Birchwood Health Care Center

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

started on [DATE REDACTED], 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 REDACTED]. The immediate jeopardy was removed and

the deficient practice corrected by [DATE REDACTED], after the facility implemented a systemic plan that included the following actions:Upon Resident R1 returning to the facility, Resident R1 was assessed for injuries.Resident 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 REDACTED], to ensure alarms are not shut off before residents at risk for elopement and wearing a Wander Guard are accounted for.Resident R1's care plan was updated to include 1:1 initially, then 15 min checks when Resident R1 went to bed.Activity staff increased activity options for Resident R1 to assist with distraction.Doors to Resident R1's unit to be shut at night to limit Resident R1's movement to her own unit for increased supervision.Staff was educated on the care plan revisions.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/13/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Birchwood Health Care Center

604 1st Street NE Forest Lake, MN 55025

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and document review, the facility failed to accurately assess elopement risk for 1 of 3 residents (Resident R1) reviewed for elopement. Findings include: Resident R1's admission Minimum Data Set (MDS) dated [DATE REDACTED], indicated Resident R1 had severe cognitive impairment, diagnoses that included dementia, and had wandering behavior 1-3 days in the 7-day look back period. Resident R1's orders dated 10/29/25, indicated check Wander Guard on right wrist every night. Resident R1's progress notes dated 11/9/25 at 9:11 p.m., indicated Resident R1 eloped out of

the chapel doors and neighbors brought Resident R1 back. Resident R1's Elopement Risk assessment dated [DATE REDACTED], indicated Resident R1 was at risk for elopement with a score of 6 because Resident R1 was able to self-propel her wheelchair, had a history of wandering, exhibited pacing or agitated behavior, was asking to go home, had a diagnosis of dementia, and was currently taking medications which may cause confusion. Resident R1's Elopement Risk assessment dated [DATE REDACTED], indicated Resident R1 was at risk for elopement with a score of 5 because Resident R1 was able to self-propel her wheelchair, had a history of wandering, exhibited pacing or agitated behavior, was asking to go home, and had a diagnosis of dementia. The assessment lacked indication Resident R1 had just eloped from the facility, family had just voiced concern about Resident R1's elopement, and Resident R1 was taking a medication that may cause confusion. Resident R1's care plan dated 10/29/25, indicated Resident R1 was an elopement risk and used a Wander Guard (security device that prevents residents at risk of wandering from leaving a designated area). The care plan further indicated Resident R1 had impaired physical mobility and required a wheelchair for locomotion and had cognitive loss/dementia with deficits in memory/recall ability, judgement, decision-making and thought process related to anoxic brain damage with an intervention to supervise and assist with all decision-making. During an interview on 11/12/25 at 3:35 p.m., registered nurse (RN)-A stated after Resident R1 eloped on 11/9/25, she performed an updated Elopement Risk assessment with Resident R1, per policy after an elopement. RN-A stated Resident R1 scored a 5, indicating elopement risk. RN-A acknowledged she had not reviewed the previous assessment, in which Resident R1 scored a 6. Upon review of the assessment, RN-A stated

she should have indicated Resident R1 was taking a medication that was sedating because Resident 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 Resident R1's husband voiced concerns when RN-A notified him of Resident 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 Resident 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 Resident 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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If continuation sheet