Inspection Report Summary
The most recent inspection on December 11, 2025, found no health deficiencies. Earlier inspections identified several deficiencies related to resident care, including issues with notification of condition changes, therapy services, respiratory care, nutrition, and infection control practices. Prior reports noted failures in securing electronic medical records, following provider orders, pressure ulcer care, and safe use of mechanical lifts. Complaint investigations were not listed in the available reports. The inspection history shows improvement, with the latest survey free of deficiencies after previous findings.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
41% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Dec 11, 2025
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Boundary Waters Care Center following a survey completed on December 11, 2025.
Findings
No health deficiencies were found during the survey.
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Oct 16, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, therapy services, respiratory care, nutrition, and notification of changes in resident condition.
Findings
The facility was found deficient in multiple areas including failure to notify the provider of a resident's change in condition, failure to assess and intervene to prevent decreased range of motion, failure to provide safe respiratory care including timely changing and cleaning of oxygen and nebulizer tubing, failure to provide a nourishing bedtime snack to residents, and failure to provide ordered physical and occupational therapy services.
Deficiencies (5)
Failed to notify the provider of a resident presenting with mentation and respiratory changes for 1 of 1 residents reviewed for change in condition.
Failed to assess, monitor, and implement interventions to prevent decreased range of motion for 1 of 4 residents reviewed for positioning, mobility, and ROM.
Failed to ensure oxygen tubing was changed according to facility policy and failed to ensure nebulizer tubing/canisters were cleaned and allowed to air dry after each use for 1 of 1 resident reviewed for oxygen therapy.
Failed to ensure a nutrient and/or calorie substantive snack was offered and provided after the evening meal and before bedtime, affecting all 32 residents.
Failed to provide physical therapy and occupational therapy as ordered for 1 of 1 resident reviewed for therapy services.
Report Facts
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 32
Residents affected: 1
Therapy discharge date: 2023
Oxygen tubing change frequency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN-A | Licensed Practical Nurse | Named in finding related to failure to notify provider of resident's change in condition |
| RN-A | Registered Nurse | Named in findings related to notification of change in condition and respiratory care |
| DON | Director of Nursing | Named in findings related to notification of change in condition, respiratory care, and therapy services |
| COTA-A | Certified Occupational Therapy Assistant | Named in findings related to range of motion and therapy services |
| OTR-A | Occupational Therapist Registered | Named in findings related to range of motion and therapy services |
| RN-B | Registered Nurse | Named in findings related to respiratory care and therapy services |
| C | Cook | Named in findings related to failure to provide bedtime snack |
| NA-A | Nursing Assistant | Named in findings related to failure to provide bedtime snack |
| CD | Culinary Director | Named in findings related to failure to provide bedtime snack |
| R30 | Resident | Named in findings related to failure to provide therapy services |
Inspection Report
Routine
Deficiencies: 6
Date: Jan 25, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to Medicare/Medicaid notices, resident privacy and confidentiality, treatment and care according to orders, pressure ulcer care, accident hazard prevention, and infection control practices.
Findings
The facility was found deficient in multiple areas including failure to provide required Medicare non-coverage notices to residents, failure to secure electronic medical records leading to potential unauthorized access, failure to follow provider orders for monitoring blood pressure, failure to provide appropriate pressure ulcer care, improper use of mechanical lifts without adequate staff, and failure to offer residents hand sanitization prior to meals.
Deficiencies (6)
Failed to provide Skilled Nursing Facility Advanced Beneficiary Notice (CMS-10055) to 2 of 3 residents whose Medicare Part A coverage ended.
Failed to ensure electronic medical record (EMR) was secured to prevent unauthorized access, potentially affecting all 31 residents.
Failed to ensure provider orders to monitor orthostatic blood pressure were followed for 1 of 5 residents reviewed.
Failed to follow provider interventions for wound care for 1 of 2 residents reviewed for pressure ulcers.
Failed to ensure staff properly utilized a total body mechanical lift requiring two staff for 1 of 2 residents reviewed.
Failed to ensure residents were offered proper hand sanitization prior to meals, potentially impacting all residents consuming meals in the dining room.
Report Facts
Residents affected: 2
Residents affected: 31
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA-A | Nursing Assistant | Observed leaving EMR open unattended and improper use of mechanical lift |
| TMA-A | Trained Medication Aide | Left EMR open and unattended multiple times |
| DON | Director of Nursing | Provided statements regarding EMR security, orthostatic blood pressure monitoring, mechanical lift use, and hand sanitization policies |
| RN-A | Registered Nurse | Observed and interviewed regarding pressure ulcer care for resident R8 |
| NA-B | Nursing Assistant | Confirmed two staff needed for mechanical lift and lack of hand sanitization assistance |
| NA-D | Nursing Assistant | Stated not taught to help residents sanitize hands before meals |
| Physician | Provided expectations for pressure ulcer care for resident R8 |
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