The Boulevard Post Acute

In the surveyor’s words

From the most serious findings on record at The Boulevard Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 9, 2026

  Based on observation, staff interview, clinical record review, and facility documentation review, the facility staff failed to provide supervision for one resident, Resident #96 (R96), to prevent a fall resulting in harm, and failed to provide a safe bed environment for one resident, Resident #100 (R100) of twenty-nine residents in the sample. The findings included1. The facility staff failed to provide adequate supervision and assistance during incontinence care of Resident #96 (R96), which resulted in R96 sustaining a fall that required immediate medical attention at the hospital and resulted in sutures, which constituted harm. […]

• Actual harm, isolatedF689Mar 10, 2022

  Based on observation, interview, clinical record review and facility documentation, and during the course of an investigation the facility staff failed to ensure Residents are free from accidents and hazards for 2 Residents (#21 & #58) in a survey sample of 32 Residents resulting in harm for Resident #21. The findings included: 1. For Resident #21 the facility staff failed to transfer the Resident using the required number of staff as indicated on the MDS and the care plan, subsequently she sustained a skin tear requiring sutures, which became infected; this is harm. On 3/9/22 a review of the clinical record revealed that Resident #21 sustained an injury to her right leg while transferring from wheel chair to bed on 2/7/22. The Resident was transferred by one staff member. […]

• No harm, potential for more than minimal, patternF684Apr 9, 2026

  Based on observation, resident interview, staff interview, facility document review and clinical record review, facility staff failed to follow physician orders for four of twenty-nine residents in the survey sample (Residents #11, #38, #41, and #72) and failed to provide care for a skin tear in a manner to promote healing for one of twenty-nine residents in the survey sample (Resident #11).The findings included:1. Resident #11 did not have care provided for a skin tear at the frequency ordered by the physician. […]

• No harm, potential for more than minimal, patternF812Apr 9, 2026

  Based on observation, staff interview, and facility documentation review, the facility staff failed to store and label food in accordance with professional standards for food safety in the main kitchen and on one of three units, (Cardinal) unit. The findings included:In the main kitchen the facility staff failed to discard items beyond the use by date in the dry storage and refrigerated storage areas and the items were available for use. In the main kitchen the facility staff failed to wear hair restraints while in food preparation areas, failed to perform hand hygiene to prevent contamination of food, and failed to maintain food holding temperatures. On 04/06/2026 at 3:10 p.m. an initial tour of the main kitchen was conducted with the Executive Chief. […]

• No harm, potential for more than minimal, isolatedF572Apr 9, 2026

  Based on observation, resident interviews, staff interviews, and review of facility documentation, the facility failed to ensure that notices of resident rights were posted in accessible areas for all residents residing on three of three units. Findings included:The facility failed to ensure that resident rights was posted in accessible locations within the facility for residents, families, and visitors.On 4/6/26 at 2:00 pm, a tour of the facility's three nursing units and lobby areas was conducted. During the tour, no postings of resident rights were observed in any of these areas.On 4/7/26 at 10:30 am, a resident council meeting was held with six residents present (Resident #11, Resident #25, Resident #43, Resident #54, Resident #74, and Resident #84). […]