Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.