building receiving psychotropic medications to ensure appropriate notification and consents were received. 3. Notification of Change Policy and Procedure was reviewed by the IDT team. All Nurses, RD, and Social Service Designee were in-serviced on the Notification of Change Policy. 4. Director of Nursing or designee will audit 25% of all psychotropic medication new orders in stand-up meetings weekly x4, then monthly x2 to ensure that notification and consent was obtained. Any concerns will be addressed. Results of the audit will be reported to QA monthly. The Director of Nursing will be in charge of sustained compliance. 5. Director of Nursing or designee will audit 25% of the residents currently on psychotropic medications to ensure the responsible party was contacted and consented to anti-psychotics and agreed to anti-anxiety and anti-depressant medication. Responsible party was also updated on all recent changes or adjustments and behaviors weekly x4, then monthly x2 to ensure that notification and consent was obtained. Any concerns will be addressed. Results of the audit will be reported to QA monthly. The Director of Nursing will be in charge of sustained compliance.
Failure to Initiate Timely PASSAR Follow-Up for Resident
Penalty
Summary
The facility failed to initiate a change in condition/PASSAR follow-up for a resident who was admitted with diagnoses including diabetes, stroke, and mental illness. The resident had impaired cognition and required extensive assistance with activities of daily living. Upon admission, a hospital exemption discharge was noted, and a tentative discharge date was scheduled within two weeks. However, the resident remained in the facility beyond the 30-day exemption period without a Level II OBRA assessment being initiated, as required if the resident's stay extended beyond 30 days. The deficiency was identified during a record review and interviews with facility staff. The Social Worker Designee and the Director of Nursing were unable to provide additional documentation regarding the resident's PASSAR correspondence. It was later revealed that a new PASSAR correspondence was documented, indicating a change in condition, but this was not completed in a timely manner. The facility's policy requires that a change in condition be submitted to the local community mental health program for review if a resident remains in the facility longer than the initial 30-day exemption period.
Plan Of Correction
1. Res. #3 had a change in condition triggered at survey by the Social Services Designee, and CMH has begun the Level 2 screening. 2. Social Service Designee reviewed all residents in building to ensure that no other residents had missed change in condition. 3. Social Service Designee and Admission Director were in-serviced on Pre-Admission Screening and Guest/Resident Review Policy and Procedure. 4. Social Service Designee will audit 25% of resident population weekly x4, then monthly x2 to ensure that all PASSARs are current and up to date. Any concerns will be addressed. Results of audit will be reported to QA Monthly. Social Service Designee will be in charge of sustained compliance.
Failure to Initiate Restorative Therapy Program
Penalty
Summary
The facility failed to initiate a restorative therapy program for a resident, identified as Resident #76, who was admitted with diagnoses including adjustment disorder, heart failure, muscle weakness, difficulty in walking, and acquired absence of right toe(s). The resident had moderately impaired cognition and required assistance with various activities of daily living. Despite the resident's expressed desire to continue therapy and denial of refusing therapy, the facility did not transition the resident to a restorative therapy program after the cessation of physical and occupational therapy. Interviews with the Therapy Manager and the Unit Manager/Restorative Therapy Nurse revealed a lack of communication and documentation regarding the resident's transition to restorative therapy. The Therapy Manager acknowledged the intention to place the resident in the restorative therapy program but noted a miscommunication that resulted in the plan not being documented in the medical records. The Unit Manager confirmed that no evaluation or referral for restorative therapy was received, despite the resident being a candidate for such a program. The Director of Nursing was informed of the communication breakdown and the failure to develop a restorative therapy plan for the resident. The facility's policy on restorative nursing emphasizes the importance of enabling residents to attain and maintain their highest practicable level of well-being through an interdisciplinary approach. However, the lack of a documented plan and communication between departments led to the resident not receiving the necessary restorative services.
Plan Of Correction
1. Resident #76 was evaluated and picked up by Physical and Occupational Therapy. 2. All residents discharged from PT or OT in the last 30 days were reviewed to ensure residents were started on a Restorative Therapy Program if ordered. 3. Therapy Director, Nursing Staff, and IDT team was educated on the Restorative Policy and Procedure as well as the ADL Policy and Procedure. 4. The Director of Nursing will audit all discharges from PT and/or OT weekly for four weeks, then monthly for two months to ensure restorative therapy programs were initiated as ordered. Any concerns will be addressed. Results of the audit will be reported to QA monthly. The Director of Nursing will be in charge of sustained compliance.
Failure to Address Sprinkler System Deficiency After Failed Inspection
Penalty
Summary
The facility failed to provide required maintenance and testing for its automatic sprinkler system in accordance with NFPA 25. During a record review, it was found that the annual fire sprinkler inspection report from November 21, 2024, documented a failure of the dry fire sprinkler system accelerator, which resulted in a failed flow test. As of the time of the survey on March 5, 2025, the deficiencies identified in the inspection report had not been addressed. These findings were confirmed through an interview with the maintenance director during the record review. No information about specific residents or their medical conditions was included in the report.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse, as evidenced by an incident involving two residents. Resident #1, who had intact cognition but a history of behavioral issues, was observed making non-consensual contact with Resident #2, who had severely impaired cognitive skills and was dependent on staff for daily activities. Despite previous warnings and room changes to prevent Resident #1 from entering Resident #2's room, Resident #1 was found with his hand on Resident #2's brief and a finger inside it while Resident #2 was asleep. Prior to the incident, Resident #1 had exhibited aggressive behavior, including yelling and physical aggression towards caregivers. He had also been observed entering female residents' rooms without permission, including Resident #2's room, despite being advised against it. On the day of the incident, staff had to repeatedly redirect Resident #1 away from Resident #2's room, but he persisted in his attempts to visit her, becoming agitated and verbally abusive when confronted. The facility's failure to adequately supervise Resident #1 and prevent him from accessing Resident #2's room resulted in the observed incident. The facility's policy on abuse prevention was not effectively implemented, as staff were unable to prevent the non-consensual contact despite being aware of Resident #1's previous attempts to engage with Resident #2. The incident was reported, and legal parties were notified, but the lack of documentation of a skin assessment following the incident was noted.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Deckerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sanilac Medical Care Facility | 8.5 mi | ★★★★★ | 12 | 0 |
| Marlette Community Hospital Ltcu | 21.8 mi | ★★★★★ | 0 | 0 |
| Lakeview Extended Care And Rehabilitation | 22.3 mi | ★★★★★ | 6 | 0 |
| Courtney Manor | 22.9 mi | ★★★★★ | 10 | 0 |
| Medilodge Of Cass City | 23.1 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.