Nursing home cited for violations tied to three deaths and alleged abuse and neglect

A West Des Moines nursing home could be facing more than $60,000 in fines after being cited for dozens of violations tied to allegations of neglect, physical abuse and three resident deaths.

Citing the home’s quality-of-care issues and recurring, pervasive urine odors that inspectors describe as “overwhelming,” the Iowa Department of Inspections, Appeals and Licensing recently cited Pine Acres Rehabilitation and Care Center for 39 regulatory violations – an extraordinarily high number for the 81-resident care facility in West Des Moines.

The department also proposed, but held in suspension, a total of $66,250 in state fines. Those fines are being held in suspension while the federal Center for Medicare and Medicaid Services determines whether a federal penalty is warranted for those same violations.

Currently, Pine Acres is one of 10 Iowa nursing homes deemed eligible by the federal government for “special focus” status due to serious and recurring quality-of-care violations.

In 2024, state inspectors cited Pine Acres for failing to ensure a male resident of the home was treated for foot ulcers, leading to a bacterial infection and the amputation of the resident’s left leg. The federal government subsequently fined Pine Acres $177,240. That was in addition to a federal fine of $71,169 imposed eight weeks earlier for violations stemming from two 2023 inspections that led to the home being cited for 62 violations, one of which was tied to a resident who contracted gangrene in the home and had to have a leg amputated.

Latest inspection tied to multiple complaints

State inspectors visited the home beginning on May 11, 2026, in response to nine complaints, all of which were deemed verified by the inspectors. Over the next 23 days, inspectors compiled a 355-page report detailing all of the violations that resulted in citations for deficient care.

Among the alleged issues: 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 regulatory 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 in a safe and sanitary manner.

The home’s administrator, Patricia Wiltfang, did not return messages from Iowa Capital Dispatch seeking comment on Wednesday.

Specific incidents detailed by the inspectors as a result of their most recent visit include:

Three deaths: According to inspectors, a male resident of the home fell from his bed on April 19, 2026, striking his face on the floor and sustaining a head injury. The facility allegedly failed to conduct ongoing neurological nursing assessments after the fall, despite a significant change in the man’s mental condition over the next seven days. On April 27, the man was admitted to a hospital’s intensive care unit and died there on May 3, 2026, of sepsis resulting from an infection and possible swelling of the brain or spinal cord.

The home was also accused of failing to provide adequate assessments for another resident, in February 2026, who experienced nausea and vomiting hours before going into cardiac arrest and dying.

Regarding the third resident who died, inspectors noted the man’s wife reported being at home the afternoon of March 23, 2026. According to inspectors, she stated that when she arrived, she saw two employees chatting outside her husband’s room and then found her husband in his room sitting in a recliner and “hanging on with fright” because the chair was tipped over so far forward the footrest was on the floor. The woman yelled for help as her husband’s oxygen levels dropped. Inspectors reported she told them the skin on her husband’s arm appeared to have been ripped off, causing him “extraordinary” pain.

The wife told inspectors she informed the staff of the issue and waited six hours for assistance with no response from the nurses, according to state records. The man, who was already receiving hospice services prior to the incident, died several hours later. “He was so fearful that he did not want me to leave him,” the wife allegedly told inspectors. “I believe he just was frightened to death.”

Resident abuse: Inspectors reported Pine Acres failed to prevent the physical abuse of one resident whose right elbow and left wrist were left bruised by a staff member holding the resident’s arms too hard. Inspectors also alleged the home failed to perform a thorough investigation regarding one resident who was left with rib fractures of an unknown cause.

The home also failed to prevent “patterned issues of neglect,” the inspectors said, citing an alleged lack of assistance provided for residents who needed help with grooming, oral care, repositioning and incontinence. Residents and family members complained the staff was disrespectful and rude at times, with one resident stating an employee had called her a “stupid b—-.”

Intimidation: A state inspector reported that during the course of the May 2026 inspection, she overheard what sounded like an argument between a female employee and a male resident, with the worker saying, “I am trying to take damn good care of you. I do everything for you. People deserve to be criticized, but you need to call those names out, just not my name. Talk about the good, not just the bad.”

According to the inspector, the resident responded, “I will let the state know. I will not give your name.” The inspector intervened and the resident allegedly stated the staff had come around earlier than usual that day to provide him with a shower, which he felt was the staff’s way of “trying to pull the wool over the eyes of the state.”

According to the inspector, the man also stated, “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.”

The inspector cautioned the worker against impeding the state’s investigation, advising her to refrain from telling residents what they could and could not say to inspectors.

Staffing levels: Pine Acres was cited for failing to have sufficient staff on hand to meet residents’ needs, with inspectors stating the problem appeared to be “widespread” given the number of complaints and written grievances filed by residents.

According to the inspectors, residents complained the staff took up to 90 minutes to answer call lights. One resident spoke to inspectors and stated that he was wet with urine at that time but knew that because of staffing issues, he wouldn’t be changed for another three hours. The state, the resident allegedly added, was the only thing that could make a difference because the facility’s leadership wasn’t going to improve matters.

Another resident allegedly complained that she once sat in her wheelchair with blood on her face and hands and used her call light to summon assistance. A worker, she allegedly told inspectors, entered her room, turned off the light, and immediately left, never to return.

Administration: The home was cited for failing to provide the necessary leadership to address residents’ grievances and the recurring quality-of-care issues within the home, leading to an ineffective quality-assurance program. Pervasive urine and ammonia odors were noted throughout the building by the inspectors and were described as “overwhelming” in some areas. One employee reportedly told inspectors she had relayed to the home’s administrator her concerns about the “terrible odor” and the fact that the housekeeping staff “cannot get the smell out.”

The administrator also was reported to have no explanation as to why the facility wasn’t publicly posting up-to-date information on staffing levels for residents and family to read. The available postings, according to inspectors, were either outdated, printed in text that was small and hard to read, or posted in the staff restroom.

Wrongful death lawsuit, allegations of neglect

In 2025, the Center for Medicare and Medicaid Services gave Pine Acres one-star ratings for quality measures and inspection results on the government’s five-star quality scale. The ratings for Pine Acres are now suspended due to what CMS calls ongoing “serious quality issues” at the home.

Pine Acres is currently being sued by the family of the late Richard M. Cox. The lawsuit alleges that on Oct. 21, 2024, Cox was able to exit the Pine Acres building unattended and without detection. He then sustained severe injuries in a fall about two blocks from Pine Acres and he died on Nov. 4, 2024, allegedly as a result of those injuries. Pine Acres has denied any wrongdoing, and a trial is scheduled for May 17, 2027.

Earlier this year, a former Pine Acres certified nurse aide, Abigail Kromah, was awarded unemployment benefits after being fired from the home due to what her bosses characterized as “numerous resident complaints” regarding quality of care.

According to a judge’s findings in her unemployment case, Kromah had received multiple disciplinary warnings for failing to answer residents’ call-lights in a timely manner, failing to properly assist residents with their personal care, and for telling a resident who needed to be toileted to go to the bathroom in their briefs.

Pine Acres’ management alleged that in August 2025, Kromah failed to check on a resident’s feeding tube throughout the entire night, leaving the resident drenched in feeding solution from head to toe. One resident of the home had allegedly become so frustrated by the lack of response to his call-light that he contacted the police for assistance.

According to federal records, Pine Acres is owned and managed by a New York-based group of investors that includes Yisroel Kaplan, who shares operational control of Pine Acres and a stake in another Iowa care facility, the Prestige Care Center in Fairfield.