Complete Care at the Boulevard: Pressure Wound Neglect - IL
She came in with a fever and dangerously low blood pressure. Her white blood cell count had climbed to 33, her blood sugar to 388, and her venous lactate to 2.2. The CT scan of her abdomen and pelvis told the rest: a stage 4 sacral ulcer with destruction of the coccyx, gas tracking into the right gluteal muscle, the right gluteal cleft, and the perineum, raising concern for necrotizing fasciitis, the flesh-eating infection that can kill within hours of onset.
Surgeons operated on August 18, 2025. What they found was a wound with frankly necrotic surrounding tissue and malodorous, murky grey liquid output. They probed it to the coccyx. The wound measured 14 centimeters wide, 18.5 centimeters long, and 3.5 centimeters deep. There was anterior tracking along the right medial gluteal fold toward the anorectal junction. Surgeons performed wide excision and debridement down to healthy tissue.
The following day, she was intubated and sedated. She could not speak for herself.
Complete Care at the Boulevard had a turning and repositioning policy dated September 1, 2024. It described a systematic approach to pressure injury prevention. The facility also had a wound treatment policy from the same date, requiring treatments in line with physician orders, documentation on the treatment record, and ongoing monitoring for lack of progression toward healing.
The inspection, filed as a complaint, found actual harm to the resident. Federal inspectors classified the level of harm as actual, not potential. A few residents were affected.
She had arrived at the emergency room febrile and hypotensive from a skilled nursing facility that had policies promising exactly the kind of monitoring that might have caught a wound before it reached the bone.
She left in an intubated state, unable to speak.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 23, 2026 · Our methodology
Complete Care at the Boulevard in CHICAGO, IL was cited for neglect violations during a health inspection on September 25, 2025.
She came in with a fever and dangerously low blood pressure.
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.