Inspection Reports for
Birkwood Village of Fort Madison

The facility was found deficient in multiple areas including failure to issue proper Medicare Non-Coverage notices, failure to update care plans and initiate specialized services per PASRR Level II, inadequate care planning for PTSD triggers, failure to ensure timely follow-up for constipation, lack of competent wound care staff for wound VAC application, inadequate documentation and monitoring of psychotropic medication use, insulin administration errors, and food safety violations including improper labeling and use of beard restraints.

The complaint investigation found that the facility failed to assess a resident's urinary catheter placement after a routine change despite signs of trauma and bloody urine over several days. The resident was diagnosed with a urinary tract infection and required hospital transfer. The investigation included review of medical records, staff interviews, and hospital documentation confirming the catheter balloon was inflated in the urethra causing trauma.

The facility failed to evaluate the placement of a urinary catheter after a routine change despite the resident having little to no urine output and bloody urine for several days, leading to trauma from the catheter balloon being inflated in the urethra and a diagnosis of urinary tract infection. The resident was subsequently hospitalized with complications including emphysematous cystitis, acute kidney injury, and pneumonia.

The complaint was substantiated. Resident #50 reported verbal abuse by Staff H, including aggressive and accusatory communication, refusal to answer call lights, and inappropriate comments about the resident's relationship and deceased husband. Staff H was placed on administrative leave and terminated after investigation.

The facility substantiated that Staff H verbally abused Resident #50, including making inappropriate comments about the resident's deceased husband and refusing to provide care. Staff H was suspended and subsequently terminated. The facility failed to notify management promptly about potential abuse concerns. The investigation included multiple staff and resident interviews and review of facility policies.

The complaint investigation was triggered by allegations of abuse and mistreatment of Resident #50 by Staff H, including verbal abuse, refusal to provide care, and intimidation. The abuse was substantiated, resulting in Staff H's termination. Additional concerns included failure to follow abuse reporting policies and other care deficiencies.

The facility was found to have failed in ensuring residents were treated with dignity, failed to follow abuse policies, had medication administration errors, inadequate pain assessment, weight loss monitoring failures, insufficient staffing for dining assistance, improper use of psychotropic medications, inadequate dental care, food temperature issues, failure to provide assistive eating devices, and lapses in infection control during medication administration. Several staff members were involved in abuse allegations, resulting in termination of one CNA.

The program failed to administer prescribed treatments and medications to 4 of 6 tenants reviewed. Specific issues included missed medications for Tenant #5, lack of documented treatment for Tenant #3's skin tear, unclear treatment provision for Tenant #2's leg ulcerations, and failure to weigh Tenant #1 as ordered.

The complaint was substantiated. The resident's prescriptions were not electronically transferred to the pharmacy prior to discharge, causing a delay in medication availability and resulting in the resident's hospitalization within 24 hours of discharge due to high blood sugar. The facility was aware of the pending discharge at least two weeks prior.

The facility failed to ensure that the resident's prescriptions were transferred electronically to the pharmacy prior to discharge, resulting in the resident not having necessary medications at home and subsequent hospitalization due to uncontrolled blood sugar. Documentation and interviews confirmed the facility sent hard copy prescriptions that the pharmacy would not accept.

The facility was found deficient in multiple areas including failure to ensure dignified dining experiences, failure to notify physicians of elevated blood sugars, failure to provide showers twice weekly, inadequate wound care and assessment, lack of licensed behavioral health professional services, medication errors exceeding 5%, significant medication errors, and failure to enforce dietary staff hairnet and beard restraint policies.

The facility was found to have multiple deficiencies including failure to ensure dignified dining experience, failure to notify physician of elevated blood sugars, incomplete care plans for catheter use, wounds, and seizures, failure to provide showers twice weekly, inadequate wound care and treatment, lack of licensed behavioral health professional services, medication errors including insulin administration outside physician orders and incorrect dosing of anticonvulsant medication, and failure to enforce dietary hairnet and beard restraint policies.