Pine Acres Rehab: Inadequate Incontinence Care - IA
Federal inspectors observed the August 20 incident during a complaint investigation at the 79-bed facility on Office Park Road. The violation occurred despite facility policy requiring staff to "cleanse buttocks and anus" during incontinence care.
The resident involved suffered from stroke, dementia, and paralysis on one side of his body. His May assessment showed he was completely dependent on staff for toilet hygiene and was always incontinent of urine and frequently incontinent of bowel. He had moderate cognitive impairment.
Inspectors watched at 8 AM as two certified nursing assistants entered the resident's room. Both staff members washed their hands and put on gloves before beginning care.
The resident lay in bed wearing a visibly wet brief. Staff A removed the soiled garment and began cleaning the resident above the penis, the penis, and the scrotum. But the assistant skipped the inner thighs entirely.
The staff then turned the resident to his side. Staff A cleaned between the resident's buttocks and the inner buttocks but failed to clean the outer buttocks and hips before finishing the procedure.
The incomplete cleaning left areas of the resident's body unwashed despite contact with urine and potential fecal matter. For residents with incontinence, thorough cleaning prevents skin breakdown, rashes, and urinary tract infections.
The facility's own perineal care policy, revised just weeks before the inspection in August 2025, explicitly required staff to cleanse the buttocks and anus during incontinence care. The policy served as the standard against which inspectors measured the observed care.
When confronted about the violation six days later, the Director of Nursing acknowledged the problem. During an interview on August 26 at 11:10 AM, the nursing director confirmed the facility's expectation that staff "cleanse all areas of buttocks and hips when completing incontinence care."
The admission highlighted a gap between written policy and actual practice at Pine Acres. Staff knew the requirements but failed to follow them during routine care of a vulnerable resident.
The violation particularly concerned inspectors because the resident could not advocate for himself. His moderate cognitive impairment from dementia meant he likely could not request proper cleaning or complain about inadequate care.
His physical limitations compounded the problem. The stroke had left him with hemiplegia, paralysis affecting one side of his body. He could not reposition himself or assist with his own hygiene needs.
The combination of incontinence, cognitive impairment, and physical disability made thorough cleaning critical for preventing complications. Residents who cannot move independently face higher risks of pressure sores and skin infections when hygiene protocols are not followed.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to residents. The finding affected few residents, suggesting the problem was not widespread throughout the facility.
However, the violation represented a fundamental failure in basic nursing care. Proper incontinence care ranks among the most essential services nursing homes provide to residents who cannot care for themselves.
The August inspection was conducted in response to a complaint, indicating someone had raised concerns about care quality at Pine Acres. The facility had not undergone a routine annual survey that would have examined broader patterns of care.
Pine Acres opened in 1999 and has operated under the same ownership for over two decades. The facility provides both short-term rehabilitation and long-term care services to residents in the Des Moines metropolitan area.
The violation occurred during a period when the facility was updating its policies. The perineal care policy had been revised the same month as the inspection, suggesting management was aware of the need to clarify hygiene procedures.
But policy updates mean nothing without consistent implementation. The observed care failure demonstrated that even recently revised procedures were not being followed by frontline staff.
The resident's family trusted Pine Acres to provide dignified, thorough care for their loved one. Instead, inspectors found staff cutting corners on basic hygiene during one of the most vulnerable moments in the resident's day.
For residents like this stroke survivor, proper incontinence care represents more than medical necessity. It preserves dignity and prevents the painful complications that arise when the most basic human needs are not met with professional competence.
The facility must now develop a plan to correct the deficiency and prevent similar violations in the future.
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
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Pine Acres Rehabilitation and Care Center in West Des Moines, IA was cited for violations during a health inspection on August 26, 2025.
Federal inspectors observed the August 20 incident during a complaint investigation at the 79-bed facility on Office Park Road.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.