Plainwell Pines Nursing And Rehabilitation Communi
Plainwell Pines Nursing and Rehabilitation Communi in Plainwell, MI — inspection on May 29, 2026.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based on observations, interviews, and record review, the facility failed to protect the residents right to be free from physical abuse by another resident for 2 (Resident #2 and Resident #14) of 3 residents reviewed for abuse, resulting in: 1. Resident #2 being struck in the head several times, slapped, and kicked in the leg by Resident #22, and experiencing fear and psychosocial harm. 2. Resident #14 being placed in a chokehold (a restraining technique in which an arm is tightly wrapped around the neck of another person) by Resident #22 and struck in the head several times.
Resident #2: Admitted with diagnoses including major depressive disorder, anxiety disorder, and post-traumatic stress disorder. A BIMS assessment showed she was cognitively intact.
Her care plan documented her history as a trauma victim and included approaches to provide a calming environment. A Trauma Informed Care Observation dated 5/27/26 documented she had experienced a life-threatening illness, physical assault, and recent event where a dementia resident hit her.
She reported being bothered by the event for more than a week and described her trigger as people coming into her room.
In an interview on 5/28/26 at 3:00pm, a Laundry Aid (LA X) reported he was across the hall from Resident #2 and heard the laundry room door slam.
Entering the hallway, he saw Resident #22 in the doorway to her room. LA X reported he saw Resident #22 kick her right shin. He ensured Resident #2 safety and placed himself between the residents. LA X described Resident #2 as scared, bothered, and shaken up, and reported he took Resident #2 to Licensed Practical Nurse (LPN) JJ.
In an interview on 5/28/26 at 1:36pm, LPN JJ reported she was not in the room at the time of the altercation but was walking toward the nurse station and saw Resident #22 in a wheelchair. LPN JJ reported Resident #22 went into Resident #2 room and punched her in the left side of her face, and she was very upset and angry. LPN JJ reported she redirected Resident #22 but he went back into the room again and hit her.
In an interview on 5/28/26 at 1:31pm, Resident #2 reported Resident #22 came into her room and when she told him to leave he slapped her. Resident #2 reported she extended her right leg to block Resident #22 and Resident #22 kicked her leg. Resident #2 reported she called out for help and LA X responded. Resident #2 stated she does not want to see Resident #22 again and stated it hit me hard that day and I fear Resident #22 coming back to her room.
In an interview on 5/29/26 at 10:37am, the Social Services Director (SS D) reported Resident #2 became emotionally upset and angry when she talked about the altercation with Resident #22. SS D reported that Resident #22 had a history of physical aggression and that appropriate interventions were not in place prior to the altercation.
Resident #14: Review of a Face Sheet revealed Resident #14 had diagnoses including severe dementia, stroke, paralysis, dysphagia, limited personal care, and speech impairments.
Review of Progress Notes dated 05/26/26 documented another resident hitting Resident #14 in the head, witnessed by staff.
Skin assessment completed, a raised red/purple area observed on her left eye approximately 1cm x 2cm.
Review of Incident Summary dated 05/26/26 reported the administrator was told there had been a witness to Resident #22 making contact with Resident #14 head with a closed hand. Resident #22 had been on a 30-day involuntary discharge notice and had recently been transferred to a local behavioral health unit, then fell and was sent to an acute care hospital, and then returned to the facility.
In an interview on 05/29/2026 at 12:05pm, CNA P reported he heard yelling and when he arrived in Resident #14 room he observed Resident #22 with his arm around her head and hitting her multiple times hard in the face. He used his body to protect her from getting punched in the face. CNA P reported after Resident #14 was transferred to the nurse station, Resident #22 was lying in bed with a bruised and swollen cheek. CNA P reported the behavior was not new for Resident #22 and the facility knew.
In an interview on 05/29/2026 at 2:57pm, the Director of Nursing (DON B) reported she was made aware Resident #22 had been hospitalized but did not inquire about his behavioral history. DON B reported she assumed Resident #22 went to the behavioral health hospital for similar reasons as before, but did not inquire about the resident behavioral history to better prepare for his return.
Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet the physical, mental, and psychosocial needs of residents and ensure adequate supervision for staffing, resulting in unmet care needs for 3 (Residents #22, #26, and others) of residents in the facility.
Resident #22: The facility did not ensure adequate supervision for Resident #22 who had severe dementia and a known history of physical aggression. On 5/23/26, Resident #22 wandered all day.
Staff reported they tried to supervise him as much as possible but could not provide the level of supervision the resident needed that day.
On 5/26/26, at the time of the altercation involving Residents #14 and #22, it was shift change.
The working nursing/CNA schedule showed that at the time of the incident involving Resident #22, the facility had 1 nurse and 3 CNAs scheduled, but 1 CNA called out. Of the 12 facility residents who required assistance, those residents not receiving 1:1 care had only one staff member available.
In an interview on 5/28/26 at 11:26am, CNA S reported the facility could not provide the level of supervision Resident #22 needed to keep him safe. In an interview on 5/28/26 at 12:04pm, CNA R reported when a missing shift slot was not filled, staff felt they could not provide quality care and had to prioritize, sometimes only able to give a bed bath instead of a full shower. In an interview on 05/28/2026 at 12:04pm, CNA R reported she regularly cared for 12-13 residents and could not provide the type of supervision Resident #22 needed given his behaviors of going into other residents rooms and yelling.
In an interview on 05/28/2026 at 1:23 PM, Maintenance Director (MD) E reported he worked as a CNA quite a bit lately, more than he would like to. He reported he would come in early for staff members who were mandated over and worked most weekends to cover call-ins. MD E reported the facility was a small building and when a nursing staff member called in that was 30% of the floor staff, so it affected the building more than it would in a larger facility.
In an interview on 05/28/2026 at 11:40 AM, CNA T reported not all the time are we staffed the way we should be. CNA T reported it was very difficult to keep an eye on Resident #22 especially when the facility was not fully staffed.
Weekends were the worst as at times it was her and another CNA covering all resident care. CNA T reported she often missed breaks and worked through her lunch. CNA T reported she was not able to spend as much time with each resident as she would like as she was always running from one resident to another.
Resident #26: Diagnosed with limited mobility requiring 2-person assist for bed mobility and transfers.
Review of a 2-person bed mobility assessment confirmed Resident #26 required assistance of 2 staff for bed mobility and transfers.
Observations on 4/27/26 documented Resident #26 activating his call light and waiting extended periods without response.
Staff deactivated his call light on multiple occasions without completing the requested task. In a confidential meeting on 4/28/26, it was reported that wait times of greater than 30 minutes were common and the facility frequently could not find a replacement staff member, requiring residents to wait for longer periods to get needed assistance.
Review of Payroll Based Journal Records showed inadequate weekend staffing during the first quarter, October-December 2025. An electronic communication confirmed from the Chief Operating Officer that staffing during the first quarter fell below the current recommended staffing level.
Based on observation, interview, and record review, the facility failed to develop and implement person-centered dementia care interventions to address needs for 1 (Resident #22) of 5 residents reviewed for dementia care, resulting in Resident #22 demonstrating unmet care needs which led to physical aggression toward others and rehospitalization.
Resident #22: An admission record revealed diagnoses which included unspecified dementia.
Review of the Care Plan for Resident #22 documented problems, goals, and approaches related to Alzheimer disease and elopement risk. Of note, the care plan did not address aggression toward others.
In an interview on 5/29/26 at 10:37am, Social Services Director (SS D) reported she did not know Resident #22 very well, did not know what triggered his wandering or his other behaviors. SS D reported she knew he had been wandering from the time of his admission and that he would set off the exit alarm on the door near his room, but she had not been able to determine where he was going. SS D reported she planned to add interventions but had not gotten to it yet. SS D confirmed Resident #22 had demonstrated physical aggression toward other residents and several incidents toward staff prior to the 5/26/26 events, and had already been seen by a behavioral health provider.
Review of Progress Notes dated 05/24/26 and 05/26/26 documented physical aggression incidents.
Review of Activity Note dated 05/15/26 noted Resident #22 enjoyed music, but this intervention was not added to his care plan.
Review of Orders for Resident #22 revealed Risperidone (an atypical antipsychotic medication used to regulate mood, emotion, and thinking) was prescribed for 07:00 AM-11:00 AM and 07:00 PM-11:00 PM windows. A subsequent Progress Note documented Risperidone was discontinued related to Risperdal usage.
Risperidone typically takes 2-3 months before benefits are felt and should be tapered when discontinuing to avoid acute withdrawal effects.
In an interview on 05/29/2026 at 11:35am, LPN J reported supervision for Resident #22 was very difficult and this was causing concerns.
Resident was always wandering throughout the shift, going through his roommate dresser. LPN J reported Resident #22 was always wandering during the day and they needed to keep anything where he could obtain it to keep him safe. LPN J reported Resident #22 would benefit from more one to one staffing. LPN J reported staff had to send in a male staff because Resident #22 was non-compliant with female staff, and that he tried to slap her. LPN J reported he was not on a scheduled medication for wandering and she was surprised he was prescribed Ativan on an as-needed basis rather than a scheduled medication.
In an interview on 05/29/2026 at 1:38pm, LPN J reported she would try to keep an eye on Resident #22 and go with him where he went in the facility to keep an eye on him throughout his stay.
Review of an electronic correspondence and learning management system records confirmed staff had not completed required dementia care training.
Review of completion report requested for Dementia Care revealed several staff had not completed required training including: Dementia Hand-in-Hand Training, Dementia Care: Maintaining Routines and Consistency, Nursing Management of Dementia-Related Behaviors, and Dementia Person Centered Care Plans.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.