Autumnwood of McBain
220 South Hughston Street, McBain, MI 49657 · Missaukee County · 95 certified beds · avg 90 residents/day · certified since Apr 29, 1985
Part of chain: CIENA HEALTHCARE/LAUREL HEALTH CARE (81 facilities, chain avg rating 2.8★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · May 27, 2025 · F-0711 · triggered by a complaint
The facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit.
Why it matters: Without regular documented doctor reviews, changes in a resident's condition and treatment can slip through the cracks.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 18, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · May 27, 2025 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 18, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Mar 26, 2025 · F-0725 · triggered by a complaint
The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care.
Why it matters: Understaffing means longer waits for help, missed care, and higher risk of falls and other harm.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Apr 22, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (34)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 27, 2025 | ▲ G · Actual harm, one-off | The facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit. · from a complaint |
| May 27, 2025 | ▲ G · Actual harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| May 27, 2025 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Mar 26, 2025 | ▲ H · Actual harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Mar 26, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 26, 2025 | F · Potential for harm, facility-wide | The facility did not have enough fresh-air ventilation, whether through windows, mechanical systems, or both. |
| Mar 26, 2025 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Mar 26, 2025 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Mar 26, 2025 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint |
| Mar 26, 2025 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 26, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Mar 26, 2025 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Mar 26, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 26, 2025 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint |
| Mar 26, 2025 | D · Potential for harm, one-off | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint |
| Mar 26, 2025 | D · Potential for harm, one-off | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Mar 26, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Mar 26, 2025 | D · Potential for harm, one-off | The facility did not honor residents' individual preferences, choices, values, and beliefs in their daily life and care. |
| Mar 26, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Mar 26, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 26, 2025 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Mar 26, 2025 | D · Potential for harm, one-off | The facility did not make sure that paid feeding assistants — staff hired to help residents eat and drink — had the training they need. |
| Apr 17, 2024 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Apr 17, 2024 | E · Potential for harm, repeated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
| Apr 17, 2024 | D · Potential for harm, one-off | When a resident had a planned discharge, the facility did not make sure the necessary information was communicated to the resident and to the doctors or facility taking over their care. |
| May 26, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| May 26, 2023 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| May 26, 2023 | E · Potential for harm, repeated | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| May 26, 2023 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| May 26, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| May 26, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| May 26, 2023 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| May 26, 2023 | D · Potential for harm, one-off | The facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows. |
| May 26, 2023 | D · Potential for harm, one-off | The facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (3 → 19).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 9 | 0 | F |
| 2024 | 3 | 0 | F |
| 2025 | 22 | 3 | H ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $39,000.
| Date | Type | Amount / length |
|---|---|---|
| Mar 26, 2025 | Fine | $39,000 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Michigan avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.85 | 4.32 | 3.95 | bottom 30% in Michigan; top 46% in the U.S. |
| Registered Nurse hours | 0.90 | 0.84 | 0.69 | top 34% in Michigan; top 21% in the U.S. |
| Weekend total nurse staffing | 3.52 | 3.79 | 3.50 | bottom 45% in Michigan; top 41% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.50 | 0.49 | 0.48 | top 36% in Michigan; top 32% in the U.S. |
| Total nursing staff turnover (%) | 35.9 | 44.1 | 45.8 | top 25% in Michigan; top 26% in the U.S. |
| RN turnover (%) | 13.3 | 39.2 | 42.9 | top 8% in Michigan; top 7% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.39, RN 0.79, weekend 3.10. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Ciena Healthcare Management INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 10/01/1999 |
| Ciena Healthcare Management INC | Organization | ADP of the SNF | NOT APPLICABLE | 03/24/2025 |
| Deutsch, Neal | Individual | ADP of the SNF | NOT APPLICABLE | 09/01/2009 |
| Frederick, Patrick | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2019 |
| Frederick, Patrick | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2019 |
| Gardina, Anna | Individual | ADP of the SNF | NOT APPLICABLE | 09/01/2009 |
| Gedeon, Brian | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/1999 |
| Gedeon, Brian | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/1999 |
| Khan, Anis | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/01/1999 |
| Khan, Anis | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/1999 |
| Khan, Anis | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/1999 |
| Mohammad a Qazi Living Trust Dated 09/26/97 | Organization | ADP of the SNF | NOT APPLICABLE | 10/01/1999 |
| Qazi, Mohammad | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/01/1999 |
| Qazi, Mohammad | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/1999 |
| Qazi, Mohammad | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/1999 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How often does each resident's doctor visit and review their care in person?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
- "How do you verify that your nurses and aides have the skills to care for residents with needs like my family member's?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How is fresh air circulated through the building, and how is the ventilation system maintained?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Wexford Senior Care Center | 10.2 mi | Cadillac, MI | ★★★★★ | 5/5 |
Compare this facility with the 1 closest →
Facility data as of CMS processing date 2026-08-01. CCN 235438.