Pine Acres Rehab: Infection Control Failures - IA
The inspection, conducted August 21 and 26, 2025, was a complaint investigation. What inspectors documented was not a single lapse but a pattern of infection control failures that reached across multiple residents and multiple staff members on the same unit.
Resident 5 carried a list of diagnoses that made proper protective equipment not optional: a multidrug-resistant organism, neurogenic bladder, pressure ulcers, cellulitis of the right upper limb, a yeast infection, an indwelling catheter, and an ostomy. The inspection report does not specify which resident was receiving the ostomy care at 1:50 p.m. on August 21 when an inspector observed the violation, identifying that resident as Resident 4. What is documented is that the staff member providing the care had no protective gown on.
A registered nurse identified in the report as Staff G was present and saw it too. She confirmed to inspectors that the staff member should have been following enhanced barrier precautions and wearing full PPE. The reason given: no gowns were available.
Staff G walked to the supply bin just outside the room. It was empty. She then opened six more bins down the hallway, bins designated for enhanced barrier precautions and PPE. One had gowns. Six did not.
She told inspectors she would restock the bins and that she had not known they were unstocked.
That answer raised its own question. If the nurse responsible for the unit did not know the PPE bins were empty, and the staff member doing the ostomy care knew and proceeded anyway, the failure was not a single worker cutting a corner. The supply chain had broken down, and no one had caught it.
The infection control problems extended beyond the missing gowns. Inspectors also documented a separate observation involving a urine collection container. During catheter bag drainage, the drain spout was allowed to touch the inside of the graduated container, a direct contamination risk. The container was then placed without a barrier underneath it.
The same observation captured something else: a package of wipes used for a resident's personal care had been set down on a different resident's bedside tray table.
These are not complicated procedures. The Director of Nursing, interviewed on August 26, laid out the expectations plainly: the urine graduate should sit on a barrier, the drain spout should never contact the inside of the container, hand hygiene should happen between residents, and one resident's supplies should not land on another resident's furniture. The DON said all of that as a statement of what should have happened. The inspection report existed because it hadn't.
The violations were cited under F0880, the federal infection prevention and control tag, with a harm level of minimal harm or potential for actual harm and a finding that some residents were affected.
"Minimal harm" is a regulatory classification. It describes the threshold at which a deficiency is cited, not a guarantee of outcome. A resident with a drug-resistant organism, open pressure ulcers, and active cellulitis has little margin for additional infectious exposure. The gown exists precisely because the organisms present on or near that resident can transfer to staff, to equipment, and from there to other residents on the same hall.
The nurse who found the empty bins said she would restock them. What the inspection report does not answer is how long they had been empty before an inspector arrived, how many care procedures had been performed in that window, and whether any of the residents on that hallway, some of them carrying infections that do not respond to standard antibiotics, had been exposed as a result.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 4, 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.
The inspection, conducted August 21 and 26, 2025, was a complaint investigation.
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.