Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 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.
Missing informed consent for psychotropic medications: The facility did not document informed consent before giving psychotropic meds to 5 reviewed residents. Records showed residents receiving antipsychotic, antianxiety, and antidepressant medications, including residents with intact cognition and one resident with severe cognitive impairment. The DON could not find consent documentation in the EHR, staff described education as being documented in progress notes, and the facility policies did not direct nursing staff to provide education on treatment options, benefits, and risks.
The facility failed to accurately code MDS assessments for psychotropic medication-related diagnoses and restraint use. Four residents had prescribed antianxiety and/or antidepressant medications tied to diagnoses that were not entered on the MDS, despite physician orders and charted conditions. Two residents had daily use of restraints documented in the care plan, MAR/TAR, and staff interviews, but the MDS showed no restraints or alarms. The DON stated the devices were physical restraints and should have been reflected on the assessments.
A resident was discharged to another facility, and staff documented the transfer, report to the receiving facility, and paperwork being faxed. However, the EHR lacked the required discharge summary/recapitulation of stay, and staff interviews confirmed the summary was not completed even though the discharge checklist called for it.
Medication administration errors exceeded the allowed rate when an LPN gave insulin without priming the pen and without following the manufacturer’s injection instructions, and a CMA failed to give a resident’s scheduled inhaler and nebulizer treatments at the ordered times because the medications were not dated when opened. The resident receiving insulin had DM, and the resident missing respiratory meds had respiratory diagnoses and continuous O2. The MAR documented missed doses, and the facility’s policy required meds to be given within one hour of the ordered time.
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.
Missing informed consent for psychotropic medications
Penalty
Summary
The facility failed to complete informed consent before administering psychotropic medications for 5 of 5 residents reviewed for unnecessary medications. The residents reviewed were receiving combinations of antipsychotic, antianxiety, and antidepressant medications, and the record review found no consent forms in the EHR progress notes or resident document sections for any of the five residents. The facility census was 54 residents. Resident #1 had diagnoses including anxiety, depression, PTSD, tracheostomy status, and dependence on a respirator status. The EHR showed orders for Seroquel for PTSD, Buspirone for generalized anxiety disorder, Citalopram for depression, and Lorazepam as needed for anxiety. During observation, the resident was resting in bed. The DON stated consent forms would be located in the resident document section or could be on a written form, but none were found for psychotropic medication education. Staff interviews indicated nurses typically provided education on risks and benefits and documented it in progress notes, while the IP stated she had done education only not that often and the Social Services Coordinator stated she was not involved in that education. Resident #2 had a BIMS score of 15 out of 15 and diagnoses including adjustment disorder with mixed disturbance of emotions. The resident was prescribed Clonazepam, Escitalopram oxalate, and Mirtazapine. Resident #3 also had a BIMS score of 15 out of 15 and diagnoses including anxiety and PTSD, with orders for Diazepam and Paroxetine Hydrochloride. Resident #4 had a BIMS score of 15 out of 15 and diagnoses including respiratory failure, tracheostomy status, dependence on a ventilator, and dependence on supplemental oxygen, with orders for Buspirone, Citalopram, Diphenhydramine Hydrochloride as needed for anxiety, and Trazodone. Resident #4 stated she did not recall anyone talking to her about the risks or side effects of her antianxiety or antidepressant medications and said she had taken the medications for a while. Resident #7 had a BIMS score of 3 out of 15 indicating severe cognitive impairment and diagnoses including acute and chronic respiratory failure, COPD, tracheostomy status, dependence on a ventilator, and dependence on supplemental oxygen. The resident was prescribed Venlafaxine and multiple short-term Ativan orders for generalized anxiety disorder. No consent forms related to psychotropic medication education were found for this resident either. The DON stated she reviewed the progress notes for each of the five residents and did not find documentation that psychotropic medication education for informed consent had been completed, and she also reported she had checked with the prior DON without finding consent information. The facility policies reviewed, including the Antipsychotic Medical Renewal Policy and the Psychotropic Drug Use Policy, did not direct nursing staff to provide education to the resident or legal representative regarding treatment, treatment options, benefits, and risk factors of psychotropic medication treatment.
MDS assessments failed to capture diagnoses and restraint use
Penalty
Summary
The facility failed to accurately assess and code resident diagnoses related to psychotropic medication use for four residents reviewed for unnecessary medications. Resident #2’s MDS listed adjustment disorder with mixed disturbance of emotions and showed prescribed antianxiety and antidepressant medications, but the MDS did not include the diagnoses of circadian rhythm sleep disorder or major depressive disorder that were documented in the physician order report. Resident #3’s MDS listed anxiety and PTSD and showed prescribed diazepam and paroxetine for obsessive compulsive disorder, but the MDS did not include obsessive compulsive disorder. Resident #4’s MDS listed respiratory failure, tracheostomy status, ventilator dependence, and supplemental oxygen dependence, while the physician orders showed buspirone for anxiety disorder, citalopram and trazodone for depression, and diphenhydramine as needed for anxiety; the MDS did not include anxiety or depression diagnoses. Resident #7’s MDS listed acute and chronic respiratory failure, COPD, tracheostomy status, ventilator dependence, and supplemental oxygen dependence, and indicated prescribed antianxiety and antidepressant medications. The physician order report showed venlafaxine for generalized anxiety disorder and Ativan for generalized anxiety disorder, but the MDS did not include an anxiety diagnosis. During interview, the MDS Coordinator stated she coded diagnoses from the most recent physician visit progress note and verified that the diagnoses were not on Resident #2’s MDS. She also stated she coded based on prior preceptor training and had a copy of the CMS RAI Manual in her office. The DON stated the facility did not think it had an MDS RAI policy and used the CMS RAI Manual to code the MDS. The facility also failed to accurately code restraint use for two residents. Resident #51’s MDS indicated no restraints or alarms were used, but the care plan and MAR/TAR documented daily use of an abdominal binder ordered to obscure the PEG tube and prevent the resident from pulling on it. Staff interviews confirmed the binder was used throughout day and overnight shifts, and the DON stated the resident had used the abdominal binder for months, could not remove it independently, and that it was a physical restraint that should be reflected on assessments. Resident #19’s MDS also indicated no restraints or alarms were used, but the care plan and MAR/TAR documented daily use of bilateral arm immobilizers ordered to prevent the resident from pulling at tubes and injuring self. Staff interviews confirmed the immobilizers were used every day and removed every 2 hours for skin checks and ROM, and the DON stated the immobilizers were physical restraints that should be reflected on assessments.
Missing Discharge Summary for Resident Transfer
Penalty
Summary
The facility failed to complete a recapitulation of stay discharge summary for Resident #63, who was discharged from the facility on 3/26/26. Record review showed a Social Services note documenting that another facility had accepted the resident and was working on transportation, and a nurse note documenting the resident’s departure at 12:25 PM with paperwork provided and faxed to the receiving facility. However, review of the electronic health record did not reveal a discharge summary for the resident. During interviews, staff described the discharge process and the use of a discharge-to-another-facility checklist that included completing a discharge summary in Matrix under observations. The RN stated she printed paperwork, completed vital signs, and gave report to the new facility, and believed the recapitulation was completed by management. The DON confirmed the discharge summary was not completed in the record and stated it had probably been missed. The DON also reported the facility did not have a policy at the time and had just developed one going forward.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to follow manufacturer instructions for insulin administration for Resident #26, who had diabetes mellitus and a care plan for insulin use. During observation, Staff C, LPN prepared and administered Lantus U-100 insulin without first priming the pen and kept the pen in place for only 2 seconds after injection. The resident’s physician order was for Lantus 35 units daily at 8:00 AM, and the manufacturer instructions required a safety check with a 2-unit test dose, checking for insulin flow, and counting to 10 before removing the pen. Staff C later stated she was not aware of special instructions for the pen, and the DON stated nurses needed to push the air out and hold it in place for 15 seconds after injecting and confirmed the pen should be primed before use. The facility also failed to administer respiratory medications at the prescribed time for Resident #22, who had a BIMS score of 11, diagnoses including respiratory failure and asthma/COPD/chronic lung disease, and continuous oxygen therapy. Physician orders included Arnuity Ellipta once daily between 7:00 AM and 10:00 AM and ipratropium-albuterol nebulizer treatments four times daily at 8:00 AM, 12:00 PM, 4:00 PM, and 8:00 PM. During observation, Staff H, CMA did not administer the inhaler or nebulizer medication because the inhaler and nebulizer vial were not dated when opened, and she stated she did not know how long they had been used. The May 2026 MAR showed Arnuity Ellipta was not administered because the drug/item was unavailable, and ipratropium-albuterol was not administered at 8:00 AM and 12:00 PM for the same reason. Staff H stated she reordered the medications and expected them later that day, and also noted the resident had a PRN albuterol nebulizer available. The facility policy stated medications are to be administered within one hour of the prescribed time unless otherwise specified, and the observed failures resulted in a 10% medication error rate for the two residents observed for medication administration.
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.
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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.
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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 | ★★★★★ | 7 | 1 |
| River Hills Village In Keokuk | 1.2 mi | ★★★★★ | 0 | 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 |
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