Plainwell Pines Nursing And Rehabilitation Communi

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Based on observation, interview, and record review, the facility failed to protect resident privacy during personal care for 1 (Resident #109) of 10 residents reviewed for privacy/dignity, resulting in the potential for feelings of embarrassment. Findings include: Review of an admission Record revealed Resident #109 was

a male with pertinent diagnoses which included cellulitis of right lower limb, edema, changes in skin texture to BLE (bilateral lower extremities), cellulitis of left lower limb, and erythematous condition (red or abnormally reddened that appears red due to inflammation, infection, and other irritation). Review of current Care Plan for Resident #109, revised on 3/21/25, revealed the focus, .Resident has a bilateral lower extremity chronic venous ulcers with potential for infection and discomfort to the area . with the intervention .Administer analgesic as ordered prior to wound care, dressing changs or debridement, avoid friction and shearing during transfers or repositioning, conduct a systemic skin inspection weekly and PRN ( as needed). CNA to observe skin integrity during daily cares . Review of Order dated 8/12/25 for Resident #109, revealed, .Unna Boot Zinc Calamine bandage; 3% -3%-4x10 yard; amt: one bandage; topical; Special instructions: apply one bandage to bilateral ankles and feet every other day unit area is healed, Once a day Every Other Day 09:00 AM . (Unna boot - zinc oxide impregnated compression bandage used to treat leg conditions like swelling and venous ulcers). During an observation on 09/15/25 at 09:19 AM, Resident #109 was observed in the hallway in his wheelchair, his bilateral lower extremities was covered with dry, flaky skin which was peeling off and he was instructed by Registered Nurse (RN) L his legs needed to wrapped and he was taken to the doorway of the nurse's station where RN L began to perform wound dressing. She had pulled a chair to the doorway and had began to wrap his lower leg with the dressing. Director of Nursing (DON B observed her performing the wound dressing in the doorway and asked her to take Resident #109 to his room, RN L reported his room was too small for her to dress his lower legs but she instructed Resident #109 to self-propel to his room so she could perform the wound dressing. Resident #109 had just returned from the whirlpool where he went to provide moisture to his lower legs. This writer observed Resident #109 seated just inside of his doorway with RN L kneeling on the floor in the hallway while she performed the wound dressing. There were no chucks on the floor under Resident #109's feet. In

an interview on 09/17/25 at 1:14 PM, Assistant Director of Nursing (ADON) C reported Resident #109 would go to the whirlpool, when finished complete wound dressing, and on his bed and on the floor next to his bed would be lined with chucks, so if there was skin and blood it would be on the chucks. Observed his feet had blood between his toes and the tops of his foot by the toes, the dressing had spots of pink, fresh blood weeping through dressing. In an interview on 09/17/25 at 2:57 PM, Director of Nursing (DON) B reported RN L should not have been performing wound dressing at the nurse's station to maintain Resident #109's dignity. She reported couldn't believe she had started to perform the wound dressing at the nurse's station within 15 minutes of this writer observing the hallways.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Plainwell Pines Nursing and Rehabilitation Communi

3260 East B Avenue Plainwell, MI 49080

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

state CT scan was normal/no changes from past. He returned to the facility. Review of Progress Notes dated 8/20/25 at 6:11 PM, .Resident return to facility via stretcher from ER (Local Hospital). Resident alert and oriented 1-2. Has no c/o (complaints of) pain or discomfort at this time. Resident is currently laying with call light in reach, fall mattress in place. Resident has no new orders from hospital noted.During an

observation on 09/15/25 at 3:25 PM, observation he had a paddle call light at the foot of his bed, bunched up behind his blankets out of resident's reach. Resident #106: Review of an admission Record revealed Resident #106 was a male with pertinent diagnoses which included dementia, lack of coordination, anxiety, muscle weakness, difficulty in walking, and history of wedge compression fracture of first thoracic vertebra (when the bone collapses and the front part of the vertebra forms a wedge shape, first thoracic vertebra is part of the upper back, just below the neck). Review of current Care Plan for Resident #106, revised on 4/22/25, revealed the focus, .At risk for falls and subsequent injury related to dementia, decreased mobility, incontinence, malnutrition, failure to thrive, hx (history) of falls. with the intervention .Provide verbal reminders to resident to call when needing assistance.Staff to assist with pillows for positioning while in bed for fall precautions.Verbal education to CNA on fall precautions. During an observation on 09/15/25 at 2:33 PM, Resident #106 was observed seated in an scoot/broda chair next to the side of his bed, his call light was placed on the center of his mattress on his bed out of Resident #106's reach. During an observation on 09/15/25 at 3:28 PM, Resident #106 was observed seated in his wheelchair and his call light was placed in

the middle of the bed out of his reach. During an observation on 09/16/25 at 3:23 PM, Resident #106 was observed seated in his broda chair and his call light was observed hanging off the side of the head of the bed behind the back rest of his broda chair, well out of Resident #106's reach. In an interview on 09/17/25 at 11:00 M, CNA T reported staff were to ensure to place the call light in reach, place water in reach, and lower bed for safety. CNA T reported Resident #104 would be able to drink her water independently as long at the tray table was placed over her lap and the water was in her reach. In an interview on 09/17/25 at 2:49 PM, Director of Nursing (DON) B reported the staff should ensure when they exit a resident's room the call light was in reach and all needs were met.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Plainwell Pines Nursing and Rehabilitation Communi

3260 East B Avenue Plainwell, MI 49080

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the Critical admission assessment was left to finish. LPN J reported at approximately 7:00 PM, he went to Resident #108's room to complete the Critical admission assessment. Observed Resident #108's torso, noticed bruising and left the room to obtain a measuring tape from the nurse's station. LPN J reported Resident #108 accused him of touching her breasts inappropriately and he denied the allegation. LPN J reported he did not touch her breasts and did not see Resident #108's nipples. LPN J reported he was confronted by Resident #108's son and he didn't know what he was accusing him of. LPN J reported Resident #108 had informed his co-worker of her concern with him , and LPN J said to the co-worker, don't try to add your take on it. LPN J stated He did not even blame the lady, he blamed his co-worker who did

the report. In an interview on 09/17/25 at 09:42 AM, Assistant Director of Nursing (ADON) C reported he had completed the initial assessments on Resident #108 needed at admission. ADON C reported for the Critical admission Assessment he only needed the last set of vitals, which he informed LPN J of this when

he came on for his shift. ADON C reported he received a call approximately around 09:30 PM there as an allegation against the nurse and an investigation was opened. ADON C reported the Critical admission Assessment was a sweetened condensed form and was a quick snapshot of the completed other assessments. ADON C reported there were multiple steps to the assessment and the nurse couldn't move to the next section unless the prior section was completed hence why he was waiting for the last set of vitals to complete the Critical admission Assessment. ADON C reported he looked over Resident #108 for

the initial skin assessment, checked whole body and her buttocks, her abdomen, and she had some scattered light bruising from receiving (Blood thinner name) shots. The bruises were light, small and fading and he didn't put them on the skin assessment as they were old bruises. In an interview on 09/17/25 at 3:40 PM, Certified Nursing Assistant (CNA) P reported he was completing cares for his resident and walked by Resident #108's room and she called him into the room. CNA P reported Resident #108 asked where she could file a complaint about what happened to her. CNA P indicated Resident #108 could talk to him or the nurse. CNA P reported LPN J walked by and CNA P reported Resident #108 stated, No, no, no not him.

CNA P closed the door to her room and obtained her written statement which Resident #108 had alleged LPN J had grabber her nipples and she felt really uncomfortable with him and continuing to stay at the facility. CNA P reported the incident to his administrator. CNA P reported he reassured Resident #108 of her safety until Resident #108's son came and picked her up from the facility.In an interview on 09/17/25 at 08:19 AM, Nursing Home Administrator (NHA) A reported she was nearby and came to the facility to begin

the investigation. NHA A reported she had reviewed LPN Js submitted written statement, and he alleged Resident #108 had bruises on her abdomen he was assessing. NHA A reported she had begun the investigation but had not finished the facility's investigation into the allegation.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Plainwell Pines Nursing and Rehabilitation Communi

3260 East B Avenue Plainwell, MI 49080

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

their transportation company and had received confirmation Resident #103 had not been back at the facility at the time the medication was signed out. When LPN I was questioned she became very defensive and denied she took the medication. At that point, Resident #103 was not here , medication was signed out as dispensed and the count was correct, so it was determined medication was misappropriated by her. NHA A reported the facility contacted the agency and informed them of the events, and requested she not return.

NHA A reported the police were contacted. During the onsite survey, past noncompliance (PNC) was cited

after the facility implemented actions to correct the noncompliance which included education with all staff

on the abuse policy, all nurses were re-trained on medication administration and controlled substance standard practice and deemed appropriate, and the facility had maintained compliance as of 9/3/25.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Plainwell Pines Nursing and Rehabilitation Communi

3260 East B Avenue Plainwell, MI 49080

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to update and revise the person-centered care plan in a timely manner with appropriate interventions for the prevention of undefined care concerns for 1 of 10 residents (Resident #102) reviewed for care plans, resulting in the potential for physical, mental, and psychosocial unmet care needs and harm. Findings include: Resident #102: Review of an admission

Record revealed Resident #102 was a male with pertinent diagnoses which included displaced midcervical fracture of right femur (break in the middle part of the neck of the femur, bone fragments, and are no longer aligned), adult failure to thrive, intracapsular fracture of femur (break of femoral neck which is located within

the hip joint's capsule), anxiety, dysphagia (difficulty swallowing foods and liquids), and stroke. Review of current Care Plan for Resident #102, revised on 12/2/24, revealed the focus, .At risk for falls and subsequent injury related to dementia with cognitive decline over the last year, hx (history) of CVA (stroke), insomnia, CKD 3 (Chronic kidney disease, stage 3), urinary frequency r/t (related to) BPH. Non-compliant with medical care. Resident has poor cognition and weakness. Fall with hip fx (fracture) and surgical repair July 2025. with the intervention .Parameter mattress.Enabler bars to Right side of bed.Call light to be in reach. (Note: Fall mattress was not developed as an intervention to Resident #102's care plan). Review of Skilled Note dated 8/12/25 at 10:43 AM, .Floor mattress in place . During an observation on 09/16/25 at 7:58 AM, Resident #102 was observed in bed on his left side, he had his call light clipped to the bedding at

the head of the side of the bed in the same position as yesterday. The fall mattress was up on its side leaning against his wheelchair. Resident #102 reported he did not get up for breakfast this morning. His wheelchair was up against his dresser which was on the opposite wall by the closet/bathroom. In an

interview on 09/16/2025 at 8:09 AM, Director of Nursing (DON) reported the fall mattress should have been by the side of the bed for Resident #102 as he had fallen out of bed before and he had a hip fracture from that fall. back on the right side as the extra pillows were for positioning. In an interview on 09/17/25 at 1:23 PM, DON B reported the care plans were updated by all the clinical staff during morning meeting. DON B reported therapy had a communication binder where they would place information there for changes in residents' transfer status or how the resident transferred. DON B reported when the care plan was updated

this was communicated to the staff verbally when the changed happened. Review of Fundamentals of Nursing ([NAME] and [NAME]) 8th edition revealed, If the patient's status has changed and the nursing diagnosis and related nursing interventions are no longer appropriate, modify the nursing care plan. An out of date or incorrect care plan compromises the quality of nursing care. Review and modification enable you to provide timely nursing interventions to best meet the patient's needs .It is necessary to revise related factors and the patient's goals, outcomes, and priorities. Date any revisions. Revise specific interventions that correspond to the new nursing diagnoses and goals. Revisions need to reflect the patient's present status. [NAME], P.A., [NAME], A.G., Stockert, P.A., & Hall, A. (2014). Fundamentals of Nursing (8th ed.). St.

Louis: Mosby, p. 257-258.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Plainwell Pines Nursing and Rehabilitation Communi

3260 East B Avenue Plainwell, MI 49080

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited Plainwell Pines Nursing and Rehabilitation Communi in Plainwell, MI for a deficiency under regulatory tag F-F0921 during a complaint investigation conducted on 2025-09-17.

Category: Environmental Deficiencies

The facility was found deficient in the following area: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 6 deficiencies cited during this inspection of Plainwell Pines Nursing and Rehabilitation Communi.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-29.