Birchwood Health Care Center: Infection Control Lapse - MN
The licensed practical nurse, identified in inspection records as LPN-A, was caring for a resident designated as R3, who was on enhanced barrier precautions, a protocol that requires gowns and gloves throughout high-contact care. LPN-A removed the old dressing, discarded it, took off her gloves, and sanitized her hands. So far, correct. Then she cleansed the feeding tube insertion site and applied a clean dressing without changing her gloves or sanitizing her hands between the soiled step and the clean one.
She caught her own mistake in an interview with inspectors on December 18. "She should have changed her gloves and sanitized her hands after cleansing R3's feeding tube insertion site," the inspection report states, "but she did not because she was nervous."
The facility's own hand hygiene policy, revised as recently as August 2025, requires staff to cleanse hands before putting on gloves, after removing gloves, and before moving from a soiled body site to a clean one. The personal protective equipment policy, updated in 2023, requires gowns and gloves for any high-contact care involving indwelling medical devices.
The director of nursing told inspectors on December 19 that staff were expected to follow hand hygiene policy and wear appropriate protective equipment during dressing changes on residents under enhanced barrier precautions. The administrator said the same thing, separately, two minutes later.
Both statements described what was supposed to happen. Neither addressed why it didn't.
The inspection, conducted as a complaint investigation, found the lapse caused minimal harm or potential for actual harm and affected few residents. Whether R3 developed any complications from the breach was not documented in the inspection report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Birchwood Health Care Center from 2025-12-19 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
BIRCHWOOD HEALTH CARE CENTER in FOREST LAKE, MN was cited for violations during a health inspection on December 19, 2025.
LPN-A removed the old dressing, discarded it, took off her gloves, and sanitized her hands.
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.