Inspection Reports for
Montgomery Place
5550 S Shore Dr, Chicago, IL 60637, United States, IL, 60637
Back to Facility Profile1 Report
Inspection Report — Jul 8, 2025
Annual Inspection
Date: Jul 8, 2025
Visit Reason
Annual Licensure Survey with violations cited in sections 295.2040, 295.3020, 295.4060, and 295.6000.
Findings
The facility failed to provide documentation of tornado drills, ensure completion of required employee orientation and ongoing training for six staff, maintain adequate staffing and access to controlled medications for memory care residents, and failed to provide ordered pain medication to a resident resulting in hospital transfer.
Deficiencies (4)
A2040 (295.2040 Disaster Preparedness) - The facility failed to provide documentation of any tornado drills by employees, potentially affecting all residents; the memory care unit census is 14 residents.
A3020 (295.3020 Employee Orientation and Ongoing Training) - Six of eight staff reviewed had not completed required orientation and ongoing training, including incomplete infection control training and missing documentation.
A4060 (295.4060 Alzheimer's and Dementia Programs) - The facility failed to provide requested pain medication to one resident due to lack of nurse access to controlled medications, resulting in the resident's hospital transfer.
A6000 (295.6000 Resident Rights) - The facility failed to provide ordered tramadol pain medication to one resident as specified in the service plan, causing significant pain and hospital transfer.
Report Facts
Residents affected: 1
Staff affected: 6
Staff reviewed: 8
Residents reviewed: 3
7 CMS Surveys
Inspection Report — Aug 6, 2025
Date: Aug 6, 2025
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, the inspection type is classified as 'other'.
Findings
The facility failed to provide an ostomy care plan for one resident (R1), which is not in accordance with professional standards and has the potential to affect the resident's quality of care.
Deficiencies (1)
F0656 - The facility failed to develop and implement a complete care plan that meets all the resident's needs, specifically failing to provide an ostomy care plan for one resident (R1).
Report Facts
Residents affected: 1
Inspection Report — Apr 29, 2025
Date: Apr 29, 2025
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type.
Findings
The facility failed to reasonably accommodate the needs and preferences of one resident by not providing the correct size diapers on weekends and night shifts, causing discomfort and requiring the resident's family to purchase supplies.
Deficiencies (1)
F0558 - The facility failed to ensure the resident's right to receive services with reasonable accommodation of needs for one resident who was given the wrong size diapers multiple times due to lack of supply.
Report Facts
Residents affected: 1
Inspection Report — Nov 15, 2024
Annual Inspection
Date: Nov 15, 2024
Visit Reason
Annual Licensure Survey
Findings
The facility was found to have multiple deficiencies including failure to document code status, late transmission of MDS records, incomplete care plans, improper use and documentation of side rails, failure to provide ordered nutritional supplements, improper respiratory care equipment handling, insufficient RN staffing, medication management issues, food safety and preparation concerns, improper waste disposal, infection control lapses, and failure to provide pneumococcal vaccination education and consent.
Deficiencies (14)
F0578 - The facility failed to determine, establish, obtain or discuss code status of 1 resident out of 4 reviewed for Advance Directives.
F0640 - The facility failed to electronically transmit MDS records within regulatory timeframes for 1 resident out of 15 reviewed.
F0656 - The facility failed to develop and implement a comprehensive care plan addressing anticoagulant use, dementia care, advance directives, and psychotropic medication use for 5 residents out of 15 reviewed.
F0689 - The facility failed to assess, obtain consent, and develop care plans for use of side or bed rails for 4 residents out of 15 reviewed.
F0692 - The facility failed to provide ordered nutritional supplement (Magic Cup) to 1 resident with weight loss out of 28 reviewed.
F0695 - The facility failed to date and store oxygen tubing and nebulizer mask properly for 2 residents out of 15 reviewed.
F0727 - The facility failed to ensure a Registered Nurse was staffed 8 hours daily on weekends, potentially affecting all 28 residents.
F0755 - The facility failed to account for and dispose of controlled medications properly and had missing signatures on controlled substance records for 1 medication cart assigned to 12 residents.
F0761 - The facility failed to ensure medications were stored in original containers, properly labeled, and separate from food for 1 medication cart assigned to 12 residents.
F0803 - The facility failed to ensure menu was followed for a resident receiving mechanical soft diet and failed to follow standardized recipes during pureed food preparation affecting 2 residents on pureed diet.
F0812 - The facility failed to ensure proper food and supply storage including labeling, dating, covering, temperature checks, hair restraints, and sanitation, potentially affecting all 26 residents receiving oral diet.
F0814 - The facility failed to ensure dumpsters were properly covered and not overflowing to prevent pest harborage, potentially affecting all 28 residents.
F0880 - The facility failed to handle linen to prevent cross contamination and failed to have measures to prevent growth of Legionella and other waterborne pathogens, potentially affecting all 28 residents.
F0883 - The facility failed to provide education and obtain consent for pneumococcal vaccination for 4 of 6 residents reviewed.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 5
Residents affected: 4
Residents affected: 1
Residents affected: 2
Residents affected: 28
Residents affected: 12
Residents affected: 2
Residents affected: 26
Residents affected: 28
Residents affected: 28
Residents affected: 4
Inspection Report — Sep 21, 2023
Date: Sep 21, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility was found to have multiple deficiencies related to resident call devices, pharmaceutical services, food safety, and sanitation. The survey identified issues affecting residents' safety and food handling practices.
Deficiencies (5)
F0558 (Reasonably accommodate the needs and preferences of each resident) - The facility failed to ensure that residents' call devices were within reach, affecting 3 of 28 residents reviewed.
F0755 (Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist) - The facility failed to maintain shift change accountability records for controlled substances, with missing nurse signatures on multiple dates.
F0804 (Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature) - The facility failed to ensure the steam table holding meals was working properly, resulting in food served at unsafe temperatures affecting two residents and potentially all 36 residents on the unit.
F0812 (Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards) - The facility failed to date refrigerated food items when opened, store food off the floor in the walk-in freezer, designate an area for dented cans, and serve food in a sanitary manner, potentially affecting all 36 residents.
F0814 (Dispose of garbage and refuse properly) - The facility failed to ensure the outside dumpster was covered and garbage was not overflowing, posing a potential risk to all 36 residents.
Report Facts
Residents affected: 3
Residents affected: 36
Residents affected: 36
Residents affected: 2
Inspection Report — Jul 17, 2023
Date: Jul 17, 2023
Visit Reason
The document does not contain an A 000 Initial Comment block specifying the visit type; therefore, inspection_type is set to 'other'.
Findings
The facility failed to implement their Inventory List, Resident's Personal policy for one of three residents reviewed, resulting in theft of money and credit cards from resident R1's purse.
Deficiencies (1)
F0602 (Protect each resident from the wrongful use of the resident's belongings or money) - The facility failed to implement their Inventory List, Resident's Personal policy for one of three residents reviewed, resulting in money and credit cards being stolen from resident R1's purse.
Report Facts
Residents affected: 1
Inspection Report — Jun 16, 2023
Date: Jun 16, 2023
Visit Reason
Not explicitly stated in an A 000 Initial Comment block; document is a deficiency statement for Montgomery Place.
Findings
The facility failed to provide resident R2 with the correct medication at discharge, resulting in urinary retention and hospitalization. The facility implemented a new patient discharge form and conducted in-service training to prevent medication errors.
Deficiencies (1)
F0684 - The facility failed to provide resident R2 with the correct medication at discharge, resulting in urinary retention and hospitalization for catheterization.
Report Facts
Residents affected: 1
Inspection Report — Jul 22, 2022
Date: Jul 22, 2022
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Montgomery Place, dated 07/22/2022. The Initial Comment block naming the visit type is not present in the provided pages, so the inspection_type is set to 'other'.
Findings
The facility was found to have multiple deficiencies including failure to maintain resident privacy, failure to update and document code status for residents, failure to follow physician orders for weighing residents with edema, failure to apply ordered heel protector boots, failure to label oxygen tubing, failure to properly label and store medications, and failure to clean reusable equipment between residents to prevent cross contamination.
Deficiencies (7)
F0550 (Resident Rights) - The facility failed to ensure residents' privacy was maintained by failing to knock and wait for a response before entering residents' rooms during medication administration.
F0578 (Advance Directives) - The facility failed to update and document the correct code status for 4 residents, including failure to enter code status for one resident and discrepancies between documented and actual code status.
F0684 (Treatment and Care) - The facility failed to follow physician orders by not weighing 2 residents with edema as ordered to monitor fluid retention.
F0686 (Pressure Ulcer Care) - The facility failed to apply ordered heel protector boots for one resident with pressure ulcers.
F0695 (Respiratory Care) - The facility failed to ensure oxygen tubing was labeled and dated for 2 residents receiving oxygen therapy.
F0761 (Medication Labeling and Storage) - The facility failed to ensure medications were labeled after opening, stored to prevent cross contamination, and discarded when expired; medication cart keys were left unattended and medication cart was unlocked with keys in the lock.
F0880 (Infection Prevention and Control) - The facility failed to ensure reusable equipment was cleaned and disinfected between resident use and medications were administered under sanitary conditions to prevent cross contamination.
Report Facts
Residents affected: 2
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 3
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