Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Birchwood Health Care Center during CMS and state inspections, most recent first.
A resident with COPD, chronic respiratory failure with hypercapnia and hypoxia, and other serious respiratory diagnoses was admitted with oxygen orders but no confirmed BiPAP order, even though hospital records and an EMR summary identified nighttime BiPAP as part of the resident’s care. When the resident’s breathing worsened and PRN inhalers, nebulizers, and increased O2 were ineffective, nursing staff did not notify the provider. The resident continued to decompensate, was sent to the ED, and arrived obtunded in respiratory failure requiring intubation.
Failure to Offer Hand Hygiene Before Meals: Staff repeatedly brought residents into the dining room and seated them for meals without offering hand wipes or another opportunity to clean their hands, even though wipes were available on the tables. In several observations, residents were instead offered beverages, and some were seen eating with their hands or helping themselves to items from the counter without hand hygiene first. Staff and the DON stated residents should be offered handwashing or hand wipes before meals, but the facility policy did not address resident hand hygiene related to meals.
Delayed response to a resident's call light led to a bladder accident. A resident admitted with post-polio syndrome and BPH was oriented, able to communicate, and had a care plan calling for a call light within reach and a urinal available, but staff did not provide a urinal on admission and multiple staff passed by while the call light remained on. The resident reported using drinking cups to urinate and having wet clothing and a wet floor before help arrived; the administrator later acknowledged the call light had been on for 14 minutes before it was answered.
A facility failed to meet bed hold notification requirements for a resident transferred to the hospital. The resident had significant medical conditions including COPD, respiratory failure, lung cancer, pulmonary HTN, oxygen dependence, and HF. The EMR lacked evidence that the resident or spouse was offered a bed hold at the time of transfer, and staff interviews showed the usual process was to notify the resident or family and document it, but that did not occur before the transfer.
Dialysis Access Monitoring Not Properly Performed: A resident with ESRD and a need for HD had orders and a care plan directing staff to check the left arm AV fistula for thrill and bruit every shift. After the resident returned from dialysis, an LPN checked vitals and the dressing but did not auscultate the access site, and later stated they did not know what a thrill or bruit was until they looked it up. The DON stated staff were expected to check the site for bleeding, thrill, and bruit after dialysis.
Lack of Orders and Assessments for Bedside Self-Administration of Medications: A cognitively intact resident with diabetes, CKD, and PVD kept multiple OTC supplements and pain products at bedside without the required orders and updated self-administration assessments. The resident’s chart showed only one prior assessment for a different supplement, while the order summary lacked bedside/self-administration orders for several products. The resident confirmed the bottles were kept on the bedside table and stated nursing had not reviewed them with the MD or pharmacist.
Failure to provide the SNF ABN when Medicare A services ended. The facility used CMS-R-131 instead of CMS-10055 for residents who stayed after Medicare A discharge, and the EMR lacked evidence that the SNF ABN was given for 4 reviewed residents. The LSW said she was not aware the SNF ABN was required, and the administrator said corporate staff had directed use of CMS-R-131 in these cases.
Failure to Investigate Elopement and Identify At-Risk Residents: A resident with severe cognitive impairment, dementia, aphasia, and a history of wandering removed his wander alert bracelet, signed himself out, and eloped from the facility. Video showed him leaving the building, propelling his wheelchair, then continuing on foot after abandoning the wheelchair. Staff relied on the bracelet, a front-desk binder, or personal knowledge to identify wandering risk, and one aide said he was unsure the resident was at risk because the bracelet was not on. The DON and administrator stated not all staff would know every resident at risk, and the facility did not comprehensively investigate the bracelet removal attempt or identify what items could be used to remove it.
Staff did not consistently follow enhanced barrier precautions, including proper use of gowns, gloves, and hand hygiene, during high-contact care activities for two residents with MRSA colonization and indwelling devices. Observations showed that staff sometimes skipped wearing gowns, failed to sanitize hands between glove changes, and did not always change gloves after cleansing insertion sites, despite being aware of facility policies.
A resident with severe cognitive impairment, dementia, wandering behavior, and a WanderGuard exited through a chapel door after activating the alarm. A NA silenced the alarm, briefly looked outside, and did not initiate a missing resident code because he did not realize the resident was gone. The resident was later found two blocks away by a community member and returned to the facility, with staff unaware of the elopement until then.
Inaccurate Elopement Risk Assessment: A resident with dementia, severe cognitive impairment, and wandering behavior eloped from the chapel doors and was brought back by neighbors. After the event, an RN completed a new elopement risk assessment but did not include the recent elopement, family concern, or a medication that could cause confusion, and the RN and DON acknowledged the assessment was not accurate.
Failure to Obtain BiPAP Orders and Notify Provider for Worsening Respiratory Status
Penalty
Summary
The facility failed to verify and obtain on admission the resident’s need for BiPAP equipment and failed to notify the provider after prescribed breathing interventions were ineffective for a resident with COPD, acute and chronic respiratory failure with hypercapnia and hypoxia, pulmonary hypertension, dependence on supplemental oxygen, heart failure, and lung cancer. The resident’s care plan addressed altered respiratory status, shortness of breath, oxygen use, pulse oximetry monitoring, and reporting abnormalities to the provider. Provider orders included continuous oxygen at 1 LPM to keep SaO2 greater than 90%, standing orders to titrate oxygen for dyspnea or hypoxia, and multiple inhaled medications. The resident’s hospital discharge information and EMR included documentation that BiPAP had been used during the hospital course and that sleep medicine had prescribed BiPAP with specific settings. The EMR also included an AI-generated summary report identifying nighttime BiPAP as an equipment need. Despite this information, the facility initially told the resident’s wife there were no orders for BiPAP, only oxygen, and staff proceeded without confirming the BiPAP need on admission. The respiratory equipment vendor stated it had received oxygen orders but had not received a BiPAP order until after the resident was discharged from the hospital to another facility. On the night before the resident’s transfer, nursing notes documented worsening respiratory status with low oxygen saturations in the mid-80s on 3 LPM, diminished and wheezy lung sounds, shallow respirations, and little or no improvement after PRN albuterol inhaler, nebulizer treatment, and increasing oxygen to 4 LPM. The resident remained uncomfortable and short of breath, but the nurse did not update another RN, the DON, or the provider. By morning, the resident’s oxygen saturation had dropped to 80% with respirations of 50, scheduled nebulizer treatments did not improve the condition, 911 was called, and EMS transported the resident to the emergency department. The hospital record stated the resident arrived obtunded and in respiratory failure requiring intubation, and the provider suspected increasing carbon dioxide retention because the resident did not have the home BiPAP machine that had been recommended.
Failure to Offer Hand Hygiene Before Meals
Penalty
Summary
The facility failed to ensure residents were given an opportunity to wash their hands prior to eating in the main dining room. During multiple observations, staff brought residents into the dining room and seated them at tables without offering hand wipes or any other opportunity to clean their hands. Hand wipes were present on the tables, but staff were not observed offering them as residents arrived and were seated. In several instances, residents were instead offered beverages such as juice or other drinks. The observations included residents being brought to the dining room for breakfast and other meals, with some residents eating with their hands or helping themselves to items from the counter without first being offered hand hygiene. One resident was given a clothing protector but not handwashing, and another resident was observed eating peanut butter toast with her hands. During interviews, nursing assistants and an RN stated that residents should be assisted or offered hand wipes before meals, and the DON stated that staff bringing residents to the dining room should offer handwashing to prevent the spread of germs. The facility's Hand Hygiene policy dated 8/2025 identified proper hand washing should be used to protect the spread of infection, but the policy did not address hand hygiene related to residents and meals.
Delayed Response to Call Light and Failure to Provide Urinal
Penalty
Summary
The facility failed to ensure a resident's call light was answered timely to prevent a bladder accident for one resident who was admitted with diagnoses including post-polio syndrome and benign prostatic hyperplasia. The resident's admission note identified him as oriented to time, place, and person, with clear speech and the ability to make himself understood, and he was documented as continent of bladder. His care plan included keeping the call light within reach and having a urinal available, but when he arrived his motorized wheelchair was not working properly and a urinal was not provided. The resident stated he had to use drinking cups to urinate in while waiting for help, and he reported that his clothes and the floor became wet during the delay. Observation showed the resident shouting for the urinal while the call light remained on for an extended period, with therapy staff and another staff member passing by without responding. The call light continued flashing and scrolling, and only after activities staff notified nursing did a nursing assistant enter the room and later return with a urinal. The resident stated his call light had been on for a long time and that he had an accident while waiting for someone to answer. Staff interviews confirmed that new admissions should be provided needed supplies such as a urinal, that all staff who see or hear an activated call light are responsible for responding, and that the administrator acknowledged the call light had been on for 14 minutes before it was answered.
Failure to Document Bed Hold Notification After Hospital Transfer
Penalty
Summary
The facility failed to meet requirements for bed hold notification for 1 of 2 residents reviewed for hospitalization, identified as R90. R90’s admission record showed diagnoses including COPD, acute and chronic respiratory failure with hypercapnia and hypoxia, malignant neoplasm of the bronchus or lung, pulmonary hypertension, dependence on supplemental oxygen, and heart failure. R90’s EMR did not contain evidence that a bed hold was offered to R90 or his spouse when he was transferred to the hospital. During interview, an LPN stated the usual process was to ask the resident if they wanted to hold the bed and provide the bed hold policy at the time of transfer, or to call the family if the resident was unable to respond. The LPN stated she saw a social work note indicating the bed hold policy was sent with the resident to the hospital, but her expectation was that the resident or family would be asked and that it would be documented at that time. A social services staff member stated that when a resident was sent out, they were sent with a copy of the bed hold and transfer form and she would follow up with the family to find out if they wanted to hold the bed. She stated she attempted to call R90’s wife after the transfer, and the wife later stated they did not wish to hold the bed. The social services staff member also stated she usually would make that call the next day or once they knew if the resident had been admitted, but time got away from her in this case.
Dialysis Access Monitoring Not Properly Performed
Penalty
Summary
The facility failed to ensure staff were properly educated on how to monitor a dialysis access site for a resident who required hemodialysis. The resident was cognitively intact and had diagnoses including end stage renal disease and a need for dialysis. The care plan directed staff to check for a thrill and bruit at the left arm AV fistula/graft access site every shift and as needed, and the orders instructed staff to monitor the AV fistula for signs and symptoms of infection every shift and to check thrill and bruit every shift. During observation, an LPN checked the resident’s vitals and looked at the AV fistula dressing after the resident returned from dialysis, but did not use a stethoscope to auscultate the access site. In interview, the LPN stated they did not know what a thrill or bruit was and needed to look it up, then later stated the thrill was felt at the site and the bruit was a sound to listen for. The LPN confirmed they had not listened for the bruit and said they would get a stethoscope to listen. The DON stated nurses were expected to obtain vitals, check the port site for bleeding, thrill and bruit, and monitor for lethargy when a resident returned from dialysis, and that auscultation for a bruit was important to ensure patency of the AV fistula.
Lack of Orders and Assessments for Bedside Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that assessments and orders were in place for self-administration and bedside storage of medications and supplements for one resident who was cognitively intact and had diagnoses of diabetes, chronic kidney disease, and peripheral vascular disease. The resident’s care plan included a focus area for medication self-administration and stated the resident was able to keep Voltaren gel at bedside and self-administer it, but the intervention section also stated the facility was to administer medications because the resident was not safe to independently administer medications at that time. The resident’s active order summary included permission to have over-the-counter medications for nerve pain in the room, but it lacked administration parameter orders and/or orders to keep at bedside for multiple supplements and products, including Amala super fruit extract, aged garlic extract, Alphacure, total pain relief supplement, Lymphavive, vision supplement, triple complex magnesium, coq10 complex, Antarctic oil, and Moringa. A medication assessment completed earlier indicated the resident was safe to keep at bedside and self-administer one supplement, Nerve Renew Supplement, twice daily, but the chart lacked evidence of subsequent self-administration assessments for oral medication administration. Multiple observations and interviews showed the resident kept numerous over-the-counter medication bottles on the bedside table in the room, and the resident confirmed ordering the products from advertisements and keeping them at bedside. The resident also stated they did not think nursing staff had taken a list of the bottles for the doctor or pharmacist to review and did not think they had been tested on taking the pills. The DON stated that if a resident wanted to self-administer medications or supplements, nursing would complete an assessment and obtain a physician order identifying which medications could be self-administered, and that most medications kept at bedside should have an order and completed assessment in place.
Failure to Provide SNF ABN When Medicare A Coverage Ended
Penalty
Summary
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on interview and document review, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN), CMS-10055, when Medicare Part A services were discontinued and residents remained in the facility. This affected 4 of 4 residents reviewed for beneficiary notices: R1, R5, R8, and R11. For each resident, the Notice of Medicare Non-Coverage (CMS-10123) identified the last covered day of Medicare A, and the census list and progress notes showed the resident stayed in the facility after that Medicare Part A discharge date. R1's CMS-10123 dated 4/21/26 showed the last covered day would be 4/23/26, R5's CMS-10123 dated 3/12/26 showed the last covered day would be 3/13/26, R8's CMS-10123 dated 2/2/26 showed the last covered day would be 2/5/26, and R11's CMS-10123 dated 5/14/26 showed the last covered day would be 5/23/26. The EMR for each resident lacked indication that the SNF ABN was provided. During interview, the LSW stated she was not aware the SNF ABN needed to be given and said the facility had been using CMS-R-131 instead. The administrator stated corporate staff had instructed the facility to use CMS-R-131 when residents were discharged from Medicare A and stayed in the facility. Facility policy dated 4/1/26 stated residents would receive CMS-10055 when discharged from Medicare A services and CMS-R-131 would be used for residents under Medicare B services.
Failure to Investigate Elopement and Identify Residents at Risk
Penalty
Summary
The facility failed to thoroughly investigate and comprehensively assess an elopement event for one resident who removed his wander alert bracelet and left the facility unsupervised. The resident had severe cognitive impairment, aphasia, a history of CVA, non-Alzheimer’s dementia, seizure disorder, hypertension, and arthritis. His quarterly MDS indicated he was independent with transfers and used a wheelchair. After an earlier incident in which he was found outside with increased confusion and delusional thoughts, the resident was assessed as being at increased risk for wandering and was placed on a wander alert bracelet, with care plan directions for staff to check the device daily and monitor for triggers to wandering or elopement. The resident later signed himself out of the facility and eloped after removing and discarding his wander alert bracelet. Facility documentation and video surveillance showed him leaving through the front door, propelling himself in his wheelchair, then continuing on foot after leaving the wheelchair near dumpsters in the parking lot. He was later found across the street near an apartment building and an intersection by a bystander who was assisting him into a car for safety. Staff reported that the resident told them he had taken off the bracelet, thrown it away, and signed himself out because he was going to the farm. The resident’s records also showed ongoing wandering behavior and attempts to remove the bracelet, and staff placed him on 15-minute checks after the incident. The facility also failed to ensure a system for all staff to identify residents at risk for elopement. During interviews, staff stated they relied on the wander alert bracelet, a binder at the front desk, or simply knowing which residents to watch. One aide stated he recognized the resident but was not sure if he was at risk because the resident was not wearing a bracelet, and he did not know where to find a list of residents requiring supervision outside the facility. The DON and administrator stated that not every staff member would memorize everyone at risk and that new residents might not be known to staff. The DON also stated that when the resident attempted to remove the bracelet, staff did not know which staff had seen it, staff interviews were not part of the investigation, and the facility had not identified what items in the resident’s room or elsewhere might be used to remove the bracelet.
Failure to Ensure Proper PPE Use and Hand Hygiene for Residents on Enhanced Barrier Precautions
Penalty
Summary
Staff failed to properly use personal protective equipment (PPE) and maintain hand hygiene for residents on enhanced barrier precautions (EBP). For one resident with a suprapubic catheter and MRSA colonization, a registered nurse performed a dressing change without wearing a gown, failed to sanitize hands between glove changes, and used the same gloves to cleanse the catheter site and apply a clean dressing. The nurse acknowledged forgetting to wear a gown and skipping hand hygiene steps due to the location of supplies. For another resident with an indwelling catheter, feeding tube, and MRSA colonization, nursing assistants and a licensed practical nurse inconsistently sanitized hands between glove changes during high-contact care activities, such as incontinence care and feeding tube dressing changes. Staff sometimes applied clean gloves without hand hygiene and did not always change gloves or sanitize hands after cleansing insertion sites. Interviews with staff confirmed awareness of the facility's expectations for PPE use and hand hygiene, but lapses occurred due to forgetfulness or nervousness. Facility policies required hand cleansing before donning gloves, after glove removal, and before moving from soiled to clean body sites, as well as the use of gowns and gloves for high-contact care activities for residents on EBP. Observations and staff interviews demonstrated that these protocols were not consistently followed during resident care.
Failure to Supervise Elopement-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was assessed as an elopement risk, had severe cognitive impairment, dementia, muscle weakness, and used a wheelchair with a WanderGuard on the right wrist. The resident’s care plan identified wandering behavior, impaired judgment and decision-making, and the need for supervision and assistance with all decision-making. The resident also had an elopement risk assessment score of 6, indicating potential for elopement. On the evening of the incident, the resident exited through the chapel doors and activated the WanderGuard alarm. Surveillance showed the resident pushing on a keypad button, then pushing on a secured exit door handle, and after more than 30 seconds, exiting the building. A nursing assistant silenced the alarm and briefly looked outside but did not step outside or initiate a missing resident code. The resident remained outside and was later returned to the facility by a community member, who found the resident two blocks away in the dark and reported that the resident said she did not know how she got there. Facility staff were not aware the resident was missing until the community member brought her back. Interviews indicated the nursing assistant did not call a code because he did not know anyone was gone, and staff later acknowledged that the resident was not safe outside alone and that the alarm should not have been turned off before all residents wearing WanderGuards were accounted for. The resident had been observed moving quickly in the wheelchair and attempting to wander into the kitchen before the incident.
Inaccurate Elopement Risk Assessment
Penalty
Summary
The facility failed to accurately assess elopement risk for one resident who had severe cognitive impairment, dementia, and wandering behavior documented on the admission MDS. The resident’s orders indicated a Wander Guard check on the right wrist every night, and the care plan identified the resident as an elopement risk with impaired physical mobility, wheelchair use, cognitive loss/dementia, and the need for supervision and assistance with all decision-making. The resident’s progress notes documented that the resident eloped out of the chapel doors and was brought back by neighbors. After the elopement, an RN completed an updated Elopement Risk assessment, but the assessment did not include that the resident had just eloped, that the resident’s husband had voiced concern about the elopement, or that the resident was taking a medication that could cause confusion. The RN stated the resident scored a 5 and acknowledged the assessment was not accurate, noting she should have included the elopement event, family concern, and the sedating medication. The DON stated the RN should have known to assign a point for the elopement and should have reviewed the medication list for accuracy. The facility’s Elopement Risk policy stated residents scoring 4 or more required interventions that may include a Wander Guard, and that a new assessment would be completed every 90 days and with attempted elopement.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Forest Lake
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadows On Fairview | 2.5 mi | ★★★★★ | 1 | 0 |
| Parmly On The Lake Llc | 6.9 mi | ★★★★★ | 4 | 0 |
| Waverly Gardens | 11.7 mi | ★★★★★ | 10 | 1 |
| Christian Community Home Of Osceola, Inc | 13.8 mi | ★★★★★ | 4 | 0 |
| Cerenity Care Center White Bear Lake | 14.2 mi | ★★★★★ | 8 | 1 |
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