Gables Of Boutwells Landing
GABLES OF BOUTWELLS LANDING in OAK PARK HEIGHTS, MN — inspection on June 10, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an observation and interview on 6/8/26 at 2:17 p.m., a container of Tums was observed on R126's bedside table. R126 stated the resident's family brought the medication to the facility. R126 stated he wanted Tums available because he had not received them when requested during a previous hospitalization.
During an interview on 6/8/26 at 3:50 p.m., registered nurse (RN)-B confirmed that R126 had a container of Tums on his bedside table. RN-B further confirmed no self-administration of medication assessment had been completed. (RN)-B further stated if a resident was to self administer medications, an order and assessment were to be completed.
During an interview on 6/10/26 at 8:07 a.m., the Director of Nursing (DON), stated when residents wished to self-administer medications, the facility's process required physician notification, completion of a nursing assessment, physician authorization, and care plan interventions to support safe self-administration.
The DON stated this process was important to promote resident autonomy while ensuring medications were managed safely.The facility's policy titled, Self-Administration of Medication Policy dated 11/2016, directed staff to assess the resident's ability to safely self-administer medications prior to allowing medications to be kept at the bedside.
245615 06/10/2026
Gables of Boutwells Landing 13575 58th Street North Oak Park Heights, MN 55082
During interview on 6/10/26, at 8:40 a.m., RN-D stated call lights should be placed within reach even if the resident didn't always use it or had issues with their cognition.
During interview on 6/10/26 at 8:42 a.m., RN-F stated all call lights should be within reach even if the resident had issues with their cognition or they didn't use the call light on a regular basis.
During interview on 6/10/26 at 10:47 a.m., the director of nursing (DON), stated before nursing staff exited a resident's room, they should ensure their call light was within reach. If the resident moved independently after they placed the call light next to them, they can't help that, but they would put the call light within reach again when they were rounding.
The DON further stated if a resident was unable to use the call light due to cognition, the call light should be removed as an intervention on their care plan.
The facility policy regarding call lights dated November of 2022, indicated the following procedure for call light use:
- All facility personnel must be aware of call lights at all times.2.
Answer all call lights promptly whether or not you are assigned to the resident.3.
See manufacturer's instructions for turning off the call light and managing the call light system.4.
Answer all call lights in a prompt, calm, courteous manner; turn off the call light as soon as possible.5.
Position the call light conveniently for the resident to use.
Tell the resident where the call light is and show him/her how to use the call light when needed.a.
Ensure the call light is accessible to the resident while in their bed or other sleeping accommodation in their room (e.g., recliner).b.
Ensure the call light is accessible to the resident if they were lying on the floor near the toilet, bath or shower.6.
Orient all new residents to the call light as appropriate.
245615 06/10/2026
Gables of Boutwells Landing 13575 58th Street North Oak Park Heights, MN 55082
During interview on 6/8/26 at 12:22 p.m., family member (FM)-A stated R28 required assistance with meals and needed to have her silverware placed out, otherwise she would eat with her fingers.
During observation on 6/9/26 at 8:56 a.m., nursing assistant (NA)-A entered R28's room and assisted her to a sitting position on the edge of her bed. NA-A explained she was going to assist with a transfer to her chair. R28 refused to transfer.
NA-A explained it was time for breakfast and left to retrieve R28's breakfast tray.
During observation on 6/9/26 at 9:20 a.m., R28 was still sitting on the side of her bed with the bedside table approximately three feet away and at a 45 degree angle from R28.
All items on the tray were covered and the silverware still rolled up in the napkin.
During continuous observation between 9:20 a.m. and 9:39 a.m., NA-A walked past R28's room several times, looked in the room but did not enter, and did not offer to set up R28's meal.
During observation on 6/9/26 at 9:39 a.m., housekeeper (H)-A walked by and stopped at R28's doorway. H-A entered and pushed the tray table over and positioned it in front of R28 who was still sitting on the edge of her bed. H-A uncovered her food and beverage, heated up the plate in the microwave, and unrolled the silverware. R28 immediately picked up the juice and began drinking and then proceeded to eat her breakfast independently.
During interview on 6/9/26 at 9:41 a.m., H-A stated she had noticed R28's tray table and breakfast were not within her reach and had not been set up for her. H-A stated she heated up R28's meal and opened everything up for her.
During observation on 6/9/26 at 10:04 a.m., R28 was done with breakfast and she had eaten approximately 75% of the eggs and 90% of what appeared to be French toast. R28 had not touched the bowl of fruit, but drank approximately 25% of both the milk and juice.
During interview on 6/9/26 at 10:28 a.m., NA-A stated R28 could eat independently after everything was set up for her. NA-A stated if the lids were not removed from the food and beverages, she often would not know what to do and would not eat.
During interview on 6/9/26 at 11:35 a.m., registered nurse (RN)-A stated would expect R28 to have her meal set up for her with lids removed and the tray table in front of her and within reach when the meal was delivered. RN-A stated this was the responsibility of nursing, and not housekeeping to ensure the resident was set up appropriately for a meal. RN-A stated R28 should be seated in a wheelchair or recliner for her meals when she was eating in her room, but she often refused.
During interview on 6/10/26 at 11:14 a.m., director of nursing (DON) stated would expect a resident who required meal setup assistance would have their tray set up appropriately and within reach.
Facility policy Meal Tray Delivery Policy - Care Center dated 7/2020, indicated, Assistance with tray set up and uncovering food items will be provided as needed.and Items will be placed so they are convenient for the individual and neatly arranged.
245615 06/10/2026
Gables of Boutwells Landing 13575 58th Street North Oak Park Heights, MN 55082
During observation on 6/10/26 at 8:25 a.m., R9 was in bed asleep and had a perimeter mattress.During interview on 6/10/26 at 7:35 a.m., registered nurse (RN)-C stated they were unsure if a resident needed a physician's order or an assessment in order to have a perimeter mattress.
During interview on 6/10/26 at 7:48 a.m., RN-D stated in order for a resident to use a perimeter mattress, they would need a doctor's order and an assessment.
During interview on 6/10/26 at 8:47 a.m., RN-A stated they typically don't give out perimeter mattresses to residents, but one of the main reason's was so they can feel the edges of the bed, so they don't fall.
They are never used to keep a resident in bed.
Before a resident was permitted to use a perimeter mattress, the interdisciplinary team (IDT) would review the situation (Ex: fall), and engineering would check to make sure the resident was the appropriate size for the mattress.
The nurse was also required to fill out a safety assessment.
During an interview on 6/10/26 at 8:15 a.m. RN-F stated in order for a resident to be able to use a perimeter mattress, IDT would need to decide if it was appropriate (in order to ensure it wasn't used as a restraint), and maintenance would need to do an assessment for the entrapment zone which should also be done yearly.
During a follow up interview at 8:42 a.m., RN-F stated the engineering department fills out the assessments.
During interview on 6/10/26 at 9:54 a.m. the director of nursing (DON) stated in order for a resident to be able to use a a perimeter mattress, IDT would meet to discuss the situation and if they felt the resident needed it, they would put a TELS request (work order) in for the engineering department.
The engineer ensures the perimeter mattress meets all the requirements.
Then a clinical manager would be responsible for completing a Mobility Physical Device and Fall Risk Assessment to ensure it meets the resident's needs and is safe to use.
These assessments are tracked on quarterly basis and through MDS assessments.
The DON verified R7's last assessment was completed on 4/11/24 and R9's was on 4/23/24 and that both lacked documentation of an assessment for a perimeter/defined edge mattress.
The facility policy titled Physical Device Assessment Policy dated November of 2022, indicated upon admission, with significant change, annually or the implementation of a new device, the resident will be assessed for physical devices.
The assessment will be reviewed quarterly.
The assessment includes but is not limited to an assessment of symptoms, ability to use the device, and potential risk and benefit.
245615 06/10/2026
Gables of Boutwells Landing 13575 58th Street North Oak Park Heights, MN 55082
clean. A facility policy titled Labeling and Dating Policy revised 8/2019, directed staff to label and
facility policy titled Safe Food Storage revised 5/219, directed staff to keep all food items stored on
opening.
245615 06/10/2026
Gables of Boutwells Landing 13575 58th Street North Oak Park Heights, MN 55082
During observation and interview on 6/9/26 at 10:54 a.m., nursing assistant (NA)-B and NA-A entered R8's room to perform incontinent care.
Both NAs performed hand hygiene, donned gloves and a gown prior to entering room. NA-B removed R8's brief and cleaned front peri area with premoistened wipes. R8 was then positioned on left side facing NA-A while NA-B wiped his bottom and removed the dirty brief. NA-A called for the nurse for a skin check and medication application to bottom.
While waiting for the nurse, R8 was repositioned on his back and covered up. At 11:04 a.m., registered nurse (RN)-A entered with appropriate PPE (personal protective equipment). No glove change had been completed by either NA.
R8 was repositioned on left side, NA-B used same gloved hands to reposition while touching R8's bare skin. R8 continued to have active soft bowel movement (BM). RN-A used wipes to clean the BM. NA-B took over incontinent care and cleaned the large amount of BM that continued to ooze out. NA-B removed all the soiled wipes, under pad, and draw sheet and placed soiled items in bags. NA-B did not change gloves and picked up the package of wipes to set aside, grabbed a new brief and opened a new package of chux (under pad) and grabbed several while RN-A applied ointment to R8's bottom.
Again, R8 was repositioned with assistance from NA-B using same gloved hands touching R8's exposed legs and back bare skin. NA-B used same gloved hands to rip a slit in the new brief to fit around the suprapubic catheter insertion site just over the dressing. NA-B then situated R8. NA-B handled the catheter tubing, touched and pulled at sheet on all sides of the sheet, adjusted the oxygen tubing and the feeding tube tubing. At 11:20 a.m., NA-B removed his gloves and donned new ones, without performing hand hygiene and then retrieved a graduate cylinder. NA-B emptied R8's catheter bag.
When asked, NA-B stated that was the first time during all of R8's cares that he had changed his gloves and confirmed he did not perform any hand hygiene in between glove change. NA-B further stated he had used the same gloves to reposition and touch other items after cleaning the BM from R8. NA-B stated he should have changed his glove and performed hand hygiene after incontinent care and prior to touching any other items.
During interview on 6/9/26 at 11:25 a.m., registered nurse (RN)-A stated NA-B should have changed gloves after incontinent care and hand hygiene should have been performed and new gloves donned.
During interview on 6/10/26 at 11:14 a.m. director of nursing (DON) stated expectation for staff to change gloves and perform hand hygiene when working from soiled to clean areas during incontinent care.
Facility policy Infection Control Standard Precautions dated 2020, indicated, Appropriate hand hygiene is essential in preventing transmission of infectious agents.
Hand Hygiene includes hand washing with soap and water and hand hygiene with alcohol-based hand rub (ABHR).Hand hygiene continues to be the primary means of preventing the transmission of infections.
The policy further indicated, Hand Hygiene should be performed.Before donning [PPE] and After removing [PPE].
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.