Plainwell Pines: Dementia Care Failures Led to Assault - MI
She hadn't gotten to it yet.
Resident 22 was rehospitalized following two physical aggression incidents documented on May 24 and May 26, the inspection report shows. The resident had already been evaluated by a behavioral health provider before those incidents occurred. His care plan addressed wandering and elopement risk. It said nothing about aggression toward others.
The social services director, interviewed the morning of the inspection, told inspectors she did not know what triggered his wandering or his other behaviors. She could not determine where he was trying to go when he set off the door alarm. She confirmed the aggression toward other residents and toward staff had happened multiple times before the May 26 incident that ended in rehospitalization.
Staff had noticed something else. An activity note from May 15 recorded that Resident 22 enjoyed music. Nobody added it to his care plan.
A licensed practical nurse, LPN J, described what supervision of Resident 22 actually looked like during a shift. He was always wandering, she said, going through his roommate's dresser, moving through the facility continuously. Staff had to remove anything he could get his hands on. She told inspectors he would benefit from one-to-one staffing. She also told them that he was non-compliant with female staff and had tried to slap her, and that the facility had to send male staff to work with him specifically because of that pattern.
LPN J said she handled supervision by trying to follow him wherever he went in the building and keep an eye on him throughout her shift. That was the plan.
She raised a separate concern about his medications. Resident 22 had been prescribed Risperidone, an antipsychotic used to regulate mood and behavior, with dosing windows in the morning and evening. A subsequent progress note documented the medication was discontinued. Risperidone typically takes two to three months before its effects are felt and should be tapered when stopped to avoid withdrawal. LPN J told inspectors she was surprised the resident had been given Ativan on an as-needed basis rather than a scheduled medication, and noted he was not on any scheduled medication for wandering.
The care failures did not happen in isolation. Inspectors reviewed the facility's electronic training records and found that multiple staff members had not completed required dementia care courses, including Dementia Hand-in-Hand Training, Nursing Management of Dementia-Related Behaviors, and Dementia Person Centered Care Plans. The training gaps touched the exact categories of knowledge that Resident 22's situation demanded.
The inspection was triggered by a complaint. It covered five residents receiving dementia care. Inspectors found the facility had failed to develop and implement person-centered dementia care interventions for Resident 22, and concluded directly that the failure resulted in unmet care needs that led to physical aggression toward others and rehospitalization.
LPN J, asked at the end of the inspection day how she planned to manage Resident 22 going forward, gave the same answer she had given that morning. She would try to keep an eye on him and go with him where he went.
Resident 22 was not there anymore. He had already been sent back to the hospital.
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 2026-05-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Plainwell Pines Nursing and Rehabilitation Communi in Plainwell, MI was cited for violations during a health inspection on May 29, 2026.
Resident 22 was rehospitalized following two physical aggression incidents documented on May 24 and May 26, the inspection report shows.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.