Resident #8 told inspectors on August 24 that the left wheel lock "did not work properly for a long time" and he wanted his wheelchair "to look clean and the brakes fixed."
The wheelchair cushion showed multiple cigarette burns extending from the center toward the edge of the seat. Debris had built up around structural components throughout the chair. The left brake was completely non-functional.
Despite requiring substantial to maximal assistance from staff for all activities of daily living, Resident #8 could operate his wheelchair independently. The broken brake meant he couldn't secure the chair safely when transferring or positioning himself.
Pine Acres Rehabilitation and Care Center's Director of Nursing told inspectors on August 26 that facility staff were supposed to clean residents' wheelchairs at minimum weekly and whenever needed.
She acknowledged the wheelchair's condition violated her own expectations. "The wheelchairs should be clean," she said, adding that maintaining clean equipment was essential "to promote a homelike environment for the residents."
The facility's Safe and Homelike Environment policy, revised in January 2025, states that housekeeping and maintenance services "will be provided as necessary to maintain a sanitary, orderly and comfortable environment."
But the policy wasn't being followed. Inspectors found the wheelchair visibly soiled during their August 24 interview with the resident, two days before they questioned the Director of Nursing about cleaning protocols.
The nursing director also acknowledged problems with carpet maintenance in the resident's room. Despite multiple shampooing attempts, stains remained embedded in the flooring. She said her expectation was for carpets to be "stain-free to promote a homelike environment."
The inspection, conducted in response to a complaint, revealed systematic failures in basic environmental maintenance affecting residents who depend entirely on staff for their daily care needs.
Resident #8's situation exemplifies how equipment failures can compound the challenges facing people who need substantial assistance. Unable to rely on his wheelchair's brakes, he faced additional safety risks during transfers and positioning.
The cigarette burns suggested the wheelchair had been damaged for an extended period without replacement or repair. The debris buildup indicated cleaning had been neglected repeatedly, not just missed once or twice.
Federal inspectors cited Pine Acres for failing to maintain a homelike environment under regulations requiring nursing homes to provide clean, comfortable living conditions for residents.
The violation affected multiple residents, though the inspection report focused primarily on Resident #8's wheelchair and room conditions.
Pine Acres operates at 1501 Office Park Road in West Des Moines. The facility was required to submit a correction plan addressing the environmental maintenance failures identified during the August 26 inspection.
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
- Browse all IA nursing home inspections