Health inspection·September 25, 2025

F 0686 Level of Harm - Actual harm Residents Affected - Few would try to put her back to bed after lunch and she would refuse.On 09/23/25 at 11:00am V9 (Wound Care Nurse) stated that R1 had no wound to her sacrum upon admission on [DATE]. V9 stated that R1 developed an unstageable pressure ulcer to her sacrum while at the facility. V9 stated that R1 was a high risk for skin breakdown due to being incontinent, immobile, and sitting up for 4 hours instead of 2 hours. V9 stated that R1's daughter informed him that she felt the R1 was not being repositioned enough. V9 stated that he began to bathe and reposition R1 himself to make sure that R1 was being cleaned and turned. V9 stated that he was on vacation from 08/06/25 through 08/18/25, and R1's sacrum wound had necrotic tissue, but was stable before his vacation. V9 said for R1 preventive measures in place for her included turn and reposition. V9 said I put an order for her to be turned and repositioned under physician orders. V9 said I informed the staff to make sure that she was not sitting up in the chair when I wasn't here. V9 said the purpose of interventions are to help and resolve any skin integrity issues. On 09/22/25 at 3:44pm V5, CNA, said sometimes R1 would be in her chair when she came on shift at 3:00PM. V5 said R1 would stay up until around 6:15PM (greater than 2 hours).On 09/24/25 at 10:43am V2 (Director of Nursing/DON) stated that it is the expectation of the facility for the nurses to follow the physician orders. V2 said it is my expectation that staff reposition the residents at least every 2 hours or more. They should clean the residents when they come in in the morning time, and at least every 2 hours they should be checking the for incontinent episodes. V2 said a care plan should be in place if a resident refuses care. If should be documented first by the nurse if a resident refuses care. V2 said for a resident with wounds interventions should include repositioning and not sitting up too long on the wound. V2 said if a resident develops a new wound that means that the preventive measures are not working. V2 said when wounds are not changed as scheduled, they could deteriorate, and the nurse is not following the doctor's orders. V2 said I am not aware that R1 had no new interventions once she developed the new wound. V2 said R1's wound care plan is not complete and is the interventions are not individualized. On 09/24/25 at 11:58am V11, LPN, said for charting in the record, normally when I press 7, it's because the wound was already done by wound care nurse. I don't know if that was a generated note. I do recall changing the sacrum dressing before and changing the groin one week before. V11 said R1's wound was so painful to her she used to scream when we had to try to clean it.On 09/24/25 at 08:52am, V18 (Wound care doctor) stated that if R1 would have been turning herself in bed, that would have helped the MASD and prevented the sacrum wound from worsening.On 9/24/25 at 1:05pm V12, Social Service director said I never was told that R1 refused care or had behaviors. V12 said social services is notified of resident care refusals. Review of R1's record shows no documentation of sacrum wound before 08/03/25. R1's wound assessment dated [DATE] documents in part, Unstageable sacrum Full Thickness.Wound size (Length by width by dept) 2.5 by 3.5 by 0.3 cm (centimeters).R1's wound assessment dated [DATE] documents in part, Unstageable sacrum Full Thickness.Wound size (Length by width by dept) 4.1 by 4.2 by 0.7 cm (centimeters).R1's physician order dated 08/07/25 documents in part, Sacrum unstageable leptospermum honey apply once daily and as needed: If saturated, soiled, or dislodged.R1's treatment administration record (TAR) documents in part, Sacrum unstageable leptospermum honey apply once daily and as needed. On 08/09/25 R1's TAR shows a code of 7, which indicates to see progress note. R1's progress note dated 08/09/25 documents in part, No dressing change needed, dressing remain intact.R1's MDS dated [DATE] section GG for Functional Abilities has a score of 2 for Personal Hygiene, which indicates R1 requires substantial/maximal assistance to maintain personal hygiene, a score of 3 for rolling left and right, which indicates R1 needs partial/moderate assistance to roll from left to right and a score of 1 for chair/bed to chair transfer, which indicates R1 is totally dependent and helper does all of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145885 If continuation sheet Page 2 of 3 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 09/25/2025 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 0686 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete effort.R1's progress noted dated 08/18/25 documents in part, Writer alerted by CNA on duty that the resident was not as responsive as usual. Upon assessment vital signs 98/54, P (pulse) 113, t (temperature) 101.9, R (respirations) 19, SPO2 (oxygen saturation of peripheral blood) 95% on room air. Notified NP (Nurse Practitioner) new orders to send to ER (emergency room).Progress note dated 8/19/25 document R1 admitted with diagnosis of Sepsis and necrotizing fasciitis in ICU intubated.Progress notes reviewed 7/30/25 - 8/19/25, no documentation that R1 refused repositioning or lay down. Review of wound care provider notes 8/8/25 and 8/13/25 do not identify R1 refusing care.R1's hospital record dated 08/18/25 documents in part, Patient presented to ED (Emergency Department) after being found to be febrile to 100.7, as well as hypotensive in her SNF (Skilled Nursing Facility). Upon arrival she was found to be afebrile, normotensive, although with leukocytosis to 33 and hyperglycemia to 388. Labs also significant for venous lactate to 2.2. Infectious workup showing sacral ulcer with underlying destruction of coccyx concerning for osteomyelitis with gas tracking into the R (right) gluteal musculature, R gluteal cleft, and perineum c/f (concern for) active infection. CT abdomen and pelvis: 1. Sacral ulcer with underlying destruction of the coccyx concerning for osteomyelitis. Additionally, there is gas tracking into the right gluteal musculature, right gluteal cleft, and perineum concerning for active infection. Given the extent of gas tracking along the subcutaneous tissues and into the right gluteal musculature there is concerning for developing necrotizing fasciitis. No drainable abscess. R1's hospital surgical report dated 08/18/25 documents in part, Findings: Stage 4 sacral decubitus ulcer with frankly necrotic surrounding tissue and malodorous murky grey output liquid output, probed to coccyx. Wide excision and debridement of wound to underlying healthy tissue. Anterior tracking along the R medial gluteal fold along anorectal junction. Wound base 14cm (centimeters) wide x 18.5 long x 3.5cm deep. R1's hospital records dated 08/19/25 documents in part, Patient intubated and sedated s/p (status post) emergent wound debridement on 8/18/25, unable to participate in interview.Facility's policy titled Turning and Repositioning dated 09/01/24 documents in part, Policy: It is our policy to implement turning and repositioning as part of our systematic approach to pressure injury prevention and management.Facility's policy titled Wound Treatment Management dated 09/01/24 documents in part, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.7. Treatments will be documented on the Treatment Administration Record or in the electronic health record.8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. Event ID: Facility ID: 145885 If continuation sheet Page 3 of 3