The incident occurred on September 17 when LPN J went to complete a critical admission assessment for Resident 108 around 7:00 PM. He had gone to her room to finish the assessment that Assistant Director of Nursing C had started earlier but left incomplete, waiting only for a final set of vital signs.
LPN J told investigators he observed bruising on the resident's torso and left the room to get a measuring tape from the nurse's station. When he returned, the resident accused him of touching her breasts inappropriately.
The nurse denied the allegation. He told investigators he "did not touch her breasts and did not see Resident 108's nipples." But his response to co-workers revealed his frustration with how the complaint was handled. When a colleague informed him of the resident's concerns, LPN J said, "don't try to add your take on it."
He blamed his co-worker for filing the report rather than the resident who made the accusation. "He did not even blame the lady, he blamed his co-worker who did the report," according to the inspection findings.
The resident's distress became apparent when Certified Nursing Assistant P walked past her room later that evening. She called him in and asked where she could file a complaint about what had happened to her.
When LPN J walked by during their conversation, the resident's reaction was immediate and clear. "No, no, no not him," she told the nursing assistant.
CNA P closed the door to her room and took her written statement. In it, Resident 108 alleged that LPN J had "grabbed her nipples and she felt really uncomfortable with him and continuing to stay at the facility."
The nursing assistant reported the incident to the administrator and reassured the resident of her safety. Her son came to pick her up from the facility that same day.
Assistant Director of Nursing C had completed most of Resident 108's initial admission assessments when his shift ended. The critical admission assessment was described as "a sweetened condensed form" and "a quick snapshot" of the other completed assessments. The computer system required each section to be finished before moving to the next, which is why ADON C was waiting for the final vital signs before LPN J could complete it.
During his initial skin assessment, ADON C had examined the resident's whole body, including her buttocks and abdomen. He found "some scattered light bruising" from blood thinner injections, but didn't document them because the bruises were "light, small and fading" and appeared to be old.
Nursing Home Administrator A came to the facility around 9:30 PM after receiving a call about the allegation. She began an investigation immediately but had not finished it by the time state inspectors arrived.
The administrator reviewed LPN J's written statement, in which he claimed he was assessing bruises on Resident 108's abdomen. This contradicted ADON C's earlier assessment that found only minor, fading bruises from injection sites.
The timing raised additional questions. ADON C had already completed a thorough skin assessment earlier in the day, examining the resident's entire body including her abdomen. If LPN J was only supposed to collect final vital signs to complete the critical admission assessment, it's unclear why he would need to conduct another physical examination of bruising.
The facility opened its investigation the same evening the complaint was made, but the resident had already decided she couldn't stay. Her son removed her from Plainwell Pines that night, just hours after she had been admitted for what was supposed to be her care and rehabilitation.
The incident highlights the vulnerability of nursing home residents during intimate medical procedures and the importance of immediate response when allegations of inappropriate conduct are made. For Resident 108, the facility's investigation came too late to address her concerns about safety and comfort during her stay.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Plainwell Pines Nursing and Rehabilitation Communi from 2025-09-17 including all violations, facility responses, and corrective action plans.
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