Complete Care at the Boulevard

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Dec 9, 2024

  Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse and mental anguish by staff and also failed to appropriately identify incident(s) of abuse. This failure affected one resident (R2) whose wrists were tied to their bed side rails using pillowcases by a facility nurse as an attempt to confine R2 in bed for the nurse's convenience. As a result, R2 experienced feelings of humiliation and despair as evidenced by being tearful as well as physical pain and discomfort in both wrists. Any reasonable person in this situation would feel humiliated and ashamed. This was identified as an immediate jeopardy which begin on 10/12/24 at 3:00pm when V6 RN (Registered Nurse) tied R2 with pillowcase to the bed side rails. […]

• Immediate jeopardy, isolatedF604Dec 9, 2024

  Based on interview and record review, the facility failed to assure that residents are free of unnecessary physical restraint(s), failed to identify the specific medical symptoms warranting the use of physical restraint(s) and failed to obtain physician orders with medical justification for physical restraint(s). This failure affected R2 whose wrists were tied to the bed side by a pillowcase by a nurse with no physician order, no consent or resident permission, and no medical justification. Any reasonable person in this situation would feel humiliated and ashamed. This was identified as an immediate jeopardy which begin on 10/12/24 at 3:00pm when V6 (Registered Nurse) tied R2 to their bedside rails with a pillowcase. […]

• Immediate jeopardy, isolatedF600Jan 19, 2024

  Based on observations, interviews, and record reviews, the facility failed to keep R6 free from abuse. This failure resulted in R6 being sprayed in the face with a chemical agent by a staff member (V26). R6 experienced eye irritation and pain which required irrigation at the emergency department. The facility further failed to keep V26 away from R6 after the incident by allowing V26 to continue to work with R6 and allowed V26 to remain on the same unit. This situation was identified as an immediate jeopardy. The Administrator, Assistant Administrator-in-training, and the Director of Nursing were presented with the immediate jeopardy template on 1/5/2024 at 9:55 AM. The immediate jeopardy began on 11/15/2023 and removed on 1/12/2024. […]

• Actual harm, isolatedF686Sep 25, 2025

  Based on interview and record review, the facility failed to develop a plan of care and assure that one resident (R1) at high risk for skin breakdown received the treatment and services to prevent the development and worsening of a new pressure ulcer. This failure resulted in R1's development and deterioration of a unstageable pressure ulcer, requiring hospitalization and surgical intervention for Sacral ulcer with underlying destruction of the coccyx.Findings include:R1's medical diagnoses include but are not limited to chronic obstructive pulmonary disease, type 2 diabetes, cognitive communication deficit, depression, essential hypertension. […]

• Actual harm, isolatedF684Mar 9, 2025

  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. 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. […]