Boulevard Temple Care Center, LLC

In the surveyor’s words

From the most serious findings on record at Boulevard Temple Care Center, LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jan 31, 2023

  Based on interview and record review the facility failed to perform life saving measures to a resident that was documented as a full code (When a person has no heartbeat and not breathing, CPR/cardiopulmonary resuscitation should be administered). This deficient practice resulted in an Immediate Jeopardy on [DATE] when nursing staff failed to perform CPR on R19 or call emergency services (911) when found with no heartbeat and was not breathing. This deficient practice placed all 95 residents at risk for the likelihood of serious injury, harm, and/or death from code status not being followed by staff. […]

• Immediate jeopardy, isolatedF689Aug 31, 2022

  This citation pertains to intakes MI 275, MI 403, MI 417. Based on interview and record review the facility failed to provide necessary supervision for one resident (3) with known impaired cognition causing an elopement (leaving a safe area or premises) and unknown whereabouts from facility on 8/5/22 at 3:12 PM for 47 minutes where he was found a mile away at a friend's home after he traveled on a 4 lane, 45 mph road., affecting one resident (R3) out of five residents reviewed for elopement, resulting in an elopement and the likelihood to cause serious injury, serious harm, serious impairment and/or death. […]

• Actual harm, isolatedF600Aug 31, 2022

  This citation pertains to intakes MI 433, MI 464, MI 564. Based on interview and record review the facility failed to prevent Resident #2 (R2) from fondling one Resident #1(R1) of six residents reviewed for abuse resulting in sexual abuse and R1 being afraid, scared, and unsafe. Findings include: On 8/31/22 at 11:47 AM a phone interview with R1, it was confirmed that R1 had been inappropriately touched. When asked what happened, R1 stated, That man fondled me. When asked if she gave him permission to do that, R1 stated, No. When asked how that made her feel at the time of the incident, R1 stated, I was afraid and scared. […]

• Actual harm, isolatedF697Oct 25, 2021

  This citation pertains to intake MI 573 Based on observation, interview and record review the facility failed to assess, monitor, and ensure pain medications were administered for 2 of 4 residents, (Resident #31, #90) reviewed for pain, resulting in inadequate pain management. Findings include: Resident #31 Review of an Admission Record revealed, Resident #31 admitted to the facility with pertinent diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment, with a reference date of 8/12/21 revealed Resident #31 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 15, out of a total possible score of 15 and had a scheduled pain medication regimen. […]

• No harm, potential for more than minimal, widespreadF812Jul 16, 2026

  Based on observation, interview, and record review, the facility failed to ensure safe preparation and storage of food, cleaning and sanitation of surfaces and equipment, and upkeep of equipment, resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 07/14/2026 at 8:51 AM, a container of sliced oranges was observed without a date or label in the walk-in cooler. In an interview at this time with [NAME] I, serving as the person in charge, [NAME] I indicated they do not think the person put a date on the container and indicated anytime you cut fruit there should be a date. On 07/14/2026 at 8:55 AM, a container of mechanically altered chicken with a facility marked use by date of 7/10 was observed in the walk-in cooler. […]