Pine Acres Rehabilitation And Care Center
Pine Acres Rehabilitation and Care Center in West Des Moines, IA — inspection on November 25, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
on.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/25/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Pine Acres Rehabilitation and Care Center
1501 Office Park Road West Des Moines, IA 50265
SUMMARY STATEMENT OF DEFICIENCIES
remember putting on the patch.
She stated she remembered telling Staff A, ARNP that something was off about the resident.
Staff C, LPN stated that she took off the old patch on the left arm as she has to before she can put on the new one.
She also stated that she had a witness when she disposed of the previous patch and put it in the drug buster.
She was unable to state where that would be documented.
She does not remember who witnessed it but it would probably be the same one who helped her take the new one out.
Then she added that if it was busy, it might have been someone else just so there was a witness.In interview on 10/22/25 at 8:08 AM Staff A, ARNP stated that Resident #3 had not been feeling well for a few days prior to her assessment on 9/5/25.
She feels that Resident #3 had a urinary tract infection with sepsis based on her symptoms as she had presented that way the first time she met Resident #3.
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. It was not a double dose as the old Fentanyl patch would have been basically completed.
She also has a fatty liver so her liver enzymes were already elevated.
Staff A stated the primary diagnosis in the ED was sepsis.In an interview on 10/22/25 at 12:59 PM the Administrator stated that the nurse who administered Resident #3's Fentanyl patch on 9/5/25 should have taken off the patch from 9/2/25.
She did see in the ED notes that Resident #3 did have 2 patches on when transported to the hospital and should not have.In a policy titled Medication Administration revised 1/2025, it is indicated that medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. In a policy titled Controlled Substance Administration and Accountability revised 1/2025, it is indicated that all controlled drug patches removed from patients are disposed of in such a manner as to prevent diversion. It lacks direction of removal of old patches prior to new patch application.
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