Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Gables Of Boutwells Landing during CMS and state inspections, most recent first.
Food storage, labeling, and sanitation deficiencies were observed in the kitchen and a serving kitchenette. Undated and unlabeled food items were found in refrigerators and freezers, milk was present past its best-by date, food debris and sticky residue were noted in freezer areas, a ceiling vent was dirty, and cooks with beards were observed without beard nets. The DD verified the findings, and staff stated items past date should be discarded and food items should be labeled and dated when stored.
A cognitively intact resident with compression fracture of the spine, epilepsy, and GERD had PRN Tums ordered, but the record did not show an assessment for self-administration before the medication was kept at the bedside. Nursing documentation and the care plan stated the resident did not choose to self-administer medications and that staff were to administer meds as ordered, yet a container of Tums was observed on the bedside table and RN-B confirmed no self-administration assessment had been completed. The DON stated the facility process required physician notification, a nursing assessment, physician authorization, and care plan interventions before bedside medication storage.
Call lights were not kept within reach for multiple residents who needed staff assistance. A resident with blindness, falls, and transfer needs was left at her table with the call light out of reach, another resident with cognitive impairment and extensive assistance needs had the light placed on the far side of the bed under a blanket, and a third resident with severe cognitive impairment and MS was found sleeping with the call light coiled on the wall out of reach. Staff interviews confirmed call lights should remain accessible even when residents do not always use them.
A resident with severe cognitive impairment, dementia, and Alzheimer’s disease was documented as needing meal setup assistance and was supposed to eat independently after setup. During observation, an NA left the resident sitting on the edge of the bed with the breakfast tray out of reach and the food still covered, and did not return to set up the meal. A housekeeper later moved the tray within reach, uncovered the food, heated the meal, and unrolled the silverware, after which the resident ate independently. The RN and DON stated nursing should have ensured the meal was set up appropriately.
Failure to assess the safety of perimeter mattresses for two residents. Both residents had severely impaired cognition and significant mobility limitations, and both care plans included use of a perimeter mattress to define the edges of the bed. However, their Mobility, Physical Device, and Fall Risk assessments lacked documentation of a perimeter/defined edge mattress assessment. Staff interviews showed inconsistent understanding of the required order, IDT review, engineering review, and safety assessment before use.
Improper glove use and hand hygiene during incontinent care: A resident with impaired cognition, a suprapubic catheter, bowel incontinence, a feeding tube, and supplemental oxygen required enhanced barrier precautions. During observed care, an NA and RN continued using the same gloves while moving between soiled and clean tasks, touching bare skin, handling clean supplies, and adjusting catheter, oxygen, and feeding tube tubing; the NA later stated no hand hygiene was done between glove changes.
A facility failed to document a clear clinical rationale for the continued use of high-risk medications for a resident at risk for falls. Despite a consultant pharmacist's request for an assessment, the provider's response lacked documentation of risks and benefits. The resident's care plans addressed medication risks, but no dosage reduction was attempted, and the facility's policy on acting upon pharmacist recommendations was not followed.
A facility failed to maintain a medication error rate below five percent, with a rate of 7.41% observed. Two residents receiving insulin for diabetes were involved. A nurse administered insulin using a Humalog KwikPen without priming the needle, contrary to the manufacturer's instructions. This error was acknowledged by the nurse and confirmed by other staff, including the DON.
A resident with a wound requiring enhanced barrier precautions (EBP) did not receive proper infection control during wound care. A registered nurse failed to wear a gown and did not perform hand hygiene between glove changes, contrary to facility policy and expectations. Interviews with staff confirmed the breach in protocol.
Two residents at an LTC facility experienced falls due to staff not following assessed fall prevention techniques. One resident, with osteoporosis and Alzheimer's, sustained an ankle fracture when staff failed to use a gait belt during a transfer. Another resident, with cognitive impairment, fell due to a missed toileting schedule. The incidents highlight deficiencies in staff adherence to care plans and communication protocols.
Food Storage, Labeling, and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food items were properly labeled, dated, stored, and kept clean in the main kitchen and a 3rd floor kitchenette. During observation of the main kitchen, a walk-in storage freezer had boxes stored on the floor and frozen tater tots scattered across one corner of the freezer floor. A refrigerator used for some independent living residents contained a tray of tartar sauce portion cups that were undated, and the bottom shelf was dirty with crumbs and food debris. A walk-in freezer had sticky floors and frozen sausage links scattered on the floor. In the main kitchen refrigerator, a tray of red sauce portion cups was not labeled or dated, a Ziplock bag of sliced meat had a date of 5/6 and appeared to have a grayish white tint, and another Ziplock bag of seasoned meat was in a container with no label or date. A ceiling vent above the main stove had brown/black dust and dirt on it. The Dietary Director verified the undated and unlabeled food items, the food spilled on the freezer floors, the dirty vent, and the lack of a beard net on a cook with a short trimmed beard. In the 3rd floor kitchenette, the small refrigerator by the steam table contained 2 half gallons of skim milk, including one unopened container with a best by date of 6/7/26 and one opened container with approximately 1/2 cup left with a best by date of 6/6/26. A cook with a medium length beard was working on the serving side of the kitchenette and was not wearing a beard net. Nursing staff stated the milk should be tossed, and the cook stated the morning cooks should have reviewed the refrigerator items and that items past their dates should be thrown out. The Dietary Director and administrator stated staff were expected to ensure food items were dated and labeled when stored, refrigerators were reviewed for out-of-date items, beard nets were worn in the kitchen and serving areas, and refrigerators, freezers, and ceiling vents were clean.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident’s ability to self-administer medications before allowing medication to be kept at the bedside. The resident, R126, was cognitively intact on the admission MDS and had diagnoses including compression fracture of the spine with routine healing, epilepsy, and GERD. Physician orders dated 5/28/26 included Calcium Carbonate (Tums) 500 mg, two tablets by mouth every four hours as needed for heartburn or upset stomach, but the orders did not indicate that R126 was able to self-administer medication. The comprehensive nursing data collection dated 5/28/26 stated the resident had not brought medications on admission and did not choose to self-administer medications, and the care plan dated 6/1/26 also stated the resident chose not to self-administer medications, with interventions directing staff to administer medications as ordered. Despite this documentation, the medical record lacked evidence that R126 had been assessed for self-administration of medications. During observation on 6/8/26, a container of Tums was seen on R126’s bedside table, and the resident stated family had brought the medication to the facility so it would be available because he had not received it when requested during a previous hospitalization. RN-B confirmed the Tums were on the bedside table and stated no self-administration assessment had been completed, adding that an order and assessment were required if a resident was to self-administer medications. The DON stated the facility’s process for self-administration required physician notification, a nursing assessment, physician authorization, and care plan interventions, and the facility policy directed staff to assess the resident’s ability to safely self-administer medications before allowing medications to be kept at the bedside.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to ensure call lights were within reach for residents who were dependent on staff assistance. During observation, interview, and record review, call lights were found out of reach for 3 of 4 residents reviewed: R106, R24, and R9. Facility staff, including an RN, left R106 in her room at her dining room table without placing the call light within reach, even though she had moderately impaired cognition, blindness, multiple falls, and required staff assistance for transfers and toileting. Two call lights were present in her room, but one was on the bed about 7 feet away and the other was in the bathroom out of reach. R24, who had moderately impaired cognition, non-traumatic brain dysfunction, arthritis, and required substantial staff assistance for toileting, dressing, and transfers, was observed seated in her wheelchair with no call light within reach. The call light was on the other side of the bed and underneath a blanket. An RN later placed it within her reach and stated a volunteer may have brought her back to the room without placing the light. R9, who had severely impaired cognition, multiple sclerosis, dementia, muscle weakness, repeated falls, and dependence on staff for toileting and transfers, was observed sleeping in bed with the call light coiled up on the wall by the foot of the bed and not within reach. Interviews with nursing and activity staff confirmed that call lights should be within residents’ reach even when residents do not always use them or have cognitive impairment. The DON stated staff should ensure the call light is within reach before leaving a resident’s room, and if a resident cannot use the call light due to cognition, it should be removed as a care plan intervention. The facility policy stated all personnel must be aware of call lights, answer them promptly, and position them conveniently and accessibly for residents in bed or other sleeping accommodations.
Failure to Provide Meal Setup Assistance
Penalty
Summary
The facility failed to provide setup meal assistance for a resident with severe cognitive impairment, dementia, and Alzheimer’s disease who was documented on the MDS as requiring setup or clean up assistance with eating and substantial/maximal assistance with mobility. The resident’s care plan stated she was independent with eating after setup, and a family member reported that she needed her silverware placed out or she would eat with her fingers. During observation, a nursing assistant helped the resident sit on the edge of the bed, left to get the breakfast tray, and did not return to set up the meal even though the resident remained in bed with the tray table out of reach and the food covered with silverware still rolled in a napkin. A housekeeper later noticed the tray was not within the resident’s reach, moved the tray table in front of her, uncovered the food and beverage, heated the meal, and unrolled the silverware. After that, the resident drank juice and ate breakfast independently. The nursing assistant stated the resident could eat independently after everything was set up and that if lids were not removed she often would not know what to do and would not eat. The RN stated the meal should have been set up by nursing with the tray within reach, and the DON stated a resident needing meal setup assistance should have the tray set up appropriately and within reach. The facility policy stated assistance with tray setup and uncovering food items would be provided as needed and items would be placed conveniently for the individual.
Failure to Assess Safety of Perimeter Mattresses
Penalty
Summary
The facility failed to ensure that 2 residents with perimeter mattresses were assessed for safety. One resident had a significant change MDS showing severely impaired cognition, dementia, reduced mobility, muscle weakness, and need for assistance with bed mobility, sitting, standing, and transfers. That resident’s care plan identified limited physical mobility related to dementia with mood disturbance and anxiety, a genetic muscle disorder, spinal stenosis, and osteoarthritis, and included use of a perimeter mattress to help find the edges of the bed for bed mobility. However, the resident’s Mobility, Physical Device, and Fall Risk assessment lacked documentation of an assessment for a perimeter/defined edge mattress. The second resident’s annual MDS showed severely impaired cognition, dementia, multiple sclerosis, repeated falls, and need for partial to moderate assistance with bed mobility. The care plan identified limited physical mobility related to weakness, falls, incontinence, hypertension, renal disease, dementia, MS, depression, and delusional disorder, and included use of a bariatric sized bed with a perimeter mattress to define the edges of the bed. That resident’s Mobility Physical Device and Fall Risk assessment also lacked documentation of an assessment for a perimeter/defined edge mattress. During observation, the resident was in bed asleep with a perimeter mattress. Staff interviews showed differing understanding of whether a physician order, assessment, IDT review, engineering review, and safety assessment were required before use of a perimeter mattress, and the DON confirmed both residents’ most recent assessments lacked documentation of a perimeter/defined edge mattress assessment.
Improper glove use and hand hygiene during incontinent care
Penalty
Summary
The facility failed to ensure proper infection control practices involving hand hygiene and glove use during incontinent care for one resident who had moderately impaired cognition, an indwelling/suprapubic urinary catheter, frequent bowel incontinence, a feeding tube, supplemental oxygen, and dependence on staff for all personal care. The resident’s care plan identified the resident as at risk for infections and required enhanced barrier precautions in addition to standard precautions during high-contact care activities. During observed incontinent care, two nursing assistants entered the room with hand hygiene, gloves, and gowns, and one assistant removed the resident’s brief and cleaned the peri area while the other assisted with care. As the resident continued to have an active soft bowel movement, the registered nurse entered and cleaned the bowel movement, and the nursing assistant continued care without changing gloves. The nursing assistant used the same gloved hands to reposition the resident, touch bare skin, remove soiled items, retrieve clean supplies, adjust the catheter tubing, and handle the oxygen and feeding tube tubing. The nursing assistant later changed gloves once and stated that was the first glove change during all of the resident’s care and that no hand hygiene had been performed between glove changes. The RN stated gloves should have been changed after incontinent care and hand hygiene performed before donning new gloves, and the DON stated staff are expected to change gloves and perform hand hygiene when moving from soiled to clean areas during incontinent care.
Failure to Document Clinical Rationale for High-Risk Medications
Penalty
Summary
The facility failed to ensure that a licensed pharmacist performed a comprehensive monthly drug regimen review for a resident, identified as R83, who was at risk for falls and adverse effects due to medication use. The report highlights that the provider did not document a clear clinical rationale for the continued use of high-risk medications, including antipsychotics, antidepressants, and opioids, which were identified as potentially inappropriate for the resident. Despite the consultant pharmacist's communication requesting an assessment of these medications, the provider's response lacked documentation of risks and benefits to justify their continued use. R83's medical history included a fall prior to admission, impaired mobility, and the use of high-risk medications such as antipsychotics and opioids. The resident's care plans addressed these risks, but there was no documented attempt to reduce medication dosages or provide a clinical rationale for their necessity. The consultant pharmacist's report specifically noted the risk of falls associated with the medications and recommended an assessment for ongoing use, but the provider's response was inadequate, merely noting 'hospice' without further explanation. Interviews with facility staff, including nursing assistants and registered nurses, indicated that R83 was stable, with no recent behaviors or mood concerns. However, the hospice RN confirmed that there had been no request to review the resident's CNS-active medications. The director of nursing believed that the hospice designation was sufficient rationale, despite the lack of documented clinical justification. The facility's policy required that recommendations from the consultant pharmacist be acted upon and documented, but this was not adhered to in R83's case.
Medication Error Due to Improper Insulin Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with a reported error rate of 7.41%. This was observed during a medication pass involving two residents, both of whom were receiving insulin for diabetes management. The first resident, identified as R25, was cognitively intact and required assistance with daily activities. R25's care plan highlighted the need for proper medication administration due to diabetes. However, during an observation, RN-A administered insulin using a Humalog KwikPen without priming the needle, which is a necessary step to ensure the correct dose is delivered. Similarly, the second resident, R34, who had moderate cognitive impairment and also required assistance with daily activities, was observed receiving insulin from RN-A without the needle being primed. RN-A initially stated that priming was unnecessary unless using a new pen, but later acknowledged the mistake. Interviews with RN-B and the DON confirmed that insulin pens should be primed to avoid dosage errors. The manufacturer's instructions for the Humalog KwikPen also specify the need for priming to ensure accurate dosing.
Infection Control Deficiency During Wound Care
Penalty
Summary
The facility failed to ensure proper infection control practices during wound care for a resident identified as R20. R20 was cognitively intact and required assistance with daily activities, with a care plan indicating the need for enhanced barrier precautions (EBP) due to a wound. Despite the presence of an EBP sign and an isolation cart with personal protective equipment (PPE) outside R20's room, a registered nurse (RN-C) did not adhere to the required precautions. During an observation, RN-C entered the room, donned gloves without a gown, and failed to perform hand hygiene between glove changes while providing wound care. Interviews with RN-C, another registered nurse (RN-B), the infection preventionist (IP), and the director of nursing (DON) confirmed the expectation for staff to follow EBP by wearing gowns and gloves and performing hand hygiene between glove changes. The facility's policy required the use of gowns and gloves for high-contact care for residents at increased risk of multidrug-resistant organism (MDRO) acquisition, including those with wounds. The policy also specified that hand hygiene should be performed before donning and after doffing PPE, which was not followed in this instance.
Failure to Implement Fall Prevention Techniques
Penalty
Summary
The facility failed to implement assessed and directed fall prevention techniques for two residents, resulting in actual harm for one resident who sustained a right ankle fracture. The first resident, who had diagnoses including osteoporosis and Alzheimer's disease, was identified as a fall risk and required assistance with transfers using a front-wheeled walker and a gait belt. However, during a transfer, staff did not utilize a gait belt as required, leading to the resident being assisted to the floor and sustaining a fracture. The second resident, also identified as a fall risk due to cognitive impairment and gait/balance problems, had a care plan that included a toileting schedule to prevent falls. Despite this, the resident experienced an unwitnessed fall in their room, as the toileting plan was not followed. The resident attempted to get out of bed to use the bathroom, indicating a lapse in the implementation of the care plan. The facility's documentation and interviews revealed that staff were not consistently following the individualized care plans and communication sheets, which outlined necessary interventions for fall prevention. The lack of adherence to these protocols contributed to the incidents, highlighting deficiencies in staff training and communication regarding resident care plans.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Oak Park Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Estates At Greeley Llc | 1.6 mi | ★★★★★ | 0 | 0 |
| The Estates At Linden Llc | 2.2 mi | ★★★★★ | 4 | 0 |
| Good Samaritan Society - Stillwater | 2.4 mi | ★★★★★ | 9 | 0 |
| Christian Community Home | 6 mi | ★★★★★ | 0 | 0 |
| Maplewood Rehabilitation Center | 9.4 mi | ★★★★★ | 26 | 0 |
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