Inspection Reports for Mississippi Valley Healthcare and Rehabilitation Center
500 Messenger Road, Keokuk, IA, 526322911
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 3, 2025 found the facility to be in substantial compliance with no deficiencies noted. Earlier inspections showed a mixed record with several deficiencies related to resident care plans, supervision, medication management, staffing levels, and infection control. Prior complaint investigations included a substantiated case involving second degree burns from elevated shower water temperatures and issues with insufficient nursing staff for resident bathing needs. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed previous deficiencies effectively, with multiple follow-up inspections confirming corrections and substantial compliance.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
63 residents
Based on a June 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 3, 2025
Visit Reason
An annual recertification survey and investigation of complaints #125817-C and #126147-C were conducted from March 31, 2025 to April 3, 2025.
Complaint Details
Investigation of complaints #125817-C and #126147-C was conducted; the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 9, 2024
Visit Reason
A complaint investigation for complaints #123401-C and #123888-C was conducted on October 8, 2024 to October 9, 2024.
Complaint Details
Complaint investigation for complaints #123401-C and #123888-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 26, 2024
Visit Reason
A revisit of the survey ending June 19, 2024 was conducted to verify correction of previous deficiencies.
Findings
All deficiencies identified in the prior survey were corrected and the facility is in substantial compliance effective June 20, 2024.
Inspection Report
Annual Inspection
Census: 63
Deficiencies: 5
Date: Jun 19, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #121390-C from June 3, 2024 to June 19, 2024.
Complaint Details
The inspection included investigation of complaints #121390-C.
Findings
The facility was found deficient in multiple areas including failure to ensure care plans reflected current resident needs, inadequate nail care, failure to maintain seizure pads and provide adequate supervision, improper catheter drainage bag placement, and administration of unnecessary medications. Corrective actions and re-education were initiated by the Director of Nursing and staff.
Deficiencies (5)
Failure to ensure the Care Plan reflected a resident’s current liquid consistency order for one of twenty-one residents reviewed (Resident #17).
Failure to trim and clean fingernails for 1 of 3 residents reviewed (Resident #62).
Failure to ensure a seizure pad remained present to both sides of the resident’s bed and failure to ensure adequate supervision for one of four residents reviewed for accidents (Resident #1).
Failure to ensure catheter drainage bags were maintained off the floor for three of three residents reviewed for catheters (Residents #17, #30, #41).
Failure to ensure a resident remained free from unnecessary medication when a resident who experienced loose stools was administered a laxative and stool medication for one of six residents reviewed (Resident #17).
Report Facts
Census: 63
Residents reviewed for care plan revision: 21
Residents reviewed for nail care: 3
Residents reviewed for accidents: 4
Residents reviewed for catheter care: 3
Residents reviewed for unnecessary medications: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Initiated corrective actions, conducted re-education meetings, and provided oversight for multiple deficiencies. | |
| DON’s designee (RN House Supervisor) | Conducted re-education meetings and audits related to nail care and catheter care. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 29, 2024
Visit Reason
A revisit of the survey ending January 24, 2024 and investigation of Complaint #119125-C was conducted on February 28, 2023 to February 29, 2023.
Complaint Details
Investigation of Complaint #119125-C was conducted during the visit.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective February 16, 2024.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 22, 2024
Visit Reason
An investigation for Complaints #118699-C and #118894-C was conducted from February 15, 2024 to February 22, 2024.
Complaint Details
Investigation was complaint-related for Complaints #118699-C and #118894-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with this investigation.
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Date: Jan 24, 2024
Visit Reason
The inspection was conducted as a complaint investigation (#118208-C) regarding an incident where a resident suffered second degree burns due to increased water temperatures during a shower.
Complaint Details
Complaint #118208-C was substantiated. The facility failed to identify increased water temperatures during a shower that caused second degree burns to Resident #1.
Findings
The facility failed to identify increased water temperatures during a shower that resulted in second degree burns to one resident. The investigation confirmed the complaint was substantiated, and corrective actions were initiated including staff discipline, re-education, adjustment of water heater settings, and installation of temperature gauges on shower heads.
Deficiencies (1)
Failure to identify increased water temperatures during a shower that resulted in second degree burns to a resident.
Report Facts
Census: 60
Dates of complaint investigation: Investigation conducted from January 18, 2024 to January 24, 2024
Water heater temperature adjustment: 115
Water heater previous setting: 120
Shower water temperature audits frequency: 5
Audit duration: 60
Date specialized shower heads installed: Installed on January 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurses Aid (CNA) | Involved in showering Resident #1 and failed to notice increased water temperature |
| Staff B | Registered Nurse (RN) | Alerted about the burn injury to Resident #1 |
| Staff C | Nurse Practitioner (NP) Chronic Wound Care Nurse (CWCN) | Documented wound care and treatment for Resident #1 |
| Staff D | Registered Nurse (RN) | Treated Resident #1's wounds per Physician's order |
| Staff E | Maintenance Supervisor | Reported water heater temperature settings and adjustments |
| Staff A | Certified Nurses Aid (CNA) | Explained and demonstrated shower process for Resident #1 |
| Director of Nursing (DON) | Director of Nursing | Reported Physician's orders, identified burns, issued disciplinary action, and provided re-education to staff |
| Facility Administrator | Administrator | Instructed Maintenance Director to adjust water temperature settings |
| Maintenance Director | Maintenance Director | Adjusted boiler water temperature, issued thermometer probes, ordered and installed specialized shower heads |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 29, 2023
Visit Reason
The document reflects acceptance of the facility's credible allegation of substantial compliance and Plan of Correction, resulting in certification of compliance effective December 29, 2023.
Findings
The facility was found to be in substantial compliance based on the Plan of Correction submitted and accepted by the surveyors.
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 1
Date: Dec 6, 2023
Visit Reason
The inspection was conducted as a complaint investigation (#115576-C) from December 4, 2023 to December 6, 2023, to determine if the facility provided sufficient nursing staff to meet resident bathing needs.
Complaint Details
Complaint #115576-C was substantiated based on findings that the facility did not meet staffing requirements to provide adequate bathing care to residents.
Findings
The facility failed to provide sufficient nursing staff to meet the bathing needs of 4 of 4 residents reviewed, as evidenced by staff interviews, clinical record review, and daily assignment sheets showing inadequate staffing levels on multiple days.
Deficiencies (1)
Facility failed to provide sufficient nursing staff to meet bathing needs for 4 of 4 residents reviewed.
Report Facts
Facility census: 58
Residents reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide | Interviewed regarding adequacy of staffing and bathing care |
| Staff B | Certified Nurse Aide | Interviewed regarding staffing sufficiency and aide education |
| Staff C | Certified Nurse Aide | Interviewed about staffing and shower aide duties |
| Staff D | Certified Nurse Aide | Interviewed about shower aide staffing and challenges |
| Staff F | Certified Nurse Aide | Interviewed about shower aide staffing and ideal staffing levels |
| Director of Nursing | Director of Nursing (DON) | Interviewed about staff scheduling and staffing ratios |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 28, 2023
Visit Reason
A complaint investigation was conducted for complaints #113794-C, #114061-C, and #114960-C from August 23, 2023 to August 28, 2023.
Complaint Details
Complaint investigation for complaints #113794-C, #114061-C, and #114960-C; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 7, 2023
Visit Reason
A revisit of the survey ending February 23, 2023 and investigation of Complaint #111793-C was conducted on June 5, 2023 to June 7, 2023.
Complaint Details
Complaint #111793-C was investigated during this visit.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective March 24, 2023.
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: Feb 20, 2023
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of Complaints #107832-C and #107930-C from February 20, 2023 to February 23, 2023.
Complaint Details
Complaint #10/930-C was substantiated.
Findings
The facility was found to have deficiencies related to resident rights, self-administration of medications, self-determination, reporting of alleged violations, care planning, behavioral health services, medication review, food safety, infection control, and hospice services. Several residents were found to have issues with dignity, medication administration, weight loss, behavioral health care, and care coordination. The facility failed to meet multiple federal requirements and was required to implement corrective actions.
Deficiencies (13)
Facility failed to ensure residents were treated with respect and dignity, including incidents of residents' incontinence briefs falling down causing psychosocial harm.
Facility failed to determine if self-administration of medication was safe and clinically appropriate for sampled residents.
Facility failed to promote self-determination and support resident choices related to nutrition and other aspects of life.
Facility failed to report allegations of abuse within required timeframes and failed to investigate allegations thoroughly.
Facility failed to provide timely and complete transfer/discharge notices to residents and representatives.
Facility failed to complete significant change assessments and accurate Minimum Data Set (MDS) assessments for residents.
Facility failed to ensure accuracy of assessments and cognitive status determinations for residents.
Facility failed to develop and implement comprehensive care plans addressing residents' needs including behavioral health and mobility.
Facility failed to provide appropriate behavioral health services and crisis intervention plans for residents.
Facility failed to conduct proper drug regimen reviews and failed to monitor psychotropic medication use appropriately.
Facility failed to maintain food safety including proper storage, labeling, and disposal of expired or unsafe food items.
Facility failed to maintain infection prevention and control program including hand hygiene and environmental cleaning.
Facility failed to provide hospice care coordination and maintain hospice documentation and agreements.
Report Facts
Residents sampled: 27
Residents reviewed for nutrition: 5
Residents reviewed for behavioral health: 1
Residents reviewed for medication self-administration: 2
Residents reviewed for abuse allegations: 1
Residents reviewed for transfer notices: 4
Residents reviewed for significant change assessment: 1
Residents reviewed for MDS accuracy: 31
Residents reviewed for care planning: 27
Residents reviewed for behavioral health care planning: 1
Residents reviewed for medication regimen: 5
Residents affected by food storage issues: 45
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gina Anderson | Infection Preventionist | Contacted for assistance in training and conducting Root Cause Analysis. |
| Director of Nursing | Named in multiple findings including medication review, abuse reporting, care planning, and hospice coordination. | |
| Social Services Director | Responsible for behavioral health care planning and monitoring. | |
| Certified Medication Aide (CMA) 1 | Observed administering medication and nebulizer treatments. | |
| Certified Medication Aide (CMA) 2 | Interviewed regarding resident incontinence briefs. | |
| Administrator | Provided multiple interviews and statements regarding facility policies and investigations. | |
| Dietary Manager | Responsible for food safety and temperature monitoring. | |
| Restorative Licensed Practical Nurse (LPN) 3 | Observed assisting residents with splint placement. | |
| Consultant Pharmacist | Conducted medication regimen reviews and education. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 17, 2022
Visit Reason
The document is a plan of correction submitted following a deficiency statement, indicating the facility's acceptance of compliance and corrective actions.
Findings
The facility was certified in compliance based on acceptance of a credible allegation of compliance and plan of correction effective May 17, 2022.
Inspection Report
Complaint Investigation
Census: 62
Deficiencies: 1
Date: Apr 26, 2022
Visit Reason
A focused infection control survey and investigation of Complaint #103172 were conducted from March 31, 2022 to April 26, 2022 due to concerns about infection control and presence of multidrug-resistant organisms (MDRO).
Complaint Details
Complaint #103172-C was substantiated.
Findings
The facility failed to follow recommendations from the Iowa Department of Public Health regarding surveillance and containment of MDRO outbreaks, resulting in multiple residents testing positive for various MDRO infections. Observations and interviews revealed lapses in infection control practices, including improper use of gowns and isolation procedures.
Deficiencies (1)
Failure to establish and maintain an infection prevention and control program as required by federal regulations, including failure to follow public health guidance for MDRO surveillance and containment.
Report Facts
Resident census: 62
Residents testing positive for MDRO: 18
Residents tested positive for CRAB 406 infection: 11
Residents tested positive for KPC 258 infection: 2
Residents tested positive for CRAB 499 infection: 2
Ventilator residents reported: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed and provided information about infection control practices and surveillance testing. | |
| Director of Nursing | DON | Interviewed and provided information about infection control practices, surveillance testing, and facility response to outbreak. |
| Staff A | Domestic Aide | Observed not wearing gown while handling linens and resident care in isolation room. |
Inspection Report
Renewal
Census: 63
Deficiencies: 6
Date: Oct 14, 2021
Visit Reason
The inspection was conducted as a Recertification Survey including complaints and facility reported incidents from 10/4/2021 to 10/14/2021.
Complaint Details
Complaint #99173-C was substantiated.
Findings
The facility was found to have multiple deficiencies related to coordination of PASARR assessments, comprehensive care plans, restorative nursing services, respiratory care, bedrails, and food safety. Several residents' care plans and assessments were incomplete or not updated, and the facility failed to maintain proper documentation and follow protocols in various areas.
Deficiencies (6)
Failed to coordinate PASARR assessments and resubmit after changes in diagnosis and medication for Resident #15.
Failed to develop and implement comprehensive care plans for residents, including measurable objectives and discharge plans.
Failed to provide restorative nursing services and documentation for residents with limited range of motion.
Failed to provide respiratory care, including tracheostomy care and oxygen tubing changes, consistent with professional standards.
Failed to assess, install, and maintain bedrails properly, including incomplete side rail assessments.
Failed to maintain proper food procurement, storage, preparation, and labeling, including moldy and improperly dated food items.
Report Facts
Census: 63
Deficiencies cited: 6
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 29, 2020
Visit Reason
A Focused Infection Control Survey was conducted by the Department of Inspection and Appeals from October 27 to 29, 2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices for COVID-19.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 13, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigations #92667 and #92673 were conducted from August 11 to 13, 2020.
Complaint Details
Complaint #92667-C was not substantiated. Complaint #92673-C was not substantiated.
Findings
Both complaints #92667-C and #92673-C were investigated and found to be not substantiated. The survey was conducted under 45 CFR Part 483, Subpart B-C.
Inspection Report
Complaint Investigation
Census: 81
Deficiencies: 1
Date: Jul 8, 2020
Visit Reason
The inspection was conducted as a COVID-19 Infection Control survey and investigation of complaints #00834, #91427, #91455, #91719, and facility reported incident #91768.
Complaint Details
Complaints #00834-C, #91427-C, and #91455-C were substantiated. Complaint #91719-C and facility reported incident #91768-I were not substantiated.
Findings
The facility failed to follow infection prevention and control policies, including staff not wearing masks properly in resident areas. Complaints #00834-C, #91427-C, and #91455-C were substantiated, while complaint #91719-C and incident #91768-I were not substantiated. Residents 2-6 remained COVID-19 free, with resident #1 passing away from other causes.
Deficiencies (1)
Failure to follow infection prevention and control program requirements, including staff not wearing masks properly within 6 feet of residents.
Report Facts
Census: 81
Complaints substantiated: 3
Complaints not substantiated: 2
Weekly audits: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Reported expectation of staff to wear masks and goggles within six feet of residents |
| Staff A | Activity Assistant | Observed providing manicures to residents without proper mask use |
| Staff B | Registered Nurse | Observed with mask below nose and mouth and chewing food |
| Staff C | Nurse Aide | Observed walking without mask and passing within one foot of residents |
| Staff D | Licensed Practical Nurse | Observed walking with mask below nose and mouth |
| Staff E | Nurse Aide | Exited spa room with mask below nose and mouth |
| Staff F | Nurse Aide | Pushed resident in wheelchair without mask in place |
Inspection Report
Abbreviated Survey
Census: 69
Deficiencies: 1
Date: Jun 9, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigations (#90559, #91281, and #91309) were conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
Complaints #90559, #91281, and #91309 were investigated and substantiated.
Findings
The facility was found not in compliance with infection prevention and control requirements, specifically failing to ensure staff followed hand hygiene procedures and used personal protective equipment properly. Complaints #90559-C, #91281-C, and #91309-C were substantiated.
Deficiencies (1)
Failure to ensure staff followed hand hygiene procedures and utilized personal protective equipment according to facility policy for 2 of 10 sampled residents.
Report Facts
Resident census: 69
Complaints investigated: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| H. Hanson | Administrator | Signed the plan of correction and was involved in the administration during the survey |
| Staff A | Licensed Practical Nurse | Reported facility mask and protective eye wear requirements |
| Staff B | Registered Nurse | Observed entering resident room with PPE and reported need to enter due to call light |
| Staff C | Respiratory Therapist | Observed not wearing proper PPE and involved in multiple observations related to infection control |
| Director of Nursing | Director of Nursing | Reported staff PPE requirements and confirmed isolation precautions |
| Administrator | Administrator | Confirmed isolation precautions and re-education of staff |
Inspection Report
Annual Inspection
Census: 76
Deficiencies: 9
Date: Feb 10, 2020
Visit Reason
The inspection was conducted as an annual health survey including review of complaints #87933, #88313, #88746, #88811, and #88831. Complaint #86564 was investigated and found not substantiated.
Complaint Details
Complaint #86564 was investigated and found not substantiated.
Findings
The facility was found deficient in multiple areas including residents' rights to communication and privacy, comprehensive care planning, prevention and treatment of pressure ulcers, sufficient nursing staff, and infection control. Several residents were observed to have unmet care needs and privacy violations during personal care. The facility failed to deliver mail on Saturdays and did not maintain proper documentation or timely response to resident needs.
Deficiencies (9)
Failure to deliver mail on Saturdays affecting residents' right to send and receive mail.
Failure to maintain personal privacy and confidentiality during resident care.
Failure to develop and implement comprehensive, person-centered care plans for residents.
Failure to prevent and treat pressure ulcers, including inadequate assessment, documentation, and care.
Failure to provide restorative services to maintain or improve residents' range of motion and mobility.
Insufficient nursing staff to meet residents' needs in a timely manner.
Failure to respond promptly to resident call lights and needs.
Failure to properly prepare and serve food in accordance with food safety standards.
Failure to maintain effective infection prevention and control program, including hand hygiene and linen handling.
Report Facts
Resident census: 76
Residents sampled for care plan deficiencies: 24
Residents sampled for pressure ulcer prevention: 5
Residents sampled for restorative services: 4
Residents sampled for nursing staff response: 16
Residents sampled for call light response: 6
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