Pine Acres Rehab: Treatment Harm Violation - IA
The incident occurred September 5, 2025, when a licensed practical nurse administered a fresh fentanyl patch to Resident #3 without taking off the patch applied three days earlier. Emergency department records confirmed the resident had both patches when transported to the hospital.
Staff C, the LPN who applied the new patch, told inspectors she remembered removing the old patch from the resident's left arm and disposing of it in the drug disposal unit. She claimed to have a witness for the disposal but couldn't identify who witnessed it or where the removal would be documented.
"She was unable to state where that would be documented," inspectors wrote. "She does not remember who witnessed it but it would probably be the same one who helped her take the new one out."
The nurse then changed her story. If the unit was busy, she said, "it might have been someone else just so there was a witness."
Staff A, an advanced registered nurse practitioner, evaluated the resident and determined she had developed a urinary tract infection with sepsis. The ARNP insisted the resident wasn't overdosed, arguing that even if the old patch had been properly removed, the outcome would have been identical.
"She does not feel that the resident was overdosed and stated that if the old patch from 3 days before had been removed, the outcome would have been the same," according to the inspection report. "It was not a double dose as the old Fentanyl patch would have been basically completed."
The ARNP noted the resident's fatty liver meant her liver enzymes were already elevated, complicating her condition. Emergency department physicians listed sepsis as the primary diagnosis.
But the facility's administrator contradicted the nurse practitioner's assessment during her October interview with state inspectors. She acknowledged the nurse should have removed the September 2 patch before applying the new medication on September 5.
"She did see in the ED notes that Resident #3 did have 2 patches on when transported to the hospital and should not have," inspectors documented.
The administrator's admission directly contradicted the LPN's claim that she had properly disposed of the old patch.
Pine Acres maintains policies requiring licensed nurses to administer medications according to physician orders and professional standards. A separate policy on controlled substance handling mandates that all drug patches removed from patients be disposed of properly to prevent diversion.
However, the controlled substance policy lacks specific direction about removing old patches before applying new ones.
The resident had been feeling unwell for several days before the September 5 assessment, according to Staff A. The ARNP recognized the symptoms as similar to the resident's previous presentation when they first met, suggesting a pattern of urinary tract infections progressing to sepsis.
Fentanyl patches deliver continuous pain medication through the skin over 72-hour periods. The powerful synthetic opioid requires careful handling and precise administration timing to prevent overdose. Each patch contains enough medication to be potentially lethal if misused.
The inspection found that few residents were affected by the medication administration failure, with minimal harm documented. However, the incident exposed gaps in the facility's controlled substance protocols and raised questions about staff training on patch removal procedures.
State inspectors interviewed multiple staff members on October 22, 2025, more than a month after the incident. The conflicting accounts from nursing staff about patch removal and disposal highlighted inconsistencies in medication handling practices.
The resident's transport to the emergency department occurred amid her developing sepsis, with medical staff discovering the dual fentanyl patches during treatment. The combination of the urinary tract infection, sepsis, and potential medication error created a complex medical situation requiring immediate intervention.
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.
Emergency department records confirmed the resident had both patches when transported to the hospital.
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.