Inspection Reports for Montgomery Place
5550 S Shore Dr, Chicago, IL 60637, United States, IL, 60637
Back to Facility ProfileDeficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Inspection Report
Annual Inspection
Census: 14
Deficiencies: 5
Jul 8, 2025
Visit Reason
Annual licensure survey conducted to assess compliance with state regulations including disaster preparedness, employee orientation and training, Alzheimer's and dementia program requirements, and resident rights.
Findings
The facility failed to provide documentation of tornado drills, ensure completion of required employee orientation and ongoing training for multiple staff, maintain adequate staffing and medication access for residents with Alzheimer's and dementia, and failed to provide ordered pain medication to a resident resulting in an emergency hospital transfer.
Severity Breakdown
Type 3: 2
Type 2: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide documentation of tornado drills by employees affecting all residents in the event of a tornado. | Type 3 |
| Failed to ensure 6 out of 8 staff completed required employee orientation and ongoing training topics. | Type 3 |
| Failed to provide an appropriate number of qualified staff with access to controlled medications for residents with Alzheimer's and dementia. | Type 2 |
| Failed to provide ordered pain medication (tramadol) to one resident resulting in resident-initiated hospital transfer due to severe pain. | Type 2 |
| Failed to uphold resident rights by not providing services specified in the service plan, including pain medication administration. | Type 2 |
Report Facts
Resident census: 14
Staff missing required training: 6
Residents reviewed for pain medication: 3
Residents with pain medication issue: 1
Medication dosage: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Named in findings related to missing tornado drills, incomplete staff training, and failure to provide pain medication |
| E2 | Director of Health | Named in findings related to staff training audit and pain medication administration issues |
| E3 | Director of Clinical Education | Involved in follow-up of resident pain medication concern |
| E4 | Resident Assistant | Caregiver present during resident pain incident and provided statements about nurse availability |
| E5 | Resident Assistant | Named as staff missing required training |
| E6 | Security Officer | Documented resident's call for ambulance due to pain medication issue |
| E7 | Interim Maintenance Manager | Stated not having tornado drill documentation |
| E8 | Licensed Practical Nurse | Named as staff missing required training |
| E9 | Resident Assistant | Named as staff missing required training |
| E10 | Resident Assistant | Named as staff missing required training |
| E11 | Resident Assistant | Named as staff missing required training |
| E13 | Human Resources Manager | Provided incomplete staff list and training documentation |
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