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Plainwell Pines Nursing and Rehabilitation Communi

3260 East B Avenue, Plainwell, MI 49080 · Kalamazoo County · (269) 349-6649

39 certified beds, about 33 residents a day · For profit - Corporation · Medicare and Medicaid since 2008

CMS abuse icon: cited for abuse in a recent inspection Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
1 of 5
Staffing
3 of 5
Quality measures
5 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 235637 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on May 29, 2026, inspectors cited 12 health deficiencies (the Michigan average is 9.9, the national average 9.2).

Of 54 health citations since May 2024, 5 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).

CMS lists 2 fines totaling $194,994 in the last three years; the largest was $161,356, and the latest is dated June 27, 2024.

Nurses and nurse aides worked 3.24 hours per resident per day, against 3.99 across Michigan and 3.86 nationally. Registered nurses accounted for 0.57 of those hours.

62.8% of nursing staff left within the year CMS measured (Michigan average 44.1%).

CMS links it to Atrium Centers, an affiliated group of 26 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 54 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
3G
1H
0I
Potential for more than minimal harm
37D
4E
7F
Potential for minimal harm
0A
0B
1C
May 29, 2026Standard inspection, Complaint inspection · 12 citations
  1. F
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    F867 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) July 8, 2026
    Inspectors wroteBased on interview and record review, the facility failed to ensure infection control data was regularly analyzed during QAPI (Quality Assurance and Performance Improvement) meetings and completed at least one PIP (Performance Improvement Plan) related to quality issues identified by the quality assessment and assurance committee, resulting in the potential for systematic failures related to infection control and other quality deficiencies.
  2. F
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    F868 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) July 8, 2026
    Inspectors wroteBased on interview and record review, the facility failed to ensure the Infection Preventionist (IP) attended the QAPI (Quality Assurance and Performance Improvement) meetings, resulting in the potential for lack of resident care policies and overall medical care that could affect all residents residing in the facility.
  3. E
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) July 8, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the physical, mental, and psychosocial well-being in 2 of 12 residents (Resident #22 & #26) reviewed for staffing, resulting in unmet care needs and the potential for physical and psychosocial harm for all residents in the facility.
  4. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 8, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to promote dignity and respect in 2 residents (Resident #25 & #5) from a total sample of 20 residents, resulting in long call light wait times and the potential for feelings of diminished self-worth, sadness, and frustration.
  5. D
    Allow residents to self-administer drugs if determined clinically appropriate.
    F554 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 8, 2026
    Inspectors wroteBased on observation, interview, and record review the facility failed to perform an assessment for self-administration of medication, obtain an order, and update the care plan for 2 residents (Resident #15, #33) of 12 Residents reviewed for self-administration of medications, resulting in the mismanagement of medications with a potential for adverse side effects.
  6. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 8, 2026
    Inspectors wroteThis citation pertains to intakes #3026243 and 3926437Based 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 review 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 (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.
  7. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 8, 2026
    Inspectors wroteBased on interview and record review, the facility failed to complete accurate assessments for 1 of 12 residents (Resident#14) reviewed for accurate assessments, resulting in an inaccurate reflection of the resident's status and the potential for impaired medical, functional, and psychosocial problems due to unidentified needs.
  8. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 8, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for medication administration for 1 resident (Resident #29) of 5 residents reviewed for medication administration, resulting in an inhaler (medication that is inhaled) being administered outside of manufacturer recommendations and oral pills being administered without following resident preference for being crushed, and the potential for adverse side effects and choking.
  9. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 8, 2026
    Inspectors wroteBased on observations, interviews and record review the facility failed to identify pressure ulcers and ensure appropriate treatment interventions were in place for 1 resident (Resident #4) of 1 resident reviewed for pressure ulcers, resulting in Resident #4 developing a Stage 2 pressure ulcer on the left buttock and the potential for overall deterioration in health status.
  10. D
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    F744 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 8, 2026
    Inspectors wroteThis citation pertains to intakes #3026243, #3026437Based on 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 symptoms of unmet care needs which included ongoing wandering, exit seeking, physical aggression toward others and rehospitalization.
  11. D
    Ensure medication error rates are not 5 percent or greater.
    F759 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 8, 2026
    Inspectors wroteBased on interview and record review the facility failed to maintain a medication error rate less than 5% in 1 resident (Resident #29) of 5 residents reviewed for medication administration, resulting in the potential for medication adverse effects. The medication error rate was 6.25%.
  12. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 8, 2026
    Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively implement Enhanced Barrier Precautions (EBP) and maintain infection control standards during incontinence (involuntary leakage of urine and feces) care per Centers for Disease Control and Prevention (CDC) guidance, in 2 residents (Resident #39 & #4) from a total sample of 20 residents, resulting in the potential for cross-contamination and the development and spread of infection to a vulnerable population.
December 17, 2025Complaint inspection · 3 citations
  1. J
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 12, 2026
    Inspectors wroteThis 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. [...]
  2. F
    Develop, implement, and/or maintain an effective training program for all new and existing staff members.
    F940 · Administration · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) January 12, 2026
    Inspectors wroteThis citation pertains to intakes #2677662 and #2648515. Based on observation, interview, and record review, the facility failed to maintain an effective training program for all facility and agency staff, consistent with their role in the facility to ensure the safety of residents in 1 resident (Resident #101) of 2 residents reviewed for elopement, and 2 residents (Resident #102 and #107) of 4 residents reviewed for the administration of controlled substance, resulting in agency staff not responding properly to door alarms and licensed nursing staff not maintaining an accurate account of controlled substances.
  3. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 12, 2026
    Inspectors wroteThis citation pertains to intake #2648515Based on observation, interview and record review, the facility failed to ensure that medication records were in order and that an account of all controlled drugs was maintained and accurately reconciled for 2 residents (Resident #102 and #107) of 4 residents reviewed for the administration of controlled medications, resulting in the potential for ineffective management of pain and the potential for diversion of controlled drugs.
September 17, 2025Complaint inspection · 6 citations
  1. E
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) October 29, 2025
    Inspectors wroteBased on observation, interview and record review the facility failed to ensure access to a call light in 4 of 10 sampled residents (Resident #104, R#102, R#105, and R#106) reviewed for call light placement, resulting in the inability to call for assistance and the potential for unmet care needs.
  2. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 29, 2025
    Inspectors wroteBased 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.
  3. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 29, 2025
    Inspectors wroteThis citation pertains to intake: 2618457 and 2618789Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from staff to resident sexual abuse for 1 resident (Resident #108) reviewed for abuse, resulting in Resident #108 feeling concerned for physical safety enough to leave shortly after admission.
  4. D
    Protect each resident from the wrongful use of the resident's belongings or money.
    F602 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteThis citation pertains to 1287744Based on interview and record review, the facility failed to prevent the misappropriation of narcotic pain medication in 1 of 10 residents (Resident #103) reviewed for misappropriation of property, resulting in the theft of narcotic medications and the potential for delayed pain treatment.
  5. D
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 29, 2025
  6. D
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    F921 · Environmental · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 29, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure clean and sanitary shared medical equipment, wheelchair cleaning for 1 (Resident #106) of 10 residents, resulting in the potential for cross contamination, infections, and bacterial harborage.
May 8, 2025Standard inspection, Complaint inspection · 18 citations
  1. F
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    F801 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteBased on interview and record review, the facility failed to employ a staff member with appropriate credentials to supervise and manage the dietary department, resulting in the potential for food service sanitation failures, food borne illness and for clinical areas of dietary needs of all residents being compromised and unmet.
  2. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper label and dating of foods and discarding of foods in the kitchen resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: During the initial tour of the kitchen on 5/5/2025 at 8:33 AM, the following was observed: The reach in refrigerator had a pitcher of iced tea, half full with a use by date of 5/4/2025. The walk-in refrigerator had 3 trays of individual juices in 12 oz plastic glasses with no label and date. During a full kitchen tour on 5/6/2025 at 9:17 AM, the following was observed in the dry storage room: [...]
  3. E
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteThis citation pertains to intake number MI00151548 Based on observation, interview, and record review the facility failed to: 1.) maintain a clean and homelike environment for 5 residents (R82, R15, R182, R134, and R135), and 2.) maintain comfortable noise level for 2 residents (R134 and R135) of 12 residents reviewed for homelike environment, resulting in potential for dissatisfaction with living conditions for the 5 residents and residents who are able to ambulate in the facility.
  4. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective infection control program that included: 1. cleaning of resident equipment for 1 of 16 residents (R82), 2. appropriate hand hygiene and glove use (PPE-Personal Protection Equipment) during resident care in 2 of 16 residents (R82 and R29), 3. implementation of Enhanced Barrier Precautions (EBP) per standards of practices for 2 of 16 residents (R29), reviewed for infection control, resulting in the potential for cross-contamination, harborage of bacteria, and increased infections in a vulnerable population.
  5. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteThis citation pertains to Intake MI00151548 Based on observation and interview, the facility failed to maintain dignity for 2 of 4 residents (R29 and R21) reviewed for dignity, resulting in the potential for feelings of embarrassment based on the reasonable person concept.
  6. D
    Allow residents to self-administer drugs if determined clinically appropriate.
    F554 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were assessed to determine if self-administration of medication was clinically appropriate in 2 of 2 residents (Resident #9, Resident #17) reviewed for self-administration of medications, resulting in unsupervised administration of medications and the potential for mismanagement of medication and adverse side effects.
  7. D
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    F578 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to complete advance directives completely and accurately for 1 (Resident #134) of 12 residents reviewed for advance directives, resulting in the potential for resident preferences for medical care to not be followed by the facility staff.
  8. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteBased on interview, and record review, the facility failed to notify the resident representative of a resident exiting the facility in 1 of 2 residents (R15) reviewed for notification of changes, resulting in the responsible party not being made aware that R15 walked out a door observed but unattended and subsequent placement of a wander guard.
  9. D
    Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
    F605 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure psychotropic medications were not used without medical indication for use for 3 (Resident #134, Resident #182, and Resident #29) of 5 residents reviewed for chemical restraints.
  10. D
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    F628 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteBased on interview and record review, the facility failed to provide a written bed hold notice and transfer/discharge notice for 1 of 1 resident (Resident #5) reviewed for hospitalizations, resulting in the potential of residents and/or resident representatives being uninformed of the reason for transfer and not being able to hold a bed in the facility.
  11. D
    Provide activities to meet all resident's needs.
    F679 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteBased on observation, interview, and record review the facility failed to provide meaningful activities to promote psychosocial well-being for 1 (Resident #27) of 12 residents reviewed for activities. This deficient practice resulted in social isolation, feelings of loneliness, frustration and boredom.
  12. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately assess, monitor, and treat a change of skin condition in 1 of 1 resident (R21) reviewed for quality of care, resulting in a delay in assessment, treatment, pain, and the potential for worsening of condition and infection.
  13. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders to complete a wound dressing in 1 of 1 resident (R29) reviewed for pressure ulcer care, resulting in a missed opportunity to provide care needed to heal a pressure wound and prevent infection.
  14. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1.) implement interventions to ensure a safe environment in 1 of 1 resident (R15) and, 2. ensure the safety of residents during wheelchair transport in 2 of 3 residents (R134 and R182) reviewed for safety, resulting in the potential for R15 to elope from the facility and increase potential for injury for R134 and R182.
  15. D
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    F690 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate urinary catheter care and assessment for the need of an indwelling catheter (catheter inserted in through the urethra and into the bladder) for 1 of 1 resident (R29) reviewed for catheter care, resulting in the potential for the dislodgement, injury, pain, development of urinary infection and decline in overall health status.
  16. D
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteBased on observation, interview and record review, the facility failed to provide ongoing communication and collaboration with the contracted dialysis facility regarding dialysis care for 1of 1 resident (Resident #135) reviewed for dialysis, resulting in the potential for unmet medical needs.
  17. D
    Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
    F887 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure COVID-19 immunizations were offered to 1 (Resident #21) of 5 residents reviewed for COVID-19 immunizations, resulting in an increased risk for infection, and the potential spread of COVID-19 infection to other residents, staff, and visitors.
  18. C
    Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
    F727 · Nursing and Physician Services · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) June 5, 2025
    Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty for 8 consecutive hours a day, seven days a week, resulting in the potential for inadequate coordination of routine or emergency care affecting all residents in the facility.
September 4, 2024Complaint inspection · 1 citation
  1. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 24, 2024
    Inspectors wroteThis citation is linked to intake # MI00145717 Based on interview and record review the facility failed to provide an environment free from abuse in 3 residents (Resident #100, Resident #101, and Resident #102) of 5 residents reviewed for abuse, resulting residents experiencing fear, avoidable pain, bruising, and a potential for more serious injury.
June 27, 2024Standard inspection · 10 citations
  1. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · Corrected (the home has a date of correction) July 22, 2024
    Inspectors wroteBased 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.
  2. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) July 22, 2024
    Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment and (2) date mark all potentially hazardous ready-to-eat food products effecting 33 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness.
  3. F
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    F921 · Environmental · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) July 22, 2024
    Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 33 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.
  4. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 14, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that promoted and enhanced resident dignity in one resident (R7) of 12 residents reviewed for dignity, resulting in the potential of feelings of humiliation and embarrassment.
  5. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 22, 2024
    Inspectors wroteBased on observations, interviews and record review, the facility failed to develop and implement person centered care plan for 1 of 12 residents (Resident #26) reviewed for care planning, resulting in unmet care needs.
  6. D
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 22, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing to meet residents needs in three residents (Resident #7, Resident #20, Resident #26) of 12 residents reviewed for staffing resulting in falls with injuries and unmet resident care needs.
  7. D
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 22, 2024
    Inspectors wroteBased on interview and record review, the facility failed to follow up on pharmacist recommendations and ensure the physician documented review of pharmacy recommendations for one resident (Resident #6) of five residents reviewed for unnecessary medication use potentially resulting in incomplete monitoring of the use of medications for residents. Findings Include: Resident #6 (R6) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R6's admission date to the facility was on 10/17/2022 and she had diagnoses of hallucinations, cognitive communication deficit, depression, and anxiety. Brief Interview for Mental Status (BIMS) score was a 12 which indicated her cognition was moderately impaired (8-12 moderately impaired). During an interview on 6/25/2024 at 10:05 AM, resident was pleasant and confused. She was unable to answer some questions. [...]
  8. D
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 22, 2024
    Inspectors wroteBased on interview and record review the facility failed to ensure that residents of the facility were free from unnecessary psychotropic medication by completing gradual dose reductions for two residents (Resident #6, Resident #22) of five residents reviewed for unnecessary medication use resulting in incomplete monitoring of medications.
  9. D
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 22, 2024
    Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a double-lock system for a controlled substance in the facility's medication refrigerator resulting in the potential for diversion and/or misappropriation of medication.
  10. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 14, 2024
    Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper use of personal protective equipmen, during cares for 2 (Resident #26 and Resident #82), hand hygiene, labeling/dating IV tubing, and clean medication administration for 1 resident (Resident #82) of 12 residents reviewed for infection control, resulting in a potential for the transmission/transfer of pathogenic organisms and cross contamination between residents and staff.
May 16, 2024Complaint inspection · 4 citations
  1. H
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · Actual harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) June 11, 2024
    Inspectors wroteThis 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
  2. G
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 11, 2024
    Inspectors wroteThis 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.
  3. G
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 11, 2024
    Inspectors wroteThis citation pertains to intake #MI00144223 Based on observation, interview, and record review the facility failed to prevent residents from insect bites and install window screen in 1 of 3 residents (Resident #108) reviewed for quality of care, resulting in Resident #108 suffering a spider bite and subsequent significant wound requiring debridement (removal of dead or infected tissue), increased pain, need for antibiotic treatment, and ongoing wound care.
  4. D
    Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
    F744 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 11, 2024
    Inspectors wroteBased interview and record review, the facility failed to ensure individualized approaches were provided to 1 (Resident #101) of 3 residents reviewed for dementia care, resulting in Resident #101 experiencing avoidable stress responses to care interventions.

Fire safety inspections

13 fire safety citations on file: 8 on May 29, 2026, 4 on May 8, 2025, 1 on June 27, 2024.

Every fire safety citation13 citations
  1. F
    Provide properly protected cooking facilities.
    K 324 · May 29, 2026 · Corrected (the home has a date of correction)
  2. F
    Install a fire alarm system that can be heard throughout the facility.
    K 341 · May 29, 2026 · Corrected (the home has a date of correction)
  3. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · May 29, 2026 · Corrected (the home has a date of correction)
  4. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · May 29, 2026 · Corrected (the home has a date of correction)
  5. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · May 29, 2026 · Corrected (the home has a date of correction)
  6. F
    Ensure proper usage of power strips and extension cords.
    K 920 · May 29, 2026 · Corrected (the home has a date of correction)
  7. F
    Have proper medical gas storage and administration areas.
    K 923 · May 29, 2026 · Corrected (the home has a date of correction)
  8. D
    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
    K 222 · May 29, 2026 · deficient, provider has
  9. F
    Have properly located and lighted "Exit" signs.
    K 293 · May 8, 2025 · Corrected (the home has a date of correction)
  10. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · May 8, 2025 · Corrected (the home has a date of correction)
  11. E
    Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
    K 222 · May 8, 2025 · Corrected (the home has a date of correction)
  12. E
    Provide properly protected cooking facilities.
    K 324 · May 8, 2025 · Corrected (the home has a date of correction)
  13. D
    Provide properly protected cooking facilities.
    K 324 · June 27, 2024 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
June 27, 2024Fine $33,638
June 27, 2024Payment Denial 22 days from July 23, 2024
May 16, 2024Fine $161,356

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeMichiganUnited States
All nursing staff (RN, LPN and aides)3.243.993.86
Registered nurses0.570.780.69
All nursing staff on weekends2.893.503.42
Nurse aides1.79
Licensed practical nurses0.88
Nursing staff turnover (share who left in a year)62.8%44.1%45.8%
Registered nurse turnover33.3%39.2%42.9%
Administrators who left1

CMS expects 3.56 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.39 on weekdays and 2.89 on weekends, 15% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 16.8% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.26 in April to June 2025 to 3.24 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.240.573.392.89 16.8%0 of 9033
Oct to Dec 20253.310.813.492.86 17.4%0 of 9233
Jul to Sep 20253.360.853.552.87 14.9%0 of 9234
Apr to Jun 20253.260.893.422.86 18.5%0 of 9134
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Michigan, Jan to Mar 20263.950.704.143.453.3%0.4% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Michigan

JobMedianMiddle halfEmployed
Michigan, all employers
CNAs (nursing assistants)$19.03$18.35 to $21.5943,290
LPNs and LVNs$31.47$29.83 to $35.5210,880
Registered nurses$45.34$39.46 to $49.74104,950
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

Work here? Share your pay anonymously

For Plainwell Pines Nursing and Rehabilitation Communi. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

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Optional questions
Mandatory overtime?
How did staffing feel on your usual shift?

Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeMichiganUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
5.310.813.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.50.80.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
1.81.51.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
7.83.03.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
0.01.11.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
9.812.014.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
1.05.14.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
7.514.815.4

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Plainwell Pines Nursing and Rehabilitation Communi's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (54.4% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

54.4% this home

No different from the national rate

US median of homes 51.5% · Michigan: 89 better, 22 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 29 eligible stays.

Potentially preventable readmissions

9.7% this home

No different from the national rate

US median of homes 10.7% · Michigan: 0 better, 9 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 27 eligible stays.

Infections that led to a hospital stay

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

US median of homes 7.1% · Michigan: 1 better, 1 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 15 eligible stays.

Self-care and mobility at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Michigan57.6% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 15 residents counted.

Falls with major injury

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Michigan0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 19 residents counted.

New or worsened pressure ulcers

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Michigan1.3% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 19 residents counted.

Medication list given at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Michigan99.5% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 8 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: ATRIUM PLAINWELL, INC.. CMS links this home to Atrium Centers, a group of 26 nursing homes averaging 2.9 stars overall.

NameRoleTypeShareSince
Atrium Centers, LLC5% or greater direct ownership interestOrganization100%10/01/2007
Bailey, Essel5% or greater indirect ownership interestIndividual74%12/27/2012
Finney, Donald5% or greater indirect ownership interestIndividual25%08/22/2012
Bailey, EsselCorporate directorIndividual10/01/2007
Finney, DonaldCorporate directorIndividual08/22/2012
Albright Ross, SusanCorporate officerIndividual01/02/2018
Ferkany, JamesCorporate officerIndividual08/01/2018
Atrium Centers Management LLCOperational/managerial controlOrganization10/01/2007
Albright Ross, SusanOperational/managerial controlIndividual01/02/2018
Lockhart, DennisOperational/managerial controlIndividual08/01/2018
Morris, BetteOperational/managerial controlIndividual07/18/2016

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 12 problems in this area, most recently on May 29, 2026: "Provide appropriate pressure ulcer care and prevent new ulcers from developing."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 11 problems in this area, most recently on May 29, 2026: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights."
  3. How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 7 problems in this area, most recently on May 29, 2026: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody."
  4. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 5 problems in this area, most recently on May 29, 2026: "Ensure medication error rates are not 5 percent or greater."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.89 hours per resident per day, below the Michigan average of 3.50.
  6. How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.

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Common questions

What is Plainwell Pines Nursing and Rehabilitation Communi's Medicare star rating?
CMS rates Plainwell Pines Nursing and Rehabilitation Communi 2 out of 5 stars overall, with 1 for health inspections, 3 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Plainwell Pines Nursing and Rehabilitation Communi get at its last inspection?
12 health deficiencies at the standard inspection on May 29, 2026. The Michigan average is 9.9.
Has Plainwell Pines Nursing and Rehabilitation Communi been fined?
Yes. CMS lists 2 fines totaling $194,994 in the last three years.
Does Plainwell Pines Nursing and Rehabilitation Communi accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Plainwell Pines Nursing and Rehabilitation Communi?
CMS lists 11 owners and managers, and links the home to Atrium Centers. Legal business name: ATRIUM PLAINWELL, INC..

Sources

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