Boundary Waters Care Center

In the surveyor’s words

From the most serious findings on record at Boundary Waters Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF886Mar 10, 2022

  Based on interview and document review, the facility failed to ensure staff who had symptoms of COVID-19 and had negative antigen test(s) were not allowed to work, and tested with a confirmatory real-time reverse transcription polymerase chain reaction (RT-PCR) test, according to CDC guidance. This deficient practice resulted in an immediate jeopardy (IJ) situation which had the high likelihood to cause serious illness and/or death to all 32 residents residing in the facility, along with staff and visitors. The IJ began on 1/10/22, when licensed practical nurse (LPN)-A reported COVID-19 symptoms and was allowed to work four shifts. The facility only conducted antigen testing, no NAAT or PCR testing to follow up, as is indicated in CDC guidance. […]

• Actual harm, isolatedF688Apr 20, 2023

  Based on observation, interview, and document review the facility failed to provide range of motion (ROM) services to prevent a decline in ROM for 1 of 1 resident (R17) reviewed for ROM. This resulted in actual harm to R17 who had functional decline in ROM to the left hand. Findings include: R17's quarterly Minimum Data Set (MDS) dated [DATE], indicated R17 had severe cognitive impairment and required extensive assist with bed mobility, transfers, dressing, eating, toileting, and personal hygiene. […]

• No harm, potential for more than minimal, widespreadF809Oct 16, 2024

  Based on interview and document review, the facility failed to ensure a nutrient and/or calorie substantive snack was offered and provided after the evening meal and before bedtime. This had the ability to affect all 32 residents who reside within the facility. Findings include: During interview on 10/14/24 at 10:30 a.m., cook (C) stated mealtimes are 8 a.m., noon, and 5 p.m. and the facility does not prepare or distribute a bedtime snack cart. During interview on 10/14/24 at 11:06 a.m., licensed practical nurse (LPN)-A stated a bedtime snack pass does not occur. Snacks such a pudding, chips, cookies, and sandwiches are always available, but not offered. If a resident wants a snack, they need to ask for one. During interview on 10/14/24 2:08 p.m. […]

• No harm, potential for more than minimal, widespreadF583Jan 25, 2024

  Based on observation, interview, and record review the facility failed to ensure the electronic medical record (EMR) was secured in a manner that prevented unauthorized individuals from viewing and or accessing confidential resident information contained within the EMR. This had the potential to affect all 31 residents residing at the facility. Findings include: During an observation on 1/24/24 at 8:33 a.m., trained medication aide (TMA)-A walked away from the medication cart located in the hallway. The EMR was open and displayed resident information. […]

• No harm, potential for more than minimal, patternF880Jan 25, 2024

  Based on observation, interview and document review the facility failed to ensure residents were offered proper hand sanitization prior to meals. This had the potential to impact all residents that consumed meals in the dining room. Findings include: During a continuous observation of the dining room on 1/24/24 from 8:26 a.m., to 9:26 a.m., residents were seated at three tables. Each resident was offered a clothing protector and assistance with meal setup and or consumption as needed. However, there were no observations of staff offering or of resident's hands being sanitized prior to meal consumption. The main entrance to the dining room had a sign on the door that read be a germ buster wash your hands. […]