Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to notify the physician of one (R1) resident of
change in condition of three residents reviewed. This failure resulted in delaying R1's transfer to the hospital
for further evaluation for a contusion and bruised right eye in a total sample of three residents.
Residents Affected - Few
Findings include:
R1 is a [AGE] year-old individual whose medical diagnosis include but not limited to: dementia in other
diseases classified elsewhere, mild, without behavioral disturbance, psychotic disturbance, mood
disturbance, and anxiety, mild intellectual disabilities, chronic obstructive pulmonary disease, unspecified,
disorganized schizophrenia.
MDS (Minimum Data Set) section C Cognitive function, dated [DATE], documents R1's Brief Interview for
Mental Status (BIMS) as 99/15 indicating R1 has severe cognitive impairment.
R1's MDS section GG -Functional Abilities documents R1 requires supervision or touching assistance while
eating, partial/moderate assistance with oral hygiene and upper body dressing, substantial/maximal
assistance with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear,
and personal hygiene.
Nursing progress notes dated [DATE], documents:
Summary of the Fall: observes resident (R1) with raised area over right eyebrow with discoloration. R1 has
raised area to right eye and broken blood vessel to right eye.
Nursing progress notes dated [DATE], documents nurse to nurse report with admitting hospital stated R1
had CT(Computed Tomography) scan showed edema and hematoma and R1 was going to be admitted for
fall and head contusion.
R1's hospital record dated [DATE], documents: A contusion is a deep bruise. Contusions are the result of a
blunt injury to tissues and muscle fibers under the skin. The injury causes bleeding under the skin.R1
presented to the hospital with bruised or swollen eye. Fall with right sided periorbital edema. Head CT
shows there is hemorrhage and edema throughout the right supraorbital and periorbital region.
On [DATE], at 10:43 AM, V5 (Licensed Practical Nurse-LPN) and surveyor observed R1 laying in bed. R1
was observed with a bruise on the right eye above and below the eyebrow. The bruise was below the
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 4
Event ID:
145885
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145885
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/09/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at the Boulevard
5905 West Washington
Chicago, IL 60644
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Actual harm
Residents Affected - Few
eye and it was covering the whole lower part of the right eye from side to side. V5 described the bruise as
black/reddish/purplish in color. V5 stated R1 does not get out of bed or try to get out of bed by herself and
needs two staff when performing ADL (Activities of Living) care. V5 stated R1 is not able to hold the
bedside grab bars to move herself and two staff move R1 from the bed to the wheelchair because R1
cannot assist with transfers.
On [DATE], at 2:10 PM, V8 (Licensed Practical Nurse-LPN [Former]) via phone stated she worked with R1
on [DATE], on the 11:00 PM-7:00 AM shift. She was not aware R1 had a fall that day. But in the morning on
[DATE], before the end of her (V8) shift, she observed R1 with a bruising above and below her (R1) right
eye. The bruise below R1's eye was a long line running the length of the right eye. V8 stated she did not
notify R1's physician or V2(Director of Nursing) about R1's change in condition. This delayed R1's care and
that is why V8 was terminated because she is supposed to notify the physician as soon as a resident has a
change in condition.
On [DATE], at 3:00 PM, V10 (Certified Nursing Assistant- CNA [Former]) via phone V10 worked on [DATE],
on the 3:00 PM-11:00 PM shift but he was not assigned to R1 when R1 fell. V10 stated V9 (Former
Certified Nursing Assistant) came and got V10 to come help V9 to transfer R1 back to bed. Upon reaching
R1's room, R1 was sitting on the floor on her bottom. V10 stated he did not know V9 had not informed the
nurse on duty that R1 had fallen and was on the floor. The facility protocol is to let the nurse know first if a
resident falls before touching the resident. V10 stated he was terminated for not informing the nurse about
R1's fall.
On [DATE], at 3:31 PM, V4 (Licensed Practical Nurse-LPN) via phone stated she worked with R1 on [DATE]
on the 7:00 AM-3:00 PM shift. She went to R1's room to take her vitals around 9:00 AM and to give R1 her
medications. She noticed R1's right side of the face by her eyebrow had a big knot. V4 stated she notified
V2 who went and saw R1's bruise and told V4 to call 911, V13 (Nurse Practitioner) and R1's family and
notify them. V4 stated 911 came, took report, and took R1 to the hospital. V4 stated during change of shift
that morning, V8 did not report R1 had a knot below and above her right eye. V4 stated if a resident has a
change in condition and a staff does not report it, that is neglect which is a form of abuse.
On [DATE], at 4:48 PM, V1 (Administrator) stated on [DATE], V9 was doing ADL (Activities of Daily Living)
care for R1, and R1 fell out of the bed. V1 stated V9 ran out of the room and went to get help from V10, and
V9 and V10 rushed to R1's room past V8 who was at the nursing station. V9 did not notify V8 that R1 fell.
V1 stated on [DATE], about 5:30 AM, V14 (CNA) noticed a swelling on R1's face and notified V8 but V8 did
not do anything about it including notifying the physician, V2 or V13 (Nurse Practitioner). V9 left at the end
of her shift at 7:30 AM.V1 stated V9 and V10 neglected R1 when they failed to notify V8 that R1 had fallen
therefore V9 and V10 were terminated for failure to follow facility policy and protocol. V8 was also
terminated for failure to follow facility policy when a resident has a change in condition which states the
nurse notifies the physician right away. V1 stated on [DATE], around 9:00 AM or 10:00 AM, V4, who was
assigned to R1, noticed R1 had a swelling on the right eye. V4 competed an assessment of R1, applied a
cold pack, notified V2 and V13 and called 911 to take R1 to the hospital for further evaluation.
On [DATE], at 5:44 PM, V2 (Director of Nursing-DON) stated on [DATE], about 10:00 AM, V4 called V2 to
R1's room. When she got to R1's room, she (V2) stated wow! what happened because R1 had a big knot
on the right forehead area. V2 stated she assisted V4 to assess R1 and put an ice pack on R1's forehead.
V4 called 911, V13 and R1's family. R1 was taken to the nearest hospital and was admitted with head
edema, hematoma, fall, and head contusion. V2 stated on [DATE], after she completed her
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145885
If continuation sheet
Page 2 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145885
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/09/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at the Boulevard
5905 West Washington
Chicago, IL 60644
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Actual harm
Residents Affected - Few
investigation regarding R1's injury, she notified V1 of her findings. After discussing with V1, he gave ok to
terminate V8, V9, and V10 for failure to follow facility's policies and procedures on reporting falls and
notifying physicians of resident change in condition. V2 stated not notifying the physician when R1 was
noted to have a swelling on the forehead caused a delay in care and R1 could have died of the head
injuries sustained during the fall. R1 is on blood thinner medications which could cause bleeding in the
brain and death. V2 stated R1 did not receive the care she needed in a timely manner and could have
resulted in her death.
On [DATE], at 6:45 PM, V15 (Restorative Manager) stated R1 is a two person assist for transfer and for bed
mobility. R1 requires a two person assist during ADLs and incontinence care for safety to prevent falls.
On [DATE], at 12:45 PM, V11 (Human Resources Manager-HR) stated HR does a background check
before employing a perspective employee and annually thereafter.
V11 stated the supervisors/administrator lets V11 know which staff has an offence. V11 and the manager
who reported the offence go through the facility's policies and procedures to determine which policy the
staff violated and if the employee will be terminated. V11 stated V8, V9, V10 were terminated because they
did not follow policies and procedures of the facility.
Policy titled Change in Condition dated 1/14 documents:
-Residents will receive full assessment of status change with notification to physician and immediate
medical emergency care via 911 if indicated.
-Resident will be assessed by the charge nurse or nursing supervisor in response to any changes or
deterioration in condition upon notification. Family and physician will be notified.
Facility Reported Incident Report -Final, dated [DATE], 4:23 PM documents:
-R1 was transferred to a nearby hospital after a fall with an above right eye raised area.
R1 was unable to communicate what happened to her
-R1's roommate (R2) was unable to state what happened to R1
-According to hospital report, R1 was admitted to hospital for fall and head contusion.
-V8 (Licensed Practical Nurse-LPN), and V9, V10(Certified Nursing Assistants-CNAs) were terminated for
not reporting the incident.
V8's HR (Human Recourses) File documents:
V8's Employee Termination Form dated [DATE], documents:
-V8 was terminated for gross misconduct, not reporting a resident (R1 change in condition).
R8's Employee Report dated [DATE] documents:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145885
If continuation sheet
Page 3 of 4
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145885
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/09/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Complete Care at the Boulevard
5905 West Washington
Chicago, IL 60644
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
-V8 failed to follow facility policy and procedures by not notifying provider of resident's change in condition.
Level of Harm - Actual harm
V9's HR (Human Recourses) File documents:
Residents Affected - Few
V9's Employee Termination Form dated [DATE], documents:
-V9-Gross misconduct- not reporting a fall, dishonesty, or theft
V9's Employee Report dated [DATE] documents:
-V9 failed to follow facility policy and procedure; did not report a resident (R1) fall to supervisor.
V10's HR (Human Recourses) File documents:
V10's Employee Termination Form dated [DATE], documents:
-V10-Gross misconduct- not reporting a fall, dishonesty, or theft
V10's Employee Report dated [DATE] documents:
-V10 failed to follow facility policy and procedure; did not report a resident (R1) fall to supervisor.
Facility policy titled -Fall Prevention Policy dated [DATE], documents:
-If a resident experiences a fall, nursed will complete an incident report and document the fall in the
resident record as well as the 24-hour report.
Facility policy titled Change in Condition dated 1/14, documents:
-Resident will receive full assessment of stats change with notification to physician and immediate medical
emergency care via 911 in indicated.
Resident will be assessed by the charge nurse or nursing supervisor in response to any changes or
deterioration in condition upon notification. Family and physician will be notified.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145885
If continuation sheet
Page 4 of 4
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the March 9, 2025 survey of Complete Care at the Boulevard?
This was a inspection survey of Complete Care at the Boulevard on March 9, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Complete Care at the Boulevard on March 9, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.