Complete Care at the Boulevard: Pressure Wound Neglect - IL
The wound had been there for weeks. The facility had a policy requiring staff to reposition her. Inspectors found no documentation that anyone did.
The resident, identified in federal inspection records only as R1, was a patient at Complete Care at the Boulevard in Chicago. A certified nursing assistant noticed on the morning of August 18 that she was less responsive than usual. A nurse checked her vital signs: blood pressure 98 over 54, pulse 113, temperature 101.9, oxygen saturation 95 percent. She was sent to the emergency room.
What the hospital found was extensive. Her white blood cell count had spiked to 33, more than three times the normal upper limit. Her blood sugar was 388. Her venous lactate, a marker of how hard the body is working to compensate for failing circulation, was elevated. A CT scan of her abdomen and pelvis showed a sacral ulcer that had eaten through to the coccyx, the bone itself destroyed, with gas tracking into the right gluteal muscle, the right gluteal fold, and the perineum. Gas in soft tissue is a hallmark of necrotizing fasciitis, the bacterial infection that kills tissue faster than surgeons can sometimes chase it.
A surgeon operated the same day. The operative report describes what they found when they got there: a Stage 4 sacral pressure ulcer with frankly necrotic surrounding tissue, malodorous discharge described as murky and grey, the wound probing all the way down to the coccyx. They cut away the dead tissue until they reached healthy margins. The wound left behind measured 14 centimeters wide, 18.5 centimeters long, and 3.5 centimeters deep, roughly the size of a paperback book cover carved into her lower back and right side.
The next morning, she was still intubated and sedated. She could not speak for herself.
Federal inspectors reviewed her progress notes from July 30 through August 18. Nowhere in those three weeks of documentation did staff record that she had refused to be repositioned or that she had resisted lying down. Notes from the wound care provider on August 8 and August 13 also contained no such notation. The facility's own turning and repositioning policy, dated September 2024, describes repositioning as part of its systematic approach to pressure injury prevention. Its wound treatment policy requires ongoing monitoring, documentation in the electronic health record, and evaluation of whether wounds are progressing toward healing.
The wound was not progressing toward healing. It was progressing toward her coccyx.
A Stage 4 pressure ulcer is the most severe classification in the grading system, indicating full-thickness tissue loss with exposed bone, tendon, or muscle. Reaching that stage from a surface wound does not happen overnight. It requires sustained, repeated pressure on tissue that is not being relieved, over days and weeks, cutting off blood supply until the tissue dies from the inside. The surgery R1 underwent, a wide excision and debridement, is not a minor procedure. It is performed under general anesthesia, it leaves a wound that requires complex aftercare, and in patients who are already septic, it carries serious risk.
The inspection, a complaint investigation, was conducted on September 25, 2025. It cited the facility at the "Actual Harm" level under the federal tag governing pressure ulcer prevention and treatment.
R1 was intubated and sedated in the ICU on August 19. The inspection record does not say whether she survived.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At the Boulevard from 2025-09-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
Complete Care at the Boulevard in CHICAGO, IL was cited for neglect violations during a health inspection on September 25, 2025.
The wound had been there for weeks.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.