Gables Of Boutwells Landing

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. A refrigerator used for some of the independent living residents contained a tray of portion cups containing tartar sauce that were undated. The bottom shelf of this refrigerator was dirty and filled with crumbs and food debris. A walk-in freezer in the main kitchen area was found to have sticky floors and several frozen sausage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. R126's provider orders lacked indication R126 was able to self-administer medication.R126's comprehensive nursing data collection dated 5/28/26, indicated R126 had not brought medications with upon admission. The assessment further indicated R126 did not choose to self-administer medications.R126's care plan dated 6/1/26, indicated R126 chose not to self-administer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and document review, the facility failed to ensure call lights were within reach for residents who were dependent on staff assistance for 3 of 4 residents (R106, R24, and R9) reviewed for call light accessibility. Findings include: R106 R106's quarterly Minimum Data Set (MDS) dated [DATE], identified moderately impaired cognition, no behaviors or rejection of care. two falls since prior assessment, one with major injury, and that she required partial to moderate staff assistance for toileting hygiene, lower body dressing, sit to stand ability and chair/bed to chair transfers. R106 required partial/moderate staff assistance in her manual wheelchair to propel 50 feet and make two turns. Diagnoses included blindness and anxiety. R106's care plan intervention dated 5/20/26, identified due to limited physical ability assist of one staff was required for stand and pivot transfers. The care plan did not identify wheelchair mobility. R106 care plan intervention dated 1/15/26, identified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide setup meal assistance for 1 of 2 residents (R28) reviewed for activities of daily living (ADLs). Findings include:R28's quarterly Minimum Data Set (MDS) dated [DATE], indicated R28 had severe cognitive impairment, required setup or clean up assistance with eating, and substantial/maximal assistance with mobility. R28's diagnoses included non-traumatic brain dysfunction (an alteration in brain function caused by internal factors such as illness, oxygen deprivation, or toxic exposure), dementia, and Alzheimer's disease. R28's care plan last reviewed 4/2/26, indicated R28 had ADL self-care performance deficit related to her diagnoses and that she was independent with eating after setup. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review the facility failed to ensure 2 of 2 residents (R7, R9) with perimeter mattresses were assessed for safety. Findings include: R7R7's significant change Minimum Data Set (MDS) dated [DATE], indicated severely impaired cognition and diagnoses of dementia, reduced mobility and muscle weakness. It further indicated R7 required partial assistance with bed mobility (roll left and right), substantial assistance with lying to sitting on the edge of the bed, sitting to standing, and transfers.R7's care plan dated 2/13/24, indicated R7 had limited physical mobility related to dementia with mood disturbance and anxiety, [NAME] disease (genetic muscle disorder), spinal stenosis, and osteoarthritis. It further indicated an intervention of a perimeter mattress to assist R9 in finding the edges of her bed for bed mobility. R7's Mobility, Physical Device, and Fall Risk assessment dated [DATE], lacked documentation of an assessment for a perimeter/defined edge mattress. R9…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure proper infection control practices involving hand hygiene and glove use during incontinent care for 1 of 1 resident (R8) observed during cares. Findings include:R8's annual Minimum Data Set (MDS) dated [DATE], indicated R8 had moderately impaired cognition, had an indwelling urinary catheter, was frequently incontinent of bowel, required a feeding tube, and was dependent on staff for all personal care. R8's diagnoses included benign neoplasm of meninges (tumors in the protective membranes of the brain and spinal cord), chronic kidney disease, dysplasia (difficulty swallowing), aphasia (condition affecting speech), dependance on supplemental oxygen, and history of nontraumatic intracerebral hemorrhage (brain bleed not due to injury). R8's care plan dated 4/2/26, indicated R8 had a suprapubic catheter (tube directly through the skin into the bladder for draining), was incontinent of bowel, had a G/J (gastrojejunostomy) tube to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure range of motion (ROM) was provided for 1 of 2 resident (R19) reviewed for mobility. Findings include: R19's quarterly Minimum Data Set (MDS) dated [DATE], indicated intact cognition, did not have hallucinations or delusions, and did not reject cares. Further, R19 had upper and lower extremity limitations in range of motion on both sides. R19's Optional State assessment dated [DATE], indicated R19 was totally dependent with bed mobility, transfers, and toileting. R19's Care Area Assessment (CAA) dated 8/7/24, indicated R19 could not ambulate, and had complications from immobility that included contractures. R19's Medical Diagnosis form indicated R19 had the following diagnoses: multiple sclerosis (a disease affecting the central nervous system), other specified polyneuropathies (nerve damage), muscle weakness, other reduced mobility. R19's physician's orders identified the following orders: • 8/1/24, Occupational therapy and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure the provider documented a clear clinical rationale for actions taken or not taken; including risks and benefits to justify the continued use of medications identified to put the resident at risk for falls and adverse effects for 1 of 1 resident (R83) reviewed for requests for clinical rationale. Findings include: R83's admission Minimum Data Set (MDS) dated [DATE], identified a fall occurred in the past two to six months prior to admission. No behaviors or rejection of care occurred, and the mood interview indicated no depression. R83's corresponding Care Area Assessments (CAA), undated, identified falls was triggered related to history of falls, impaired mobility, cognition, hearing, pain, incontinence, anticipated decline, and medication side effects and care planning was in place to minimize risks and provide symptom relief or palliative measures. Additionally, psychotropic medication use was triggered related to high risk…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure they were free of a medication error rate of five percent or greater. The facility had a medication error rate of 7.41% with 2 errors out of 27 opportunities for errors involving 2 of 7 residents (R25 and R34) who were observed during the medication pass. Findings Include: R25 R25's quarterly minimum data set (MDS) dated [DATE], identified R25 was cognitively intact and required staff assistance with most activities of daily living. The MDS indicated R25 had diabetes mellitus (DM) and received insulin daily in the 7-day lookback period. R25's care plan revised 5/14/24, identified a risk for alteration in blood glucose levels related to the diagnosis of diabetes and tasked staff with providing medications per orders. R25's provider order dated 6/28/24 indicated, HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro). Inject as per sliding scale: if 141-180 = 2 units give before meals, anything above 400 gives 14 units. May sub…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and document review, the facility failed to ensure proper infection control practices were followed when staff failed to utilize enhanced barrier precautions (EBP) and proper hand hygiene for 1 of 1 resident (R20) observed during wound care. Findings include: R20's admission minimum data set (MDS) dated [DATE], identified R20 was cognitively intact, required partial to substantial staff assistance in most activities of daily living, and at risk for developing pressure ulcers. Diagnoses included debility (general weakness), chronic obstructive pulmonary disease (COPD), and oxygen therapy. R20's care plan (CP) dated 6/18/24, identified EBP was placed due to a wound. The CP directed staff to follow EBP, in addition to standard precautions, by wearing gown and gloves during high-contact care activities. R20's physician orders dated 6/18/24 indicated wound care to coccyx every shift and as needed for wound integrity. During an observation on 7/8/24 at 1:55 p.m., R20's door had an EBP…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.