Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 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.
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 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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Illustrative
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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 | ★★★★★ | 1 | 0 |
| Waverly Gardens | 11.7 mi | ★★★★★ | 7 | 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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.