When asked where his call light was, the wheelchair-dependent man confirmed he couldn't reach it.
Federal inspectors documented the scene at Pine Acres Rehabilitation and Care Center on August 26, finding multiple residents left without access to emergency help despite facility policies requiring call lights remain within reach.
Resident #11, who suffered from stroke and hemiplegia that left one side of his body paralyzed, depended on staff for nearly all care except eating. Medical records showed he couldn't propel his own wheelchair.
Yet inspectors found him twice with his call light unreachable. On August 19, the call light lay on the floor between his bed and wall, five feet away. A week later, staff had draped the cord over his bed's footboard with the button trapped beneath the mattress.
The facility's own policy, revised in October 2022, required staff to ensure call lights stayed "within reach of resident and secured, as needed."
Other residents described waiting up to an hour for responses to their calls for help.
Resident #8 told inspectors during an August 19 interview that staff routinely took an hour to answer his call light "anytime of the day." He said staff would enter his room, turn off the light, promise to return, then disappear.
Resident #5, who used a wheelchair and required daily insulin injections for diabetes, watched the clock during her waits for help. She told inspectors on August 25 that call lights sometimes went unanswered for an hour.
"She watched the clock and often had to leave the room in her wheelchair and look for staff herself to get help," the inspection report stated.
Her call light worked properly. Staff simply didn't respond.
The Director of Nursing acknowledged during an August 26 interview that the facility had no written policy addressing response times for call lights. She said her personal expectation was that staff answer within 15 minutes and keep call lights within residents' reach.
But the inspection revealed a systematic failure to meet even basic accessibility standards.
Medical assessments showed the affected residents retained their cognitive abilities. Resident #11 scored 15 on a mental status evaluation, indicating no cognitive impairment. Resident #5 scored the same, despite battling anxiety and depression alongside her diabetes.
These residents understood their predicament. They knew help should come when they called. They watched clocks tick past reasonable response times.
Resident #5's determination to wheel herself through hallways searching for staff illustrated the desperation created by the system's failures. A diabetic woman dependent on daily insulin injections shouldn't need to hunt for caregivers when medical needs arise.
The violations affected multiple residents, not isolated incidents involving confused or difficult patients. The inspection classified the harm level as minimal, but the potential for serious consequences loomed large.
A paralyzed resident who cannot reach emergency help faces risks that extend far beyond inconvenience. Falls, medical emergencies, and basic dignity all depend on timely staff response to calls for assistance.
The facility's policy existed on paper. Staff training presumably covered proper call light placement. Yet inspectors found the same resident twice in identical situations, suggesting systemic disregard rather than occasional oversight.
Pine Acres Rehabilitation and Care Center operates at 1501 Office Park Road in West Des Moines, serving residents who depend entirely on staff competence and attention for their most basic needs.
The inspection occurred following complaints, indicating problems serious enough to trigger federal scrutiny. The August 26 survey revealed violations that put vulnerable residents at risk daily.
Resident #8's description of staff behavior captured the callousness involved. Entering a room, silencing the call light, making promises, then abandoning the resident created a cycle of false hope and genuine neglect.
For wheelchair-bound residents like #11, an unreachable call light represents complete isolation from help. His stroke had already stolen half his body's function. Staff negligence threatened to steal his access to care when emergencies struck.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pine Acres Rehabilitation and Care Center from 2025-08-26 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Pine Acres Rehabilitation and Care Center
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