Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mississippi Valley during CMS and state inspections, most recent first.
A resident with hereditary motor and sensory neuropathy, COPD, chronic respiratory failure, and dependence for bed mobility and transfers was assisted onto a bedpan by one CNA, during which the resident slid from the bed and sustained a left femur fracture. Documentation and staff interviews showed inconsistent and conflicting information about whether one or two staff were required for bed mobility and toileting: MDS and ADL notes variously described extensive two-person assist, assist of 1–2, and independence with repositioning, while the care plan and Kardex did not clearly specify staffing levels for repositioning or bedpan use. Multiple CNAs and nurses reported that, in practice, two staff were needed to safely reposition the resident and place him on a bedpan, but some staff relied on personal judgment, word of mouth, or incomplete Kardex and Restorative Communication forms that lacked explicit direction on the number of staff required, leading to the deficient practice.
A resident with a history of seizures fell from bed due to inadequate supervision and missing seizure pads. The CNA removed a seizure pad for transfer preparation and left the resident unattended, resulting in a fall and head injury. The facility's supervision policy was not followed, contributing to the incident.
A resident with severely impaired cognition had a Care Plan that inaccurately reflected their liquid consistency order. The Care Plan indicated nectar-thick liquids, while the current orders specified thin liquids. The discrepancy was acknowledged by the MDS Coordinator, and the DON noted the lack of a facility policy on care plans.
A resident with intact cognition and respiratory issues was found to have long and dirty fingernails due to inadequate nail care in the facility. Despite being dependent on staff for personal hygiene, the resident's nails were neglected due to time constraints and the absence of a house supervisor responsible for trimming. The facility lacked a specific nail care policy, leading to this deficiency.
The facility failed to maintain catheter drainage bags off the floor for three residents, compromising infection control. Observations revealed catheter bags touching the floor, and staff acknowledged the issue. The facility's policy did not address this concern.
A resident with severely impaired cognition and bowel incontinence was administered both a laxative and stool softener despite experiencing loose stools and diarrhea. The facility continued the medication regimen without consulting the physician, leading to unnecessary medication administration. The DON later acknowledged the need to hold medications and contact the doctor, but the facility's policy did not address this action.
Failure to Provide Clear, Resident-Specific Assistance Levels for Bed Mobility and Bedpan Use Resulting in Fall with Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide clear, resident-specific directions to staff regarding the level of assistance required for bed mobility and use of a bedpan for a dependent resident, which resulted in a fall with fracture. The resident had intact cognition with a BIMS score of 15, and diagnoses including hereditary motor and sensory neuropathy, COPD, and chronic respiratory failure with hypoxia. The MDS identified the resident as non-ambulatory, using a wheelchair for mobility, and dependent for rolling and bed-to-chair transfers. ADL documentation around the time of the incident was inconsistent: one entry described the resident as an extensive two-person assist with bed mobility, another documented assist of 1–2 staff for toileting, and another documented assist of 2 for bed mobility but also stated the resident was independent with repositioning. Prior to the fall, the care plan addressed fall risk and limited physical mobility but did not clearly specify the number of staff required for repositioning and toileting. On the day of the fall, a CNA assisted the resident with use of a bedpan. The CNA reported asking the resident to roll to his side and observed him attempting to grab the assistance rail; during this process, his legs slid off the bed, causing the rest of his body to follow and he slid to the floor. The nurse responding to the call found the resident on his back on the floor beside the bed with external rotation and visible deformity of the left leg and inability to move it. Hospital records later confirmed a left femur fracture resulting from a fall out of bed. The facility’s self-report stated that at the time of the event, only one staff was required for assisting the resident with repositioning in bed, and that the CNA was following those expectations. Multiple staff interviews revealed inconsistent understanding and communication regarding the required level of assistance for this resident’s ADLs, particularly bed mobility and bedpan use. Several CNAs and nurses reported that, in practice, two staff were needed to safely reposition the resident and to place him on or off a bedpan, especially after he had gained weight, become more short of breath, and was no longer able to assist effectively. Some staff relied on word of mouth or personal judgment rather than written guidance, and contract staff reported there was no clear place to look up whether one or two staff were needed for ADLs. The Kardex posted in the resident’s room at the time did not specify the number of staff required for assistance with ADLs, and the Restorative Therapy to Nursing Communication form in effect at the time of the fall contained no instructions about staffing levels for ADL assistance. The facility’s Safe Resident Handling and care planning policies required that resident handling tasks be carried out in accordance with care plans and that care plans reflect MDS assessment results and current clinical functioning, but the resident’s care plan and supporting tools did not provide clear, consistent direction on the number of staff needed for repositioning and bedpan use prior to the fall. The deficiency is further supported by staff statements that they interpreted or applied assistance levels differently. Some CNAs stated the resident had always been a two-assist for everything including repositioning and bedpan use, while others stated they sometimes used one staff depending on the day or the resident’s performance. Nursing staff who completed ADL assessments indicated the resident required two staff for bed mobility on night shift due to his size and limited grip, and that two staff were needed for placing him on a bedpan, but this was not clearly translated into the care plan or bedside communication tools. The DON acknowledged that the Kardex in the room at the time of the fall indicated a one-staff assist for bed mobility and toileting and that CNAs were expected to follow the Kardex, while also stating she was unsure of the precise meaning of MDS dependency levels. Overall, the lack of clear, consistent, resident-specific written directions regarding the number of staff required for repositioning and bedpan use, combined with reliance on variable staff judgment and verbal communication, led to the resident being assisted by a single CNA during bedpan use when multiple staff and nurses believed two staff were needed, culminating in the fall and fracture.
Failure to Ensure Seizure Pad and Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a seizure pad was present on both sides of a resident's bed and did not provide adequate supervision, leading to an accident. The resident, who was rarely to never understood and had a history of frequent seizure activity, was left unattended in bed without the required seizure pads on both sides. This lapse in safety measures resulted in the resident falling from the bed, sustaining a laceration and hematoma to the back of the head, and requiring hospitalization. The incident occurred when a CNA was preparing the resident for transfer to a wheelchair. The CNA removed one of the seizure pads to facilitate the transfer and left the resident unattended while seeking assistance from another staff member. During this brief period, the resident, who was capable of moving around in bed, fell through a gap between the split rails and onto the floor. The CNA returned to find the resident on the ground with a head injury. Interviews with staff and observations revealed that the seizure pad was not replaced before the CNA left the room, and the resident was left unsupervised. The Director of Nursing acknowledged that the seizure pad should have been put back in place, especially given the resident's seizure risk. The facility's policy on resident supervision emphasizes the need for reasonable observation to ensure safety, which was not adhered to in this case.
Care Plan Inaccuracy for Liquid Consistency
Penalty
Summary
The facility failed to ensure that the Care Plan for a resident accurately reflected the current liquid consistency order. The resident, who had severely impaired cognition as indicated by a score of 6 out of 15 on the Brief Interview for Mental Status (BIMS) exam, was at risk for choking and swallowing difficulty. The Care Plan, dated March 23, 2021, included an intervention for a diet with thicken liquids to nectar consistency. However, the Diet Order and Communication Form dated February 27, 2024, and subsequent Physician Orders indicated a diet of mechanical soft texture with thin liquids. An observation on June 5, 2024, showed the resident drinking from a cup with a lid and straw, which was inconsistent with the Care Plan. The MDS Coordinator acknowledged the oversight in the Care Plan, and the Director of Nursing confirmed the absence of a facility policy on care plans.
Deficiency in Resident Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for a resident, identified as Resident #62, who was dependent on staff for personal hygiene and activities of daily living. The resident, who had intact cognition and was diagnosed with acute and chronic respiratory failure with hypoxia, reported receiving bed baths once a week and expressed a desire for his nails to be trimmed. Observations over several days revealed that the resident's fingernails were long and dirty, indicating a lack of proper nail care. Interviews with staff, including CNAs and RNs, revealed that nail trimming was typically performed by nurses or the house supervisor, but due to time constraints and the supervisor's absence, the resident's nails were neglected. The Director of Nursing acknowledged the expectation for staff to maintain the resident's nail hygiene, especially since the resident primarily received bed baths. However, there was no specific policy for nail care, and the facility followed standard practices. The resident's nails were reportedly trimmed only twice since admission, and monthly audits for nail care were not conducted in May. This oversight resulted in the resident's nails remaining untrimmed and uncleaned, highlighting a deficiency in the facility's care practices.
Improper Maintenance of Catheter Drainage Bags
Penalty
Summary
The facility failed to ensure proper maintenance of catheter drainage bags for three residents, leading to a deficiency in infection control practices. Resident #17, who had severely impaired cognition and required a suprapubic urinary catheter, was observed with their catheter drainage bag touching the floor. Similarly, Resident #30, who was rarely understood and had an indwelling catheter, was found with their catheter bag on the floor. Resident #41, also rarely understood and with an indwelling catheter, had their catheter drainage bag and call light on the floor. Staff interviews confirmed the deficiency, with a Certified Nursing Assistant acknowledging that catheter bags should be positioned on the bed railing and not touch the floor. The Director of Nursing also recognized the issue as an infection control concern. The facility's policy on catheters, dated November 2019, did not address the specific issue of catheter bags being on the floor, indicating a gap in the facility's infection control protocols.
Failure to Prevent Unnecessary Medication Administration
Penalty
Summary
The facility failed to ensure a resident remained free from unnecessary medication, as evidenced by the administration of both a laxative and stool softener to a resident experiencing loose stools. The resident, who had severely impaired cognition, was given Docusate Sodium and Gavilax daily, despite having a history of diarrhea and several documented instances of loose stools. The resident's care plan indicated bowel incontinence, and progress notes detailed ongoing issues with diarrhea, including projectile vomiting and increased heart rate, which led to further medical interventions. Despite the resident's condition, the facility continued administering the medications without holding them or consulting the physician for alternative instructions. The Director of Nursing later acknowledged that she would have held the medications and contacted the doctor, but the facility's medication administration policy did not address holding medications. This oversight contributed to the resident receiving unnecessary medications, exacerbating their condition.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 54 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Keokuk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Southeast Iowa Healthcare Center | 0.6 mi | ★★★★★ | 6 | 0 |
| River Hills Village In Keokuk | 1.2 mi | ★★★★★ | 6 | 0 |
| Montrose Health Center | 7.3 mi | ★★★★★ | 4 | 0 |
| Birkwood Village Of Fort Madison | 14.1 mi | ★★★★★ | 6 | 0 |
| Clark County Nursing Home | 17.1 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mississippi Valley.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.