Gables of Boutwells Landing: Infection Control Failures - MN
Federal inspectors documented the sequence in detail during a June 9 visit to Gables of Boutwells Landing, a nursing facility in Oak Park Heights. The resident at the center of it, identified in inspection records only as R8, had a suprapubic catheter inserted directly through the skin into his bladder, a feeding tube delivering his nutrition, supplemental oxygen through a nasal cannula, and a care plan that flagged him as being at elevated risk for infection. He was also dependent on staff for every aspect of his personal care.
The inspection report identified the nursing assistant as NA-B. He and a colleague entered the room at 10:54 a.m. Both performed hand hygiene and put on gloves and gowns before entering. The start was correct. What followed was not.
NA-B cleaned the front area, repositioned the resident, and wiped his bottom. A registered nurse was called in for a skin check and to apply ointment. While waiting, the resident was repositioned onto his back. Neither nursing assistant changed gloves. When the nurse arrived ten minutes later, NA-B used those same gloves to reposition the resident again, touching bare skin, while the resident continued to have an active bowel movement.
NA-B then took over cleaning a large amount of feces that continued to come. He removed soiled wipes, an underpad, and a draw sheet, bagged them, and, without changing gloves, picked up a package of clean wipes to set aside. He grabbed a new brief. He opened a fresh package of underpads and pulled out several. He helped reposition the resident again, his contaminated gloves on the man's exposed legs and back.
Then he used those same gloves to tear a slit in the new brief to fit around the catheter insertion site and its dressing. He situated the resident. He handled the catheter tubing. He adjusted the oxygen tubing. He touched the feeding tube.
At 11:20 a.m., he finally changed his gloves. He did not wash his hands first.
When inspectors asked him about it, NA-B confirmed that was the first glove change during the entire 26 minutes of care. He confirmed he had not performed hand hygiene between the glove change. He said he had used the same gloves to reposition and touch other items after cleaning the feces. "He stated he should have changed his glove and performed hand hygiene after incontinent care and prior to touching any other items," the inspection report noted.
The registered nurse who was present, RN-A, told inspectors afterward that NA-B should have changed gloves after the incontinent care and washed his hands before putting on new ones. The director of nursing said the same thing the following morning: the expectation is that staff change gloves and perform hand hygiene when moving from soiled to clean areas during this kind of care.
Everyone agreed on what should have happened. Nobody stopped it while it was happening.
R8's medical history made the lapse particularly stark. His conditions included brain tumors affecting the protective membranes of the spine, chronic kidney disease, a history of brain bleeding, difficulty swallowing, and a speech impairment that left him unable to communicate in the way most people can. He was dependent on staff for everything. He could not advocate for himself during the 26 minutes NA-B moved between soiled materials and his catheter site with the same pair of gloves.
Inspectors cited the facility for failing to ensure proper infection control practices, rating the level of harm as minimal harm or potential for actual harm. The facility's own infection control policy, dated 2020, stated that hand hygiene is the primary means of preventing the transmission of infections and must be performed after removing personal protective equipment.
R8's catheter runs directly into his bladder through a surgical opening in his skin.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Gables of Boutwells Landing from 2026-06-10 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
GABLES OF BOUTWELLS LANDING in OAK PARK HEIGHTS, MN was cited for violations during a health inspection on June 10, 2026.
Federal inspectors documented the sequence in detail during a June 9 visit to Gables of Boutwells Landing, a nursing facility in Oak Park Heights.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.