A West Des Moines nursing home is facing more than $60,000 in proposed fines after state inspectors cited it for 39 regulatory violations — an extraordinarily high number — following a 23-day investigation triggered by nine complaints, all of which were verified. Three residents died during the period covered by the inspection. Inspectors described the facility’s urine and ammonia odors as “overwhelming,” documented staff intimidating residents ahead of visits, and found residents waiting 90 minutes for call lights while sitting in their own urine.
According to the Iowa Capital Dispatch, the Iowa Department of Inspections, Appeals and Licensing cited Pine Acres Rehabilitation and Care Center following an inspection that began on May 11, 2026. Over the next 23 days, inspectors compiled a 355-page report. The department proposed $66,250 in state fines, held in suspension while CMS determines whether an additional federal penalty is warranted. Pine Acres currently holds a one-star CMS rating — its ratings are now suspended entirely due to what CMS calls ongoing “serious quality issues.” The facility has 81 residents.
The 39 violations cited include: resident abuse; failure to treat pressure sores; violations of residents’ rights; failure to provide a safe, clean, and homelike environment; failure to investigate or report alleged violations; inadequate quality of care; failure to manage residents’ pain; insufficient nursing staff; a lack of competent nursing staff; a significant rate of medication errors; and failure to prepare or serve food safely.
Three residents died in connection with documented failures. A male resident fell from his bed on April 19, 2026, struck his face, and sustained a head injury. The facility failed to conduct neurological assessments despite a significant change in his mental condition over the following week. He was admitted to an ICU on April 27 and died on May 3 of sepsis resulting from an infection and possible brain or spinal cord swelling. A second resident experienced nausea and vomiting for hours before going into cardiac arrest and dying in February 2026, with the facility failing to provide adequate assessments. A third resident — already receiving hospice care — was found by his wife sitting in a recliner tipped so far forward the footrest was on the floor, “hanging on with fright,” with his oxygen levels dropping. His wife waited six hours for assistance with no response from nursing staff. The skin on his arm appeared to have been ripped off, causing him “extraordinary” pain. He died several hours later. “He was so fearful that he did not want me to leave him,” she told inspectors. “I believe he just was frightened to death.”
On the staffing front, inspectors found the problem “widespread.” Residents reported waiting up to 90 minutes for call lights. One resident told inspectors he was sitting wet with urine and knew he would not be changed for another three hours due to staffing issues. Another resident said she once sat in her wheelchair with blood on her face and hands, pressed her call light, and watched a worker enter her room, turn off the light, and immediately leave without a word. A third resident told inspectors: “Damn it, I am at the facility because I need to be, not because I want to be, and the staff go through the motions just to get the state off their backs but they don’t really make any changes.”
During the inspection, a state inspector overheard a staff member arguing with a male resident, telling him: “I am trying to take damn good care of you. I do everything for you.” The resident later told the inspector that staff had provided his shower earlier than usual that day as a way of “trying to pull the wool over the eyes of the state.” The inspector cautioned the staff member against impeding the investigation by telling residents what they could and could not say to inspectors. Inspectors also found the administrator had no explanation for why up-to-date staffing levels were not posted for residents and families — postings were either outdated, printed in hard-to-read text, or posted in the staff restroom.
The facility’s history of serious violations predates this inspection. In 2024, CMS fined Pine Acres $177,240 after inspectors found it failed to treat a resident’s foot ulcers, leading to amputation of his left leg — on top of a $71,169 federal fine imposed eight weeks earlier for violations from 2023 inspections that included a resident who developed gangrene and also required amputation. Pine Acres is one of only 10 Iowa nursing homes currently eligible for federal “special focus” status due to serious and recurring quality-of-care violations. The facility is currently being sued by the family of Richard M. Cox, who exited the facility undetected in October 2024, fell two blocks away, sustained severe injuries, and died. Pine Acres is owned by a New York-based investor group that includes Yisroel Kaplan. The administrator did not return requests for comment.
Thirty-nine violations at a single facility in a single inspection cycle is extraordinary. The pattern at Pine Acres — prior amputations from untreated wounds, six-figure federal fines, now three more deaths and 39 new violations — is the picture of a facility that has failed repeatedly, been fined repeatedly, and continued to operate and accept new residents without meaningful correction. The residents quoted by inspectors in this report describe a facility where the appearance of compliance is managed when the state is watching, and where the same problems return the moment inspectors leave.
The fact that Pine Acres is one of only 10 Iowa nursing homes eligible for “special focus” status from CMS — a designation reserved for facilities with the most serious and persistent patterns of poor care — means regulators already know this facility is a chronic problem. Yet residents continue to live there, to wait 90 minutes for call lights, to sit in urine, and to die from preventable conditions.
Every story documented in the Pine Acres inspection report — a man dying of sepsis after a fall went unmonitored, a resident tipped forward in his chair for hours while his wife begged for help, residents waiting 90 minutes for a call light while sitting in their own urine — describes a failure of the most basic duties of care. These are not complex medical scenarios. They are situations that required someone to show up, pay attention, and act. That did not happen. The facility was warned. It was fined. It repeated the same failures.
Families who have a loved one at Pine Acres or at any facility with a comparable record of serious violations deserve honest answers about the care their family member is receiving. If a loved one has been harmed, neglected, or died under circumstances that were not fully explained to you, contact us to speak with one of our experienced attorneys about your rights and what options may be available.
Iowa Capital Dispatch
https://iowacapitaldispatch.com/2026/07/01/nursing-home-cited-for-violations-tied-to-three-deaths-and-alleged-abuse-and-neglect/
