Boundary Waters Care Center
200 West Conan Street, Ely, MN 55731 · Non profit - Corporation · 38 certified beds · (218) 365-8705 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no harm-level citations in the current inspection record
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 13.8% | 18.2% | 15.4% | better |
| Long-stay residents who lose too much weight | 4.3% | 4.1% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.0% | 1.9% | 0.9% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with a urinary tract infection | 0.0% | 2.6% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 4.1% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 3.6% | 4.0% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 5.1% | 20.5% | 16.1% | better |
| Long-stay residents on antianxiety or hypnotic medication | 8.4% | 12.5% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.1% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 5.5% | 5.2% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 26.8% | 24.5% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.6% | 17.1% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.9% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 95.7% | 82.7% | 79.4% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.26 therapist hours per resident per day in 2026Q1 — more than 38% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 38 beds and averages 28.5 residents a day — about 75% occupied, or roughly 10 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.29 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.30 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.61 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.61 hrs/resident/day on weekends vs 4.56 on weekdays — 21% thinner on weekends — a notable drop. RN hours go from 1.52 to 0.75 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
11 citations, most serious first — scroll within the box to see all.
- Potential for harm · F2024-10-16 · tag F0809 — failed to serve meals on a reasonable schedule — widespreadEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
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. nursing assistant (NA)-A stated a bedtime snack pass does not occur and if a resident wants a bedtime snack, they need to ask for one. Not all residents ask for a bedtime snack. During interview on 10/15/24 8:55 a.m., culinary director (CD) confirmed mealtimes are 8 a.m., noon, & 5 p.m. and snacks are available, but not offered at bedtime.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-16 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to notify the provider of a resident presenting with mentation and respiratory changes for 1 of 1 residents (R6) reviewed for change in condition. Findings included, R6's Quarterly Minimum Data Set (MDS) dated [DATE], identified R6 had moderate cognitive impairment. Diagnoses included coronary artery disease, cerebrovascular accident (CVA), chronic obstructive pulmonary disease (COPD) and respiratory failure. The MDS indicated R6 was not comatose. R6 could also hear adequately without hearing aides, speak clearly, and usually understood others. R6's care plan, last revised [DATE], identified respiratory concerns but lacked notification to provider for intervention changes. R6's provider signed Minnesota Provider Orders for Life-Sustaining Treatment (POLST), dated [DATE] indicated under section A- Cardiopulmonary Resuscitation (CPR) R6 was a do not attempt resuscitation (DNR). It also indicated under section A when not in cardiopulmonary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-16 · tag F0688 — failed to keep residents mobile / prevent decline — isolatedProvide 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assess, monitor, and implement interventions to prevent decreased range of motion (ROM) for 1 of 4 residents (R5) reviewed for positioning, mobility, and ROM. Finding include: R5's quarterly Minimum Data Set (MDS) dated [DATE], identified R5 was cognitively intact and had functional range of motion (ROM) impairment of the right and left upper extremities (shoulder, wrist, and/or hand). R5 requires partial to moderate assistance for upper body dressing and was dependent on staff to for personal hygiene. During the assessment period (9/10/24 to 9/17/24) R5 did not receive physical therapy (PT), occupational therapy (OT), or restorative nursing services. R5's OT evaluation and plan of treatment dated 4/11/23, identified R5 did not have functional limitations due to a contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity, rigidity of joints, and reduced ROM). During interview on 10/13/24 at 3:25 p.m., R5…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-16 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure oxygen tubing was changed according to facility policy as well as failed to ensure nebulizer tubing/canisters were cleaned and allowed to air dry after each use for 1 of 1 resident (R21) reviewed for oxygen therapy. Findings include: R21's annual Minimum Data Set (MDS) dated [DATE], identified R21 was cognitively intact and had continuous oxygen therapy. Diagnoses included chronic obstructive pulmonary disease (COPD). R21's provider order dated 12/28/23, identified orders to change oxygen tubing and nebulizer tubing weekly on Saturday night. Provider orders dated 6/20/23, identified Ipratropium-Albuterol Inhalation Solution 0.5-2.5 milligram(mg)/3 Milliliters (ml) (a respiratory medication utilized to treat COPD). 3ml inhale orally every 4hr for COPD while awake. Provider orders dated 8/29/24 indicated oxygen 2-4 liters(L) continuous. R21's care plan undated, identified R21 needed continuous oxygen therapy and to administer…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-16 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide physical therapy and occupational therapy as ordered for 1 of 1 resident (R30) reviewed for therapy services. Findings include: R30's admission Record undated, identified R30 was admitted from another long-term care (LTC) facility on 5/7/24, Diagnoses included acute infarction of spinal cord and paraplegia. R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30 had intact cognition and did not exhibit behavioral symptoms. The MDS identified R30 had impairments to both lower extremities, could not ambulate, and needed maximal assistance for transfers. R30's discharge instructions and summary from R30's former LTC facility, dated and signed 5/6/24, identified R30 was discharged to Boundary Waters Care Center. Instructions included under section F-Activity/Therapy/Current Mood/Behavior part B indicated orders for therapy for transfers to another facility included PT to OT. The orders lacked documentation orders were only…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-01-25 · tag F0583 — failed to protect personal privacy — widespreadKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. TMA-A assisted another staff access a storage room around the corner and then returned to the medication cart. During a continuous observation on 1/25/24 at 8:22 a.m., the medication cart in the hallway was unattended and the EMR was open and displayed a resident's medication list. - 8:25 a.m., the cart was unattended and the EMR continued to display resident information. - 08:29 a.m., no change, multiple staff walked by the medication cart and did not notice the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-01-25 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
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. Staff observed to be assisting residents during this time included nursing assistant (NA)-A, NA-B, NA-C, NA-D, and activities aide (AA)-A and AA-B. During a continuous observation on 1/24/24 12:05 p.m., to 12:51 p.m., residents were seated at four tables. There were no observations of residents already seated in the dining room or being brought into the dining room being offered to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · tag F0582 — isolatedGive residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and document review, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN; CMS-10055) to 2 of 3 residents (R17, R137) reviewed whose Medicare Part A coverage ended while in the facility. Findings included: R17's Notice of Medicare Non-Coverage (CMS-10123), dated 11/15/23, indicated R17's last day of skilled services was on 11/17/23. The form was signed by resident representative (RR) and dated 11/15/23. In addition, R17's Advance Beneficiary Notice of Non-Coverage (ABN; CMS-R-131) had been provided which indicated a potential cost of over $329.48 / day to R17 if paying privately for care and services at the facility. However, R17's medical record lacked evidence the required CMS-10055 had been reviewed and/or provided to R17 prior to their Medicare Part A coverage ending. R137's Notice of Medicare Non-Coverage (CMS-10123), dated 1/10/24, identified R137's last day of skilled services was on 1/12/24. The form identified R137 signed on 1/10/24. In addition, R137's Advance Beneficiary Notice of Non-Coverage (ABN; CMS-R-131)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and document review, the facility failed to ensure provider orders to monitor blood pressure were followed for 1 of 5 residents (R3) reviewed for unnecessary medications. Findings include: R3's quarterly Minimum Data Set (MDS) dated [DATE], identified intact cognition and diagnoses of essential hypertension, history of cerebral vascular attack (CVA), and schizoaffective disorder. R3's care plan dated 3/22/18, identified the potential for medication side effects including hypotension (low blood pressure) with an intervention to monitor for orthostatic hypotension (low blood pressure upon standing). R3's provider orders dated 4/8/21, identified an order for orthostatic blood pressure readings (one reading taken while seated and one minute later a reading taken after standing) to be taken on R3's shower day every 28 days and to make a progress note if not obtained. R3's electronic health record did not reflect orthostatic blood pressure readings or notes regarding why it was not obtained. During…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to follow provider interventions for wound care for 1 of 2 residents (R8) reviewed for pressure ulcers. Findings include: R8's quarterly Minimum Data Set (MDS) dated [DATE], identified R8 as moderately cognitively impaired, was dependent on staff for transfers and repositioning, and had lower extremity impairment. R8's diagnoses included multiple sclerosis (autoimmune disease in which the insulating covers of nerve cells are damaged), functional quadriplegia (weakness or paralysis leading to partial or total loss of function in the arms, legs, trunk and pelvis), nondisplaced transverse fracture of shaft of right tibia (bone fracture of the tibia in right leg), heart disease, diabetes mellitus, and an unstageable pressure injury on the right foot. R8's care plan dated 1/2/24, identified R8 was at risk for impaired skin integrity including skin tears, bruising, and/or pressure injury. Intervention instructed staff to float R8's heel with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-01-25 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, facility failed to ensure staff properly utilized a total body mechanical lift for 1 of 2 residents (R15) reviewed for accidents. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 was severely cognitively impaired, required substantial assistance with activities of daily living (ADLs), and was dependent on staff for transfers. R15's diagnoses included Parkinson's disease (progressive disease of the nervous system), heart disease, and dementia (progressive or persistent loss of intellectual functioning). R15's care plan dated 1/8/24, identified R15 required use of a total body mechanical lift for transfers with assist of two staff. R15's care guide dated 1/24/24, identified R15 required use of Hoyer lift (manufacturer of mechanical lifts) with an assist of two staff. On 1/24/24 at 9:01 a.m., nursing assistant (NA)-A was observed pushing R15 in wheelchair to resident's room. NA-A left R15 in room and brought a total body…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to HEALTH DIMENSIONS GROUP — 10 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 3.2 | +1.8 vs chain |
| Health inspection | 5 of 5 | 2.8 | +2.2 vs chain |
| Staffing | 5 of 5 | 4.0 | +1.0 vs chain |
| Quality measures | 5 of 5 | 3.7 | +1.3 vs chain |
The other 9 homes this chain runs (chain average 3.2★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| CHAMPA, KATHLEEN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | since 06/01/2022 |
| FORSMAN, MICHAEL | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | since 04/01/2015 |
| JOHNSON, WARREN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR | since 07/01/2024 |
| LOBE, JONEENE | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER | since 02/01/2023 |
| PEKURI, ROGER | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2015 |
| ELY-BLOOMENSON COMMUNITY HOSPITAL | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 09/30/2011 |
| HEALTH DIMENSIONS CONSULTING INC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/17/2011 |
| BRISCOE, DAVID | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 03/07/2011 |
| BRISCOE, PATRICIA | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 03/07/2011 |
| HENNESSEY, ERIN | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 01/01/2020 |
| MASLOSKI, ADAM | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 06/01/2016 |
| ROGOTZKE, AMBER | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 03/07/2011 |
| SCHWINGHAMER, JOSEPH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 10/01/2011 |
| SHVETZOFF, SERGEI | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 03/07/2011 |
| SHVETZOFF, TAMI | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 03/17/2011 |
CMS files one row per role, so the 26 rows in the source record cover these 15 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MN
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Minnesota Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 245138. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.