All citations for Boundary Waters Care Center

State inspectors check nursing homes that take Medicare or Medicaid against federal rules, usually about once a year, and also look into complaints. Each rule a home did not meet is a citation.

Back to Boundary Waters Care Center

Last standard health inspection on record

December 11, 2025

Showing 1 to 25 of 27 citations

  1. No harm, with potential for more than minimal harm

    To conduct inspection, testing and maintenance of fire doors by qualified individuals.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0761, Miscellaneous Deficiencies. Inspection of December 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (January 13, 2026).

  2. No harm, with potential for more than minimal harm

    Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

    Widespread (many residents). CMS level F.

    Health citation F-0809, Nutrition and Dietary Deficiencies. Inspection of October 16, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 18, 2024).

  3. No harm, with potential for more than minimal harm

    Have horizontal exits used in accordance with safety requirements.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0226, Egress Deficiencies. Inspection of October 16, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 18, 2024).

  4. No harm, with potential for more than minimal harm

    Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0741, Miscellaneous Deficiencies. Inspection of October 16, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 18, 2024).

  5. No harm, with potential for more than minimal harm

    Keep residents' personal and medical records private and confidential.

    Widespread (many residents). CMS level F.

    Health citation F-0583, Resident Rights Deficiencies. Inspection of January 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 24, 2024).

  6. No harm, with potential for more than minimal harm

    Follow proper procedures when the fire alarm was out of service for more than 4 hours.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0346, Smoke Deficiencies. Inspection of January 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 24, 2024).

  7. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of January 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 24, 2024).

  8. No harm, with potential for more than minimal harm

    Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0372, Smoke Deficiencies. Inspection of January 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 24, 2024).

  9. No harm, with potential for more than minimal harm

    Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0521, Services Deficiencies. Inspection of January 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 24, 2024).

  10. No harm, with potential for more than minimal harm

    Have simulated fire drills held at unexpected times.

    Widespread (many residents). CMS level F.

    Fire safety citation K-0712, Miscellaneous Deficiencies. Inspection of January 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 24, 2024).

  11. No harm, with potential for more than minimal harm

    Ensure proper usage of power strips and extension cords.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0920, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of October 16, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 18, 2024).

  12. No harm, with potential for more than minimal harm

    Provide and implement an infection prevention and control program.

    Pattern (more than a few residents). CMS level E.

    Health citation F-0880, Infection Control Deficiencies. Inspection of January 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 24, 2024).

  13. No harm, with potential for more than minimal harm

    Have horizontal exits used in accordance with safety requirements.

    Pattern (more than a few residents). CMS level E.

    Fire safety citation K-0226, Egress Deficiencies. Inspection of January 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 24, 2024).

  14. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of December 11, 2025. Found during a standard inspection.

    The home gave a date the problem would be corrected (December 29, 2025).

  15. No harm, with potential for more than minimal harm

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0580, Resident Rights Deficiencies. Inspection of October 16, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 18, 2024).

  16. No harm, with potential for more than minimal harm

    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0688, Quality of Life and Care Deficiencies. Inspection of October 16, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 18, 2024).

  17. No harm, with potential for more than minimal harm

    Provide safe and appropriate respiratory care for a resident when needed.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0695, Quality of Life and Care Deficiencies. Inspection of October 16, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 18, 2024).

  18. No harm, with potential for more than minimal harm

    Provide or get specialized rehabilitative services as required for a resident.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0825, Quality of Life and Care Deficiencies. Inspection of October 16, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 18, 2024).

  19. No harm, with potential for more than minimal harm

    Install noncombustible or limited-combustible interior walls.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0163, Construction Deficiencies. Inspection of October 16, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 18, 2024).

  20. No harm, with potential for more than minimal harm

    Inspect, test, and maintain automatic sprinkler systems.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0353, Smoke Deficiencies. Inspection of October 16, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 18, 2024).

  21. No harm, with potential for more than minimal harm

    Ensure that testing and maintenance of electrical equipment is performed.

    Isolated (one or a few residents). CMS level D.

    Fire safety citation K-0921, Gas, Vacuum, and Electrical Systems Deficiencies. Inspection of October 16, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (November 18, 2024).

  22. No harm, with potential for more than minimal harm

    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0582, Resident Rights Deficiencies. Inspection of January 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 24, 2024).

  23. No harm, with potential for more than minimal harm

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0684, Quality of Life and Care Deficiencies. Inspection of January 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 24, 2024).

  24. No harm, with potential for more than minimal harm

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0686, Quality of Life and Care Deficiencies. Inspection of January 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 24, 2024).

  25. No harm, with potential for more than minimal harm

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    Isolated (one or a few residents). CMS level D.

    Health citation F-0689, Quality of Life and Care Deficiencies. Inspection of January 25, 2024. Found during a standard inspection.

    The home gave a date the problem would be corrected (February 24, 2024).

Source: CMS Provider Information, Fire Safety Deficiencies, Health Deficiencies, Citation Code Look-up, data as of September 30, 2026. Inspection results describe the home at the time of each inspection.