Mississippi Valley

In the surveyor’s words

From the most serious findings on record at Mississippi Valley, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 12, 2026

  Based on observations, clinical record review, policy review, resident and staff interviews, the facility failed to provide staff with clear resident specific directions for the level of assistance a dependent resident required for repositioning and the use of a bed pan for 1 of 4 residents (Resident #1) who experienced a fall with fracture when assisted with the use of a bed pan. The facility reported a census of 56 residents.Findings include: Review of the Minimum Data Set (MDS) assessment, dated 12/18/25, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. […]

• Actual harm, isolatedF689Jun 19, 2024

  Based on observation, staff interview, and record review the facility failed to ensure a seizure pad remained present to both sides of the resident's bed while the resident was left unattended in bed and failed to ensure adequate supervision of the resident during this time by a staff member for one of four residents reviewed for accidents (Resident #1). Resident #1 fell from the bed, was found on the floor by staff member, sustained a laceration and hematoma to the back of the head, and was sent to the hospital. The facility reported a census of 63 residents. Findings include: The Minimum Data Set (MDS) assessment for Resident #1 revealed the resident was rarely to never understood. […]

• Actual harm, isolatedF689Jan 24, 2024

  Based on clinical record review, observation and staff interviews the facility failed to identify increased water temperatures during a shower that resulted in second degree burns to one of three residents reviewed (Resident #1). The facility reported a census of 60 residents. Findings include: The Quarterly Minimum Data Set (MDS) Assessment for Resident #1 dated 12/14/23, listed diagnoses including debilitating cardiorespiratory (relating to the action of both heart and lungs) condition, quadriplegia (paralysis of all four limbs) and respiratory failure. […]

• Actual harm, isolatedF550Feb 23, 2023

  Based on observation, interview, record review, and review of facility policy, the facility failed to ensure that two (Resident (R) 21 and R25) of 27 sampled residents were treated in a respectful and dignified manner. Specifically, the facility allowed R21's body to be repeatedly exposed to public view due to ill-fitting pants and/or incontinence briefs. Multiple incidents in which the resident's pants fell down resluted in psychosocial harm, with the resident expressing embarrassment, becoming tearful, and/or expressing fear that she would be sent from the facility in response to the incident. Additionally, staff stood over the R25 while assisting the resident with eating, rather than sitting at the resident's eye level, maintaining face-to-face contact. […]

• No harm, potential for more than minimal, patternF552May 21, 2026

  Based on observations, clinical record review, facility policy review, resident and staff interviews, the facility failed to complete an informed consent prior to the administration of psychotropic medications for 5 of 5 (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #7) residents reviewed for unnecessary medications. The facility reported a census of 54 residents. Findings include: 1. Review of Resident #1's Minimum Data Set (MDS) assessment dated [DATE], revealed a list of diagnoses which included anxiety, depression, post-traumatic stress disorder (PTSD), tracheostomy status and dependence on a respirator status. The Medication section of the MDS indicated Resident #1 prescribed high-risk drug antipsychotic, antianxiety, and antidepressant medications. […]