Autumnwood of McBain

In the surveyor’s words

From the most serious findings on record at Autumnwood of McBain, in the surveyor’s own words.

• Actual harm, patternF725Mar 26, 2025

  This citation pertains to Intakes MI00150419 and MI00151063. Based on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the physical, mental, and psychosocial well-being in 19 residents (#37, #51, #7, #87, #35, #36, #42, #48, #65, #81 and nine confidential residents) reviewed for staffing. This deficient practice resulted in actual harm for Residents #37, #7, #35, #42, and #48 who were forced to lay in their own excrement or urine for extended periods of time or delay a bowel movement due to insufficient staffing, resulting in reported feelings of frustration, helplessness, humiliation, and anger and/or inference of these feelings based on the reasonable person concept. […]

• Actual harm, patternF880Mar 1, 2022

  Based on observation, interview, and record review, the facility failed to: 1. Maintain a functioning infection control program; 2. Failed to follow facility policy regarding personal protective equipment (PPE) use for quarantined residents related to COVID-19; and 3. Failed to ensure housekeeping staff were aware of the procedure to mix and use the disinfectant chemical for COVID-19 positive or COVID-19 quarantined resident areas to ensure elimination of the COVID-19 pathogen. […]

• Actual harm, isolatedF689Jun 10, 2026

  Based on interview and record review, the facility failed to ensure safety during transport of one Resident (#10) of three residents reviewed for falls resulting in a fractured 1st cervical (neck) fracture, prolonged pain and fear of paralysis and failed to implement interventions for one Resident (#51) of one resident reviewed for handling of hot liquids, who was deemed unsafe to handle hot liquids without supervision and/or interventions in place.Findings include:Resident #10 (R10) On 6/9/2026 at 11:32 AM, an interview was conducted with R10 regarding her history of falls in the facility. R10 indicated she fractured her atlas (the first neck vertebra) as a result of tipping backward in a wheelchair in a transport vehicle and striking her head on the van floor. […]

• Actual harm, isolatedF711May 27, 2025

  Based on interview and record review, the facility failed to ensure the physician reviewed medication orders for accuracy for one Resident (#3) of three residents reviewed for physician visits. This deficient practice resulted in Resident #3 experiencing a significant medication error and subsequent severe adverse effects. Findings include: This citation pertains to intake numbers: MI00153136 and MI00153196. Resident #3 (R3) Review of R3's face sheet revealed admission to the facility on [DATE], with diagnoses including, cirrhosis (chronic liver damage), diabetes mellitus, hypertension (elevated blood pressure), hypothyroidism (not producing enough thyroid hormone), and Parkinson's disease (central nervous system disorder affecting movement). […]

• Actual harm, isolatedF760May 27, 2025

  Based on interview and record review, the facility failed to accurately transcribe and double check admission medications per standards of practice for one Resident (#3) of three residents reviewed for new admissions. This deficient practice resulted in Resident #3 experiencing a significant medication error and subsequent severe adverse effects. Findings include: This citation pertains to intake numbers: MI00153136 and MI00153196. Resident #3 (R3) Review of complaint intake number MI00153136 submitted to the State Agency (SA), dated [DATE] revealed, R3 was admitted to (skilled nursing facility name) on [DATE] and discharged on [DATE]. Upon discharge from an acute care hospital, R3 was ordered to receive Carbidopa/Levodopa five times per day and Levothyroxine once a day. […]