Plainwell Pines Nursing and Rehabilitation Communi

In the surveyor’s words

From the most serious findings on record at Plainwell Pines Nursing and Rehabilitation Communi, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 17, 2025

  This citation pertains to intake #2677662Based on interview, and record review, the facility failed to provide adequate monitoring and supervision to prevent elopement and respond appropriately to door alarms and Wanderguard (an alert bracelet that triggers an alarm near specific exits in the facility) alarms to ensure resident safety in 2 residents (Resident #101 and #104) of 2 residents reviewed for elopement/supervision, resulting in an Immediate Jeopardy when on 11/23/25 at approximately 6:00 PM, Resident #101 who was an elopement risk, exited the facility, unbeknown to facility staff, and was found by another resident, standing outside of the facility at an emergency exit door and the potential for Resident #104 to elope due to unknown Wanderguard functionality. […]

• Immediate jeopardy, isolatedF689Aug 26, 2021

  This citation pertains to Intake # MI 012. Based on observation, interview, and record review the facility failed to provided adequate supervision to prevent the elopement in 1 of 1 resident (Resident #100), reviewed for elopement risk, resulting in an Immediate Jeopardy when on 8/5/2021 unbeknownst to staff at approximately 5:25 AM Resident #100 eloped through an unsecured door and was found approximately 1.6 miles away. The facility was alerted by the Hospital as to the whereabouts of the resident. […]

• Actual harm, patternF600May 16, 2024

  This citation pertains to intakes: MI0014331, MI00143140, MI00142071, MI00139687, and MI00144696 Based on observation, interview, and record review, the facility failed to protect residents rights to be free from mental abuse, verbal abuse, and physical abuse by staff and other residents in 5 of 8 residents' (Resident #101, Resident #103, Resident #105, Resident #106, and Resident #107) reviewed for abuse, resulting in Findings include: Resident #101: Review of an Admission Record revealed Resident #101, was originally admitted to the facility on [DATE] with pertinent diagnoses which included: vascular dementia without behavioral disturbance, aphasia (deficit with verbally expressing self) delusional disorder, psychotic disorder, and anxiety disorder. […]

• Actual harm, isolatedF689Jun 27, 2024

  Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent falls for 2 (Resident #26 and Resident # 7) of 12 residents reviewed for falls, resulting in falls with fractures, decline in functional abilities, increased pain, and a potential for further injuries. Findings include: Resident #26 Review of an Admission Record revealed Resident #26, was originally admitted to the facility with pertinent diagnoses which included: history of falling, unspecified dementia, and type 1 diabetes mellitus (lifelong condition in which the pancreas does not make sufficient insulin to maintain stable blood sugar levels) with diabetic retinopathy (damage to the blood vessels in the eyes causing poor vision). […]

• Actual harm, isolatedF610May 16, 2024

  This citation pertains to intake number MI00144696. Based on interview and record review, the facility failed to throughly implement the abuse policy to protect, investigate, report and prevent staff to resident abuse and bruises of unknown origin for 3 of 5 residents (Resident #101, Resident #105, and Resident #106) reviewed for abuse, resulting in ongoing staff to resident verbal and mental abuse of Residents #101 and Resident #105, escalation of the abuse to staff to resident physical abuse of Resident #101. […]