Inspection Reports for
Montgomery Place
5550 S Shore Dr, Chicago, IL 60637, United States, IL, 60637
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.8 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
151% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
35% occupied
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 6, 2025
Visit Reason
The inspection was conducted to evaluate compliance with care planning requirements, specifically regarding the adequacy of the ostomy care plan for a resident.
Findings
The facility failed to provide a complete and individualized ostomy care plan for one resident, resulting in potential harm due to lack of appropriate care planning and supply management.
Deficiencies (1)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs, including an ostomy care plan with measurable timetables and actions. The resident's ostomy care plan was missing despite physician orders and resident requests for timely ostomy changes.
Report Facts
Residents affected: 1
Physician order date: May 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse/Agency | Mentioned as V3 who took ostomy supplies from resident | |
| Administrator | Mentioned as V1 who clarified supply issues | |
| Director of Nursing | Mentioned as V2 who confirmed missing care plan and resident distress |
Inspection Report
Annual Inspection
Census: 14
Deficiencies: 5
Date: 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.
Deficiencies (5)
Failed to provide documentation of tornado drills by employees affecting all residents in the event of a tornado.
Failed to ensure 6 out of 8 staff completed required employee orientation and ongoing training topics.
Failed to provide an appropriate number of qualified staff with access to controlled medications for residents with Alzheimer's and dementia.
Failed to provide ordered pain medication (tramadol) to one resident resulting in resident-initiated hospital transfer due to severe pain.
Failed to uphold resident rights by not providing services specified in the service plan, including pain medication administration.
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 |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 29, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide the correct size diapers for a resident, resulting in discomfort and requiring the resident's family to purchase supplies.
Complaint Details
The complaint was substantiated. The resident and family reported multiple instances of the facility running out of the correct size diapers, and staff confirmed the issue. The Director of Nursing acknowledged the problem and explained the protocol that was not followed.
Findings
The facility failed to ensure the resident's right to receive services with reasonable accommodation of needs, specifically failing to provide the correct size diapers on multiple occasions due to staff not accessing the basement supply storage.
Deficiencies (1)
F 0558: The facility failed to reasonably accommodate the needs and preferences of a resident by not providing the correct size diapers, causing discomfort and requiring family intervention. Staff did not notify security to access the basement supply where the correct size diapers were stored.
Inspection Report
Annual Inspection
Census: 28
Deficiencies: 14
Date: Nov 15, 2024
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care, including resident rights, care planning, medication management, infection control, staffing, dietary services, and vaccination policies.
Findings
The facility was found deficient in multiple areas including failure to document resident code status and advance directives, late transmission of MDS records, incomplete care plans, improper use and documentation of bed rails, failure to provide ordered nutritional supplements, improper respiratory equipment storage, inadequate RN staffing, medication management issues including controlled substances, improper medication storage and labeling, food safety and sanitation violations, inadequate infection control practices, and failure to provide pneumococcal vaccination education and consents.
Deficiencies (14)
F578: Facility failed to determine, establish, obtain or discuss code status of 1 resident out of 4 reviewed for advance directives.
F640: Facility failed to electronically transmit MDS records within regulatory timeframes for 1 resident out of 15 reviewed.
F656: Facility failed to develop and implement comprehensive care plans addressing resident needs including advance directives, anticoagulant and psychotropic medication use for 5 residents out of 15 reviewed.
F689: Facility failed to assess, document, and obtain consent for use of side/bed rails for 4 residents out of 4 reviewed, and failed to attempt alternatives prior to installation.
F692: Facility failed to provide ordered nutritional supplement (Magic Cup) to a resident with weight loss.
F695: Facility failed to date and store oxygen tubing and nebulizer mask properly for 2 residents, increasing infection risk.
F727: Facility failed to ensure a Registered Nurse was staffed 8 hours daily on weekends, potentially affecting all residents.
F755: Facility failed to account for and dispose of controlled medications properly and had expired medication in refrigerator.
F761: Facility failed to ensure medications were stored in original containers, properly labeled, and separated from food in medication storage areas.
F803: Facility failed to ensure menus were followed for a resident on mechanical soft diet and failed to follow standardized recipes for pureed food preparation.
F812: Facility failed to properly cover, label, date, and discard food items in storage; failed to ensure kitchen staff wore hair restraints; failed to store frozen foods off floor; failed to check food temperatures before serving; and failed to sanitize blender after pureed food preparation.
F814: Facility failed to ensure dumpsters were properly covered and not overflowing to prevent pest harborage.
F880: Facility failed to follow infection control procedures by not sanitizing hands before handling clean linens and failed to have measures to prevent Legionella growth in water systems.
F883: Facility failed to provide education, assess eligibility, and obtain consents for pneumococcal vaccination for 4 residents reviewed.
Report Facts
Residents reviewed: 15
Residents affected: 28
Residents assigned to west medication cart: 12
Missing RN staffing days: 2
Weight records: 153
Weight records: 159
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V2 | Director of Nursing | Interviewed regarding code status, MDS transmission, bed rail use, medication policies, and vaccination education |
| V17 | Social Services | Interviewed regarding advance directives and code status |
| V19 | MDS Manager | Interviewed regarding MDS transmission and regulatory compliance |
| V10 | Licensed Practical Nurse | Involved in medication cart inspection and controlled substance count |
| V3 | Director of Dining Services | Interviewed regarding dietary services, menu compliance, and food safety |
| V7 | Registered Dietitian | Interviewed regarding nutritional supplements and menu adequacy |
| V13 | Facilities Director | Interviewed regarding infection control and waste management |
| V1 | Administrator | Interviewed regarding staffing and infection control |
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 5
Date: Sep 18, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements in a nursing home facility.
Findings
The facility was found deficient in ensuring residents' call devices were within reach, maintaining shift change accountability records for controlled substances, keeping food at safe temperatures, proper food storage and sanitation practices, and proper garbage disposal. These deficiencies affected multiple residents and had potential safety and health impacts.
Deficiencies (5)
F 0558: The facility failed to ensure residents' call devices were within reach, affecting 3 of 28 residents reviewed. Residents were unable to reach their call lights, posing a safety risk.
F 0755: The facility failed to maintain shift change accountability records for controlled substances, with missing nurse signatures on multiple dates in August and September 2023, affecting all 36 residents on the second floor.
F 0804: The facility failed to ensure the steam table used to hold meals was working properly, resulting in food served at unsafe temperatures to residents on the second floor.
F 0812: The facility failed to date refrigerated food items when opened, store food off the floor in the walk-in freezer, store dented cans in a designated area, and serve food in a sanitary manner, risking food contamination for all residents.
F 0814: The facility failed to ensure the outside dumpster was covered and garbage overflowing on the floor was picked up, posing a sanitation risk to all residents.
Report Facts
Residents on second floor: 36
Missing nurse signatures: 8
Residents reviewed for call devices: 28
Residents affected by call device issue: 3
Room trays observed: 6
Temperature of spaghetti: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | V12 moved call light for resident R29 | |
| Unit Manager | V4 acknowledged call light issue for resident R3 | |
| Certified Nurse Assistant | V8 commented on call light accessibility for resident R4 | |
| Licensed Practical Nurse | V5 observed missing signatures on controlled substances records | |
| Director of Nursing | V2 stated expectation for nurses to sign accountability sheets | |
| Dietary Aide | V9 measured food temperature and served food unsanitarily | |
| Dietary Manager | V11 acknowledged steam table malfunction and food safety concerns | |
| Administrator | V1 provided census and addressed dumpster issue | |
| Director of Facility | V16 notified about dumpster condition and vendor communication | |
| Director of Dining Services | V13 observed food storage issues in kitchen | |
| Executive Chef | V14 committed to ensuring staff follow food storage policies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 17, 2023
Visit Reason
The inspection was conducted in response to a complaint regarding missing money and credit cards reported by resident R1.
Complaint Details
The complaint investigation was substantiated. Resident R1 reported missing $24 and five credit cards from her purse, which was confirmed by the facility's failure to complete the required inventory list and secure valuables.
Findings
The facility failed to implement its Inventory List, Resident's Personal policy for one of three residents reviewed, resulting in financial exploitation due to missing money and credit cards from resident R1's purse. The investigation found that the inventory list was not completed upon admission as required by policy.
Deficiencies (1)
F 0602: The facility failed to protect resident R1 from wrongful use of personal belongings by not completing the Inventory List of Resident Personal Belongings upon admission, resulting in theft of $24 and five credit cards.
Report Facts
Missing cash amount: 24
Missing credit cards: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V1 | Administrator | Informed of missing money and credit cards, reimbursed resident $24, and involved in investigation |
| V11 | Agency Licensed Practical Nurse/LPN | Responsible for completing resident R1's inventory list upon admission |
| V12 | Certified Nurse Assistant (CNA) | Responsible for completing resident R1's inventory list upon admission; not available for interview |
| V19 | Registered Nurse | Stated that nurse and CNA should complete resident inventory list upon admission |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 16, 2023
Visit Reason
The investigation was triggered by a medication error complaint involving resident R2, who was discharged with another resident's medication, resulting in urinary retention and hospitalization.
Complaint Details
The complaint investigation found that R2 was discharged with medication intended for another resident, causing urinary retention and hospitalization. The facility was unaware of the error until notified by R2's physician 2 to 3 weeks after discharge. The medication error was substantiated.
Findings
The facility failed to provide R2 with the correct medication at discharge, causing R2 to ingest Oxybutynin, which led to urinary retention and hospitalization for catheterization. The error was discovered weeks after discharge when the physician notified the facility.
Deficiencies (1)
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences, resulting in a medication error where R2 was discharged with incorrect medications causing actual harm.
Report Facts
Residents reviewed for discharge: 3
Residents affected: 1
Medication dosage: 5
Medication dosage: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V3 | Director of Nursing | Provided statements about the medication error and discharge process |
| V4 | Agency Nurse | Responsible for medication teaching and packing medications at discharge |
| V6 | Licensed Practical Nurse | Described discharge medication reconciliation and education process |
| V9 | Physician/Medical Director | Confirmed medication error and described clinical consequences for R2 |
| V1 | Administrator | Reported unavailability of V4 for interview |
Inspection Report
Routine
Deficiencies: 7
Date: Jul 22, 2022
Visit Reason
Routine inspection to evaluate compliance with resident rights, advance directives, treatment orders, medication administration, infection control, and other regulatory requirements.
Findings
The facility was found deficient in maintaining resident privacy, updating and documenting code status for advance directives, following physician orders for weighing residents, applying ordered pressure ulcer care, labeling oxygen tubing, proper medication labeling and storage, and infection control practices during medication administration.
Deficiencies (7)
F 0550: The facility failed to ensure resident privacy by not knocking before entering residents' rooms during medication administration.
F 0578: The facility failed to update and document the correct code status for 3 residents and failed to enter code status for 1 resident in a sample of 14.
F 0684: The facility failed to follow physician orders by not weighing 2 residents with edema as ordered.
F 0686: The facility failed to apply ordered heel protector boots for 1 resident with pressure ulcers.
F 0695: The facility failed to ensure oxygen tubing was labeled and dated for 2 residents receiving oxygen therapy.
F 0761: The facility failed to ensure medications were labeled after opening, stored to prevent cross contamination, discarded when expired, and secured to prevent unauthorized access.
F 0880: 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: 3
Residents affected: 1
Residents affected: 2
Weights missing: 5
Weights missing: 5
Residents affected: 1
Residents affected: 2
Medication storage rooms reviewed: 2
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| V5 | Agency Licensed Practical Nurse | Named in privacy violation and infection control findings related to medication administration and equipment use |
| V9 | Registered Nurse | Named in privacy violation and medication administration infection control findings |
| V3 | Director of Nursing | Provided statements regarding privacy, code status, oxygen tubing labeling, medication storage, and infection control policies |
| V6 | Agency Registered Nurse | Provided statements regarding oxygen tubing labeling and medication storage |
| V7 | Unit Coordinator | Provided statements regarding oxygen tubing labeling |
| V8 | Registered Nurse | Observed and provided statements related to pressure ulcer care |
| V10 | Nurse Practitioner | Provided statements regarding weighing residents with congestive heart failure |
| V2 | Director of Nurses/DON | Provided statements regarding weighing residents and pressure ulcer care |
| V4 | Social Service Director | Provided statements regarding code status and advance directives |
| V11 | Dietary Manager | Observed weighing resident R2 |
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