Complete Care at the Boulevard: Kitchen Hygiene Failures - IL
Inspectors watched it happen for nearly an hour.
On the morning of March 28, the aide identified in inspection records as V9 entered the dish room at 9:36 a.m. and immediately began pushing racks of soiled dishes into the dishwasher. She then pulled the clean trays out and placed them on a cart without changing her gloves or washing her hands. She continued cycling dirty racks through the machine, changing gloves each time she transitioned to handling clean items, but never stopped to wash her hands before putting on fresh gloves. The pattern repeated across dome plate covers, partitioned plates, and standard trays. Inspectors counted multiple glove changes. The handwashing station in the dish room went unused throughout.
Inspectors documented the sequence in detail: V9 rinsed a rack of dirty trays and partitioned plates, changed gloves, then pulled clean plate domes from the dishwasher and loaded them onto the cart. Clean gloves over unwashed hands.
The facility's own dietary manager, identified as V10, explained during an interview at 11:24 that morning exactly what the procedure was supposed to look like. "Hand hygiene is done after the dishes are pushed through, change glove then grab clean dishes with new gloves," V10 said. "They should wash their hands for infection control because that would be considered as cross contamination."
The manager knew the standard. The aide in the dish room wasn't meeting it, and inspectors were watching in real time.
A second dietary aide, V15, offered a different kind of explanation during a phone interview that afternoon. The dish room is supposed to run with three staff members, V15 said. That day, there were two. "I go upstairs to pull carts down, scrap, load the dishwasher," V15 said. "We try to change gloves as much as possible. If you don't have a third person, it is kind of difficult."
The dietary manager gave a different staff count. V10 said the standard was two people in the dish room, not three, with one pushing dirty racks through the machine and the other catching clean dishes on the far side. Whether the shortfall was one person or the process simply wasn't being followed, the result was the same: an aide cycling between contaminated and sanitized surfaces without hand hygiene, over and over, for the better part of an hour.
The facility's own training document, issued the same day inspectors were present, spelled out the requirement in plain terms: remove gloves after touching soiled dishes, wash hands with soap and warm water for at least 20 seconds, dry hands, then apply new gloves before handling clean items. An undated internal document on warewashing and a separate handwashing guide were also on file. The facility's written policies, dated September 2021, required staff to wash hands prior to putting on gloves and between glove changes.
None of that happened during the 9:36 a.m. observation.
The inspection covered 127 residents who received meals from the kitchen. Four of the facility's 131 residents were listed as NPO, meaning nothing by mouth, and were not affected. The remaining 127 ate food handled, plated, and served using dishes that passed through the dish room that morning.
CMS rated the violation at the lowest level of harm, noting minimal harm or potential for actual harm. The finding did not rise to immediate jeopardy. But the gap between what the facility's own documents required and what inspectors observed in the dish room was not subtle. It was a worker changing gloves again and again, each time skipping the step that makes changing gloves meaningful, while clean dishes for more than a hundred residents moved down the line.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Complete Care At the Boulevard from 2026-03-29 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 18, 2026 · Our methodology
Complete Care at the Boulevard in CHICAGO, IL was cited for violations during a health inspection on March 29, 2026.
Inspectors watched it happen for nearly an hour.
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.