Birchwood Health Care Center
BIRCHWOOD HEALTH CARE CENTER in FOREST LAKE, MN — inspection on November 13, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
started on [DATE], to leave the alarm on until all the residents who wore Wander Guards were accounted for, and that had always been the policy. We are supposed to call a code green when the alarm goes off and a resident is not accounted for near the alarm.
The Elopement Risk policy dated 5/24, indicated residents who scored 4 or more on the Elopement Risk Assessment required interventions that may include using a Wander Guard.
Residents who had an attempted elopement required a new review, and all residents who wore the WanderGuard were not to be outside the building without staff or family members.
The past non-compliance immediate jeopardy began on [DATE].
The immediate jeopardy was removed and the deficient practice corrected by [DATE], after the facility implemented a systemic plan that included the following actions:Upon R1 returning to the facility, R1 was assessed for injuries.R1 was placed on 1:1 staffing upon return. 15-minute observations following.Nursing assistant (NA)-A was suspended, was verbally retrained but remains on suspension until he gets a full retraining.All Wander Guard systems (exits and bracelets) were tested and found to be in working condition. (Testing continues to meet Manufacturer's recommendations).Training started [DATE], to ensure alarms are not shut off before residents at risk for elopement and wearing a Wander Guard are accounted for.R1's care plan was updated to include 1:1 initially, then 15 min checks when R1 went to bed.Activity staff increased activity options for R1 to assist with distraction.Doors to R1's unit to be shut at night to limit R1's movement to her own unit for increased supervision.Staff was educated on the care plan revisions.
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IDENTIFICATION NUMBER:
A.
Building
COMPLETED
11/13/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Birchwood Health Care Center
604 1st Street NE Forest Lake, MN 55025
SUMMARY STATEMENT OF DEFICIENCIES
During an interview on 11/12/25 at 3:35 p.m., registered nurse (RN)-A stated after R1 eloped on 11/9/25, she performed an updated Elopement Risk assessment with R1, per policy after an elopement. RN-A stated R1 scored a 5, indicating elopement risk. RN-A acknowledged she had not reviewed the previous assessment, in which R1 scored a 6.
Upon review of the assessment, RN-A stated she should have indicated R1 was taking a medication that was sedating because R1 was taking Seroquel which could contribute to an altered mental state. RN-A further acknowledged she should have scored a point for the elopement that just occurred, and should have scored a point for family who voiced concerned as R1's husband voiced concerns when RN-A notified him of R1's elopement. RN-A acknowledged it was not an accurate assessment, and stated she would update it.
During an interview on 11/13/25 at 11:38 a.m., the director of nursing (DON) stated R1's elopement triggered RN-A to perform a new Elopement Risk Assessment, so RN-A should have known to assign a point for the elopement.
The DON stated RN-A should have reviewed R1's medication list when it was completed to ensure accuracy of the assessment.
The DON acknowledged the assessment was not accurate and had not been updated yet.
The Elopement Risk policy dated 5/24, indicated residents who scored 4 or more on the Elopement Risk Assessment required interventions that may include using a Wander Guard, and further stipulated a new assessment would be completed every 90 days and with attempted elopement.
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