Birkwood Village of Fort Madison

In the surveyor’s words

From the most serious findings on record at Birkwood Village of Fort Madison, in the surveyor’s own words.

• Actual harm, isolatedF690Oct 30, 2024

  Based on record review and staff interviews, the facility failed to evaluate the placement of the urinary catheter after a routine catheter change with little to no urine output along with bloody urine for 2 days and then continued to have bloody urine for an additional 2 days before sending the resident to the hospital 4 days where it was found the balloon inserted in the urethra causing trauma and the resident diagnosed with a UTI (Urinary Tract Infection) for 1 of 3 residents reviewed for urinary catheters (Resident #1). The facility reported a census of 59 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. […]

• Actual harm, isolatedF684Mar 14, 2023

  Based on observation, interview, and record review, the facility failed to thoroughly assess and implement interventions for a worsening non-pressure wound and failed to promptly treat two non-pressure wounds for three of three residents reviewed for non-pressure wounds (Resident #14, Resident #38, Resident #165). The facility reported a census of 64 residents. Findings include: 1. The Minimum Data Set (MDS) assessment for Resident #14 dated 2/14/23 revealed the resident scored 12 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated moderately impaired cognition. […]

• Actual harm, isolatedF689Nov 17, 2022

  Based on observations, interviews and record reviews, the facility failed to ensure fall prevention interventions were being followed for 1 of 3 residents reviewed (Resident #1). Resident #1 fell in her room which resulted in a fractured arm. Staff were unable to verify that the care planned alarm sounded. This resident later passed away.The facility reported a census of 62. Findings include: 1. A Minimum Data Set (MDS) dated [DATE], documented diagnoses for Resident #1 included generalized muscle weakness and [CONDITION(S)]. This resident's Brief Interview for Mental Status score was 14 out of 15, which indicated intact cognition. This resident required limited assist of 1 for transfers and bed mobility. […]

• No harm, potential for more than minimal, patternF812Apr 16, 2026

  Based on observations, facility policy review and staff interviews, the facility failed to ensure kitchen staff followed safe food handling practices during the preparation and serving for the noon meal. The facility reported a census of 64 residents.Findings included:On 4/14/26 at 10:11 AM, during an interview, Staff A, Cook, reported she planned to serve baked chicken, baked potatoes or roasted potatoes and mixed vegetables for the lunch meal. Staff A planned to prepare 5 pureed servings and 5 mechanical soft (ground) meat servings. Observation of the meal preparation, during the same interview, revealed Staff A was already wearing a pair of gloves. […]

• No harm, potential for more than minimal, patternF812Apr 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure proper labeling and dating of all food items, failed to discard food items in appropriate time frames, and failed to ensure proper use of beard restraints. The facility reported a census of 54 residents. Findings include: On 4/21/25 at approximately 10:40 AM during the initial tour of the kitchen, the following items observed in the walk in refrigerator: a. One 5 lb (pound) container of tuna salad dated 4/6 b. One 5 lb container of chicken salad dated 4/4 Observation of the ice machine present in the kitchen revealed dust present on the air filter. […]