Inspection·July 22, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure the safety of a resident using a mobility device. This failure affected one resident (R2) out of 5 reviewed for adaptive equipment use in the facility.Findings include:R2's face sheet shows that R2 has diagnoses which includes but not limited to benign prostatic hyperplasia, retention of urine, urogenital implants, hypertension, anemia, osteoarthritis, and pleural effusions.R2's Minimal Data Set (MDS) documents in part, Section C: Brief Interview of Mental Status (BIMS) score is a 9. R2 has moderate cognitive impairment. Section GG: Mobility devices: C. wheelchair. On 7/21/25 at 11:00 am, observed R2 in room sitting in wheelchair next to bed. R2 brought to surveyor's attention that the wheelchair R2 was sitting in was broken. R2's right brake on the wheelchair noted to be broken and was unable to lock. Surveyor inquired to R2 if staff assist with transferring to the wheelchair? R2 stated, No, I get in the wheelchair by myself.On 7/21/25 at 12:45 pm, Surveyor inquired to V7 CNA (Certified Nursing Assistant) how do they lock and secure the wheelchair when transferring R2 to the wheelchair? V7 looked at the wheelchair and stated, I (V7) was not aware of the wheelchair being broken. R2 gets into the wheelchair by himself. I will put it in the repair book that the wheelchair is broken.On 7/21/25 at 1:34 pm, V6 Maintance Director stated, Rounds is made every two hours and I (V6) look at the maintenance book or sometimes the residents or staff will say if something needs to be fixed. Surveyor inquired to V6 if V6 was aware of R2's wheelchair brake being broken? V6 stated, I am not aware.On 7/22/25 at 11:24 am, R2 in room sitting in wheelchair with right brake still broken.On 7/22/25 at 11:30 am, V4 LPN (License Practical Nurse) stated that R2's wheelchair is not safe, because R2 could fall with the brake being broken. The purpose of the brake is to prevent the chair from moving. It the chair move while transferring it could cause an incident. R2 is a one person assist. On 7/22/25 at 12:12 pm, (V6) Maintenance Director, stated, I (V6) did not look at the Maintance log today my assistant was supposed to have looked. I was aware that the wheelchair was broke yesterday, but I did not get a chance to go look at it. I got caught doing many things at the same time. It is not safe for the resident to have a broken brake on the wheelchair. They can fall and have to be sent to the hospital. The patient is the priority for safety.On 7/22/25 at 12:30 pm, (V16) Maintenance Assistant stated, I (V16) did not check the maintenance book.On 7/22/25 at 1:56 pm, V9 Restorative Director stated I (V9) went to R2's room yesterday to remove the broken wheelchair. I explained to R2 that one of the brakes is not good and we need to fix it. R2 was gesturing and did not want the wheelchair removed. I went to tell the maintenance that there is a request for the wheelchair to be fixed. Surveyor inquired to V9, is it safe to leave the wheelchair with the brake broken? V9 stated, Most times R2 doesn't use the chair. If R2 chooses to use the chair it should not be broken. Surveyor inquired to V9, should all equipment in the facility be functioning and in safe working condition? V9 stated, Absolutely, it was not safe to leave the wheelchair. Social service was supposed to be notify of the refusal. I did not notify social service.On 7/22/25 at 2:40 pm, V3 SSD (Social (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 2 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 07/22/2025 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)