Gables of Boutwells Landing

In the surveyor’s words

From the most serious findings on record at Gables of Boutwells Landing, in the surveyor’s own words.

• Actual harm, isolatedF689May 30, 2024

  Based on observation, interview and document review, the facility failed to implement assessed and directed fall prevention techniques for 2 of 3 residents (R1,R2) reviewed for falls. This resulted in actual harm for R1 who had an assisted fall to the floor when staff were not utilizing a gait belt during a transfer as assessed and R1 sustained a right ankle fracture. Findings include: R1's annual Minimal Data Set (MDS) dated [DATE], indicated R1 had diagnoses which included osteoporosis, Alzheimer's disease, and R1 had moderately impaired cognition. […]

• No harm, potential for more than minimal, widespreadF812Jun 10, 2026

  Based on observation, interview, and document review, the facility failed to ensure milk was not in use past the use by date, refrigerated items were labeled and dated, and maintain cleanliness of ceiling vent, refrigerator, and freezers in the main kitchen. Furthermore, the facility failed to ensure beard nets were used in food preparation and service areas. This had the potential to affect all residents who received food from the facility kitchen. Findings include: An observation on 6/8/26 at 11:19 a.m., the main kitchen was observed. A walk-in storage freezer was observed to have boxes stored on the floor and several frozen tater tots scattered across one corner of the freezer floor. […]

• No harm, potential for more than minimal, patternF550Aug 17, 2023

  Based on observation, interview, and document review, the facility failed to provide a dignified dining experience for 6 of 6 residents (R6, R10, R36, R45, R50, R82) who required assistance with eating. This has the potential to impact all residents residing on memory care who require assistance with eating. Findings include: R6's significant change MDS dated [DATE], indicated R6 had severe cognitive impairment and diagnoses of Parkinson's disease and dementia. Furthermore, R6's MDS indicated R6 required extensive assist of one person for eating. R10's quarterly MDS dated [DATE], indicated R10 had mild cognitive impairment and had diagnoses of Parkinson's disease and dementia. […]

• No harm, potential for more than minimal, patternF880Aug 17, 2023

  Based on observation, interview, and document review, the facility failed to ensure hand hygiene was completed during wound cares and wound cares were provided to minimize risk of cross contamination for 1 of 2 residents (R17) observed for pressure injuries. Furthermore, the facility failed to ensure hand hygiene was completed for 2 of 2 residents (R15, R29) observed for incontinent cares and 7 residents (R6, R10, R36, R45, R50, R54, R82) who required assistance with eating. The facility also failed to ensure disinfection of a glucometer was performed for 1 of 1 resident (R9) observed for medication administration. […]

• No harm, potential for more than minimal, isolatedF554Jun 10, 2026

  Based on observation, interview, document review, the facility failed to assess a resident's ability to self-administer medications for 1 of 1 resident (R126) reviewed for self-administration of medications. Findings include: R126's admission Minimum Data Set (MDS) dated [DATE], indicated R126 was cognitively intact. R126's diagnoses included compression fracture of the spine with routine healing, epilepsy (seizures), and gastroesophageal reflux disease (GERD) (heartburn).R126's physician orders dated 5/28/26, included Calcium Carbonate (Tums) 500 milligrams (mg), two tablets by mouth every four hours as needed for heartburn or upset stomach. […]