Birchwood Health Care Center: Elopement Risk Failures - MN
She had a Wander Guard on her right wrist. Her care plan flagged her as an elopement risk. She was on Seroquel, which her nurse later acknowledged could contribute to an altered mental state. Her husband had been worried. None of that stopped her from leaving, and almost none of it made it into the paperwork filed after she did.
The resident, identified in inspection records only as R1, had been assessed as an elopement risk before the incident, scoring a 6 on the facility's internal risk tool. That score reflected her ability to self-propel her wheelchair, her history of wandering, her pacing and agitated behavior, her repeated requests to go home, her dementia diagnosis, and the sedating medication she was taking. The Wander Guard order on her chart dated to October 29th, two weeks before she left through the chapel doors.
After the elopement, the facility's policy required a new assessment. Registered Nurse A completed one. R1 scored a 5.
The number went down.
The updated assessment did not include the elopement that had just occurred. It did not include the concern R1's husband expressed when the nurse called to tell him his wife had left the building. It did not include the Seroquel. RN-A acknowledged all of this during an interview with inspectors on November 12th, saying she should have assigned a point for the elopement, a point for the family concern, and should have noted the sedating medication. She said she had not reviewed the previous assessment before completing the new one. She said the assessment was not accurate and that she would update it.
By the following morning, when the director of nursing spoke with inspectors, it still had not been updated.
The director of nursing said the elopement itself should have been enough to remind RN-A to assign that point, since the whole reason a new assessment was required was the elopement. The director also said RN-A should have reviewed R1's medication list for accuracy. The director acknowledged the assessment was wrong.
What the record shows is a woman whose risk level, by any reasonable accounting, went up the night she rolled out of the chapel, and whose paperwork said it went down. The three factors RN-A missed were not obscure. The elopement was the event that triggered the form. The husband's concern came up in the same phone call where RN-A learned she needed to complete it. The Seroquel was already flagged in the earlier assessment that RN-A said she never looked at.
The facility's own elopement risk policy, dated May 2024, requires a new assessment every 90 days and after any attempted elopement. It sets the intervention threshold at a score of 4 or above. R1 was above that threshold either way. The practical consequence of the scoring error was not that she lost her Wander Guard or that her care plan changed. But the assessment is the document that is supposed to capture, after something goes wrong, exactly what went wrong and what the risk picture looks like now. It is supposed to be more complete after an elopement, not less.
R1's care plan described her as having cognitive loss and dementia with deficits in memory, recall, judgment, decision-making, and thought process related to anoxic brain damage. The intervention listed was to supervise and assist with all decision-making. Her admission records noted wandering behavior in the week before she arrived.
She had been asking to go home.
On the night of November 9th, she found a way out. It was neighbors who made sure she got back.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Birchwood Health Care Center from 2025-11-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 22, 2026 · Our methodology
BIRCHWOOD HEALTH CARE CENTER in FOREST LAKE, MN was cited for violations during a health inspection on November 13, 2025.
She had a Wander Guard on her right wrist.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.