Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
BOUNDARY WATERS CARE CENTER
ELY, MN · 38 certified beds · Last Life Safety survey December 11, 2025
CMS Certification Number 245138 · first certified July 1967
Ownership
Operated by HEALTH DIMENSIONS GROUP · Non profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MN
16 citations — more than 70% of the 338 certified nursing homes in MN. Compared within MN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 2 citations; the earlier surveys in the window averaged 7. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens November 2026 — about 1 month from now. This facility’s last Life Safety survey was December 2025. Facilities in MN are typically surveyed 11–14 months after the last one (median 13), measured over 613 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 16 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in MN, and nationally. Surveyors differ markedly between states, so the MN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 16 |
| Median facility in MN | 12 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| January 25, 2024 | 8 |
| October 16, 2024 | 6 |
| December 11, 2025 | 2 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-12-11 |
| K-0226 | Have horizontal exits used in accordance with safety requirements. | 2 | 2024-10-16 |
| K-0281 | Install proper backup exit lighting. | 1 | 2024-01-25 |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | 1 | 2024-10-16 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2024-01-25 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2024-01-25 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2024-10-16 |
| K-0163 | Install noncombustible or limited-combustible interior walls. | 1 | 2024-10-16 |
What the citations cover
- Smoke Deficiencies 6
- Egress Deficiencies 3
- Miscellaneous Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Egress Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Construction Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 11, 2025 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 29, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (January 13, 2026) |
October 16, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0163 | Install noncombustible or limited-combustible interior walls. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0226 | Have horizontal exits used in accordance with safety requirements. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (November 18, 2024) |
January 25, 2024 — 8 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0226 | Have horizontal exits used in accordance with safety requirements. | Deficient, Provider has date of correction (February 24, 2024) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (February 24, 2024) |
| K-0346 | Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Deficient, Provider has date of correction (February 24, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (February 24, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (February 24, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (February 24, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (February 24, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (February 24, 2024) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.