Pine Acres Rehab: Medication Error Violations - IA
Resident #3 arrived at the hospital on September 5, 2025, with both patches still attached to her body. Emergency department notes confirmed she had two fentanyl patches when transported from Pine Acres Rehabilitation and Care Center.
The medication error began on September 2 when a nurse applied a fentanyl patch to the resident's left arm. Three days later, on September 5, Staff C, a licensed practical nurse, was supposed to remove that patch before applying a fresh one.
She didn't.
Staff C told inspectors she remembered putting on the new patch but couldn't recall removing the old one. When questioned about disposal procedures, she said she would have had a witness when disposing of the previous patch and putting it in the "drug buster," but she couldn't identify who that witness was or where the disposal would be documented.
"It would probably be the same one who helped her take the new one out," Staff C said. "Then she added that if it was busy, it might have been someone else just so there was a witness."
The resident had been feeling unwell for several days before September 5. Staff A, an advanced registered nurse practitioner, assessed her that morning and believed she had developed a urinary tract infection with sepsis.
Staff A defended the medication error during her interview with inspectors on October 22. She insisted the resident wasn't overdosed and claimed that even if the old patch had been properly removed three days earlier, "the outcome would have been the same."
"It was not a double dose as the old Fentanyl patch would have been basically completed," Staff A told investigators. She noted the resident already had elevated liver enzymes due to fatty liver disease and said the primary diagnosis in the emergency department was sepsis, not overdose.
The administrator took a different view. During her interview the same day, she acknowledged that the nurse who administered the September 5 fentanyl patch should have removed the patch from September 2. She confirmed seeing in the emergency department notes that Resident #3 had two patches when transported to the hospital and "should not have."
Pine Acres has policies governing medication administration and controlled substance accountability, both revised in January 2025. The medication administration policy states that medications are given by licensed nurses "as ordered by the physician and in accordance with professional standards of practice."
The controlled substance policy requires that "all controlled drug patches removed from patients are disposed of in such a manner as to prevent diversion." But inspectors found the policy "lacks direction of removal of old patches prior to new patch application."
Fentanyl patches deliver continuous pain medication through the skin over 72 hours. Medical protocols require removing the old patch before applying a new one to prevent medication buildup in the patient's system.
The inspection report doesn't specify how long Resident #3 remained hospitalized or her condition upon discharge. Staff A remembered telling another staff member "that something was off about the resident" during the days leading up to her emergency transport.
The violation was classified as causing minimal harm with few residents affected. Federal inspectors completed their investigation on November 25, 2025, more than two months after the medication error occurred.
Staff C's uncertainty about basic safety procedures raised additional concerns. When asked about witness requirements for controlled substance disposal, she gave conflicting explanations and couldn't identify specific documentation or personnel involved in the process.
The case highlights gaps in both policy enforcement and staff training at Pine Acres. While the facility had written procedures for controlled substance handling, the policies failed to explicitly address patch removal protocols, and staff demonstrated confusion about basic medication safety requirements.
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 2025-11-25 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 November 25, 2025.
Resident #3 arrived at the hospital on September 5, 2025, with both patches still attached to her body.
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.