Pine Acres Rehabilitation And Care Center

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

further documented Resident #8 required substantial/maximal assistance total from staff for performing activities of daily living but he was able to independently use the wheelchair. In an interview with Resident #8 on 8/24/25 at 10:30 am it was noted the wheelchair was visible soiled and a buildup of debris around the structural parts. The cushion seat had multiple cigarette burns extending from the center towards the edge of the seat. The lock on the left side of the wheel was not functional. Resident #8 stated the lock did not work properly for a long time and he wanted his wheelchair to look clean and the brakes fixed.In an

interview with the Director of Nursing (DON) on 8/26/25 at 10:30 am she stated that the facility staff were to clean residents' wheelchairs at a minimal weekly and on as needed basis. She further stated that the carpet in room [ROOM NUMBER] had been shampooed multiple times but the stains were not lifted successfully. The DON further stated that her expectations were for the wheelchairs to be clean and the carpets to be stain-free to promote a homelike environment for the residents. The facility provided policy titled Safe and Homelike Environment revised 1/2025 documented: Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pine Acres Rehabilitation and Care Center

1501 Office Park Road West Des Moines, IA 50265

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Based on observation, staff interview, and policy review the facility failed to provide appropriate incontinence care for one (#11) of three residents reviewed. The facility reported a census of 79 residents.

Findings include:The Minimum Data Set (MDS) assessment for Resident #11, dated 5/22/25, included diagnoses of stroke, Non-Alzheimer's Dementia, and hemiplegia (paralysis of one side of the body). The MDS identified the resident was dependent on staff for toilet hygiene and was always incontinent of urine and frequently incontinent of bowel. The MDS indicated the resident had a Brief Interview for Mental Status score of 9, indicating moderate cognitive impairment. Observation on 8/20/25 at 8 AM, Staff A, Certified Nursing Assistant (CNA) and Staff C, CNA entered Resident 11's room and washed hands and donned gloves. With the resident lying in bed, Staff A removed the resident's visibly wet brief, cleansed above the penis, the penis, and the scrotum, without cleansing the inner thighs. The resident was turned to his side and Staff A cleansed between the resident's buttocks and inner buttocks, didn't cleanse the outer buttocks and hips.Facility policy Perineal Care, revised 08/2025, documented cleanse buttocks and anus.Interview

on 8/26/25 at 11:10 AM, the Director of Nursing stated expectation to cleanse all areas of buttocks and hips when completing incontinence care.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pine Acres Rehabilitation and Care Center

1501 Office Park Road West Des Moines, IA 50265

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725

Interview for Mental Status score of 14, indicating mild cognitive impairment.

Level of Harm - Minimal harm or potential for actual harm

Interview on 8/19/25 at 12:25 PM, Resident #8 stated it takes about 1 hour for staff to answer his call light frequently and that can be anytime of the day. The resident stated the staff will come in and turn off the light, say they will be back, and don’t come right back.

Residents Affected - Some

1. 5. The MDS assessment for Resident #12, dated 7/1/25, included diagnoses of stroke and hemiplegia

(paralysis of one side of the body). The MDS identified the resident was dependent on staff for all cares except eating, was wheelchair dependent, and not able to propel self in wheelchair. The MDS indicated the resident had a Brief Interview for Mental Status score of 15, indicating no cognitive impairment.

Observation on 8/19/25 at 11:30AM, Resident #11 in his room, reclined in a wheelchair approximately 5 feet from the bed with the call light down between the resident’s bed and wall, not within reach of

the resident.

Observation on 8/26/25 at 7:50AM, Resident #11 in his wheelchair approximately 4 feet from his bed, with

the call light cord draped over the resident’s bed foot board, with the call button down between the mattress and footboard, not within reach of the resident. Resident asked where the call light was and confirmed he was not able to reach the call light.

Facility Policy Call Lights: Accessibility and Timely Response revised 10/202 documented staff will ensure

the call light is within reach of resident and secured, as needed

Interview on 8/26/25 at 11:10 AM, the Director of Nursing stated the facility policy did not address the timeliness of answering a call light but her expectation was for call lights to be answered within 15 minutes and for call lights to be within reach of the residents.

2. 6. The MDS for Resident #5 dated 7/24/25 documented BIMS of 15 indicating no cognitive impairment. The

MDS further documented Resident #5 had diagnoses of anxiety, depression and diabetes type 2 with daily insulin injections.

In an Interview on 8/25/25 at 12:00 pm Resident #5 revealed call light is not answered for up to 1 hour sometimes. Resident #5 further revealed she watched the clock and often had to leave the room in her wheelchair and look for staff herself to get help. The call light in her room was functioning.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Pine Acres Rehabilitation and Care Center

1501 Office Park Road West Des Moines, IA 50265

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

resident’s roommate’s bedside tray table.

Level of Harm - Minimal harm or potential for actual harm

Interview on 8/26/25 at 11:10 AM, the Director of Nursing (DON) stated expectations for the urine graduate container to be placed on a barrier and to not allow the drain spout to touch the inside of the graduated container when emptying the catheter bag. The DON further stated expectation for staff to complete hand hygiene between assisting residents and a resident’s package of wipes used for cares to not be placed on another resident’s bedside table.

Residents Affected - Some

1. 5. The MDS dated [DATE REDACTED] for Resident #5 documented the following diagnoses: multidrug-resistant

organism (MDRO), neurogenic bladder, pressure ulcers, cellulitis of right upper limb, and yeast infection.

The MDS also indicated use of an indwelling catheter and ostomy.

An observation on 8/21/25 at 1:50 pm of Resident #4 revealed a staff member was in the room providing ostomy care without a personal protective gown on.

In an interview with Staff G, Registered Nurse (RN) on 8/21/25 at 1:52 pm she visualized staff completing

the ostomy care and confirmed the staff in Resident #4’s room should have been following enhanced barrier precautions and utilizing Personal Protective Equipment (PPE) but was not and she was told it was because there were no gown available. Staff G proceeded to look into the supply bin located outside of Resident #4’s room and there were no gowns. Staff G proceeded to walk down the hallway and opened 6 other supply bins with enhanced barrier items/PPE, but only found 1 cart had gowns

in it. She stated she will restock the PPE bins and she wasn’t aware of the bins not being stocked with PPE.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet