Inspection·July 22, 2022

F 0550 Policy: Level of Harm - Minimal harm or potential for actual harm Titled Resident Rights undated document in part: Nursing home residents have patient rights and certain protections under the law. Resident rights usually include: Respect; You have the right to be treated with dignity and respect. Privacy: You have the right to privacy. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 2 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145748 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Place 5550 South Shore Drive Chicago, IL 60637 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to update the resident record with the correct code status for 3 of 3 (R9, R23, R28) residents. The facility also failed to enter the code status for 1 (R133) resident reviewed for Advance Directives in a sample of 14. Findings Include: R9 was admitted to the facility on [DATE] with diagnosis not limited to Cerebral Ischemia, Concentration Deficit Cognitive Social or Emotional Deficit and Adult Failure to Thrive. R9 Order Summary Report dated [DATE] - [DATE] document in part: DNR (Do Not Resuscitate) Order status [DATE], End date [DATE]. Initial review on [DATE] of R9 Electronic Medical Record and Face Sheet Advance Directives document in part: DNR. Updated Face Sheet on [DATE] document in part Advance Directives Full Code. R23 was readmitted to the facility on [DATE] with diagnosis not limited to Unspecified Dementia, Atrial Fibrillation Mild Cognitive Impairment and Cognitive Communication Deficit. Order Summary Report dated [DATE] - [DATE] document in part: Full Code Order date [DATE], End date [DATE]. Order Summary Report dated [DATE] - [DATE] document in part: DNR (Do Not Resuscitate) Order date [DATE]. Do-Not-Resuscitate (DNR) Practitioner Orders For Life Sustaining Treatment (POLST) Form document in part: Do Not Attempt Resuscitation/DNR Selective Treatment dated [DATE]. Initial review on [DATE] of R23 Electronic Medical Record and Face Sheet Advance Directives document in part: Full Code. Updated Face Sheet on [DATE] document in part Advance Directives DNR. R28 was admitted to the facility on [DATE] with diagnosis not limited to Hemiplegia and Hemiparesis, Chronic Ischemic Heart Disease, Essential (Primary) Hypertension, Malignant Neoplasm of Prostate and Mild Cognitive Impairment. Order Summary Report dated [DATE] - [DATE] document in part: Full Code. Practitioner Orders For Life Sustaining Treatment (POLST) Form document in part: Do Not Attempt Resuscitation/DNR Comfort-Focused Treatment dated [DATE]. Progress note dated [DATE] document in part: Code Status: DNR (POLST [DATE]) Initial review on [DATE] of R28 Electronic Medical Record and Face Sheet Advance Directives document in part: Full Code. R133 was admitted to the facility [DATE] with diagnosis not limited to Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Obstructive Sleep Apnea, Heart Failure and Atrial Fibrillation. Face Sheet and Order Summary Report dated [DATE] - [DATE] has no documented Code status. Updated Order Summary Report dated [DATE] - [DATE] document in part: Full Code Order date [DATE]. On [DATE] at 12:21 PM V6 (Agency Registered Nurse) stated R133 was admitted to the facility on [DATE]. If R133 was found unresponsive we would do CPR (Cardio-Pulmonary Resuscitation). There is no order for R133 code status, and I do not see it in the computer. V6 (Agency Registered Nurse) checked the computer and stated R9 is a DNR (Do Not Resuscitate), R23 and R28 are Full Codes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 3 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145748 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Place 5550 South Shore Drive Chicago, IL 60637 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Record review of R133 Physician Order and Care Plan has no document Code status. Level of Harm - Minimal harm or potential for actual harm On [DATE] at 12:37 PM V7 (Unit Coordinator) stated R133 Code status should be entered upon admission from the hospital. If the residents are not a DNR they are considered a full code. An order should be written and flagged on the resident face sheet. If the resident is a DNR social service come back and label the chart with a sticker indicating DNR. If a resident that is a DNR is treated as a full code that is a liability on our part and an error for resuscitation. Residents Affected - Some On [DATE] at 12:58 PM V3 (Director of Nursing) stated the Code status is entered when the resident is admitted . The admitting nurse and Supervisor check and reconcile the code status. If there is no code status, then CPR will be initiated. We would do CPR if it were an emergency situation and there is nothing documented to tell us the code status. On [DATE] 10:47 AM V4 (Social Service Director) stated the Code status process is the nurse get the status from the hospital or if a resident verbalizes, they want an advance directive the POLST (Physician Order for Life Sustaining Treatment) form is filled out and signed by the resident or POA (Power of Attorney). The POLST form is uploaded in the computer and a copy is put in the chart, make sure the nurse is aware, provide the nurse with a copy and the code status is changed in the system. When initially entering the facility, the residents are considered a full code unless we have the POLST form. The Code status is verified by nurse then entered into the computer. There should be an order for R133 code status and in the Electronic Medical Records so anyone that look in the Electronic Medical Records should be able to see the code status. The order is received on admission and should be entered into the Electronic Medical Record. If there is no order and the code status is not in the computer, the resident is considered a full code. Our Nurse Practitioner does catch the code status if the resident is a DNR. If the paperwork from the hospital document the code status and we do not have the POLST form I follow up or if it is brought to my attention that the resident is a DNR. The physicians upon assessment ask the resident if they want to be a DNR. I can check R28 chart. If a resident is a DNR and documented as a Full code that is not good at all. I don't have R28 POLST form on the referral information that I received. That is not good if a resident is a DNR, but we have Full code on the face sheet because we will be doing life sustaining interventions on someone who preference is a DNR. There would be an error in treatment. I just uploaded R23 POLST form in the Electronic Medical Records. R23 was in assistant living and came to us for rehab but is transitioning to Long Term Care. R23 paperwork did not come over with R23 and the paperwork was still in assistant living. I addressed the Code status after it was brought to my attention and when I was looking for the POLST form. R133 should have had an order stating she (R133) is a full code upon admission. R9 does not have a POLST form and should have been listed as a full code and not a DNR. I let them know the order needed to be changed. On [DATE] at 11:35 AM V4 (Social Service Director) stated R28 is a DNR. I found the POLST form in the paper chart. There was no DNR sticker on R28 chart for a DNR. An orange sticker is placed on the spine of the paper charts for residents that are DNR's. I was not able to find a POLST form for R9 Document titled Residents' Rights for People in the Long-Term Care Facilities document in part: You have the right to make a Durable Power of Attorney for Health Care, Living Will, Declaration for Mental Health or Do Not Resuscitate Order. Email dated [DATE] document in part: Subject POLST Form. R9 and R133 full code. R23 DNR selective form and R28 Full code no POLST. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 4 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145748 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Place 5550 South Shore Drive Chicago, IL 60637 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Policy: Level of Harm - Minimal harm or potential for actual harm Titled Advance Directives undated document in part: Advance directives will be respected in accordance with state laws and facility policy. 3. Prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance Directives. 4. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 5. b. Do No Resuscitate - Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, health care proxy, or representative has directed that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. Residents Affected - Some Titled Do Not Resuscitate undated document in part: 4. Do not resuscitate orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order. 5. The Interdisciplinary Care Planning Team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 5 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145748 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Place 5550 South Shore Drive Chicago, IL 60637 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician orders by not weighing 2 (R2, R29) out of 2 residents reviewed for edema in a sample of 14 residents. Residents Affected - Few Findings include: 1. R2 was admitted to the facility on [DATE] with primary diagnosis, not limited to, Acute on Chronic Diastolic (Congestive) Heart Failure. R2 has mild cognitive impairment, according to R2's most recent minimum data set (MDS). R2 physician note dated 07/07/2022 reads: M W F weights. please notify MD if >3lb gain in 24-hour period. R2 had the following Weights Missing dated: 7/8/22, 7/11/22, 713/22, 7/15/22, 7/18/22 R2's weights for the following dates are as followings: 7/6/2022 23:54 136.6 Lbs (pounds)- Staff member did not correctly subtract the weight of the resident's wheelchair. 4/22/2022 09:52 126.0 Lbs 3/10/2022 18:28 125.8 Lbs During interview on 07/20/22 11:13 AM R2 stated, I do not know when the last time I was weighed. 07/20/22 11:33 AM R2 observed being weighed by V11 (Dietary Manager) . R2 is 161.2lbs, wheelchair weight will be subtracted. On 07/20/22 at 12:35 PM, R2 re-weighed on standing scale, standing with a walker. R2's weight 114.8lbs. 07/20/22 02:26 PM V2 (Director of Nurses/DON) stated, R2 has a diagnosis of CHF and she needs to be weighed to be monitor for fluid retention. The nurse is responsible for making sure the resident's weights get entered into the computer. R2 weighed on 07/21/2022. R2 weighed 125lb. On 07/22/2022 at 11:51 AM, V10 (Nurse Practitioner) stated, residents with congestive heart failure or edema issues need their weights monitored so we know if they are retaining fluid in their bodies. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 6 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145748 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Place 5550 South Shore Drive Chicago, IL 60637 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 07/20/22 at 11:26 AM V5 (LPN) stated, I do not know if R2 has an order to be weighed on a weekly basis, I will double check R2's order. On 07/20/22 at 11:37 AM, V8 (RN) stated, R2 does have an order from 07/07/2022 to be weighed Monday, Wednesday, and Friday. The last weight for R2 was on 7/6/2022. R2 has chronic congestive heart failure (CHF). The weights are an indicator of fluid retention. 2. R29 was admitted to the facility on [DATE] with primary diagnosis, not limited to, Polymyalgia Rheumatica and Abnormal Weight Loss. R29 is cognitively intact, according to R2's most recent minimum data set (MDS). On 07/20/22 at 11:02 AM, R29 stated, I do not know when the last time I was weighed. My feet are swollen. On 07/20/22 at 11:38 AM, V8 (RN) stated, R29 should be getting weighed every Monday and Wednesday. On 07/20/22 at 11:58 AM, V8 (RN) stated, R29's last weight was on 7/1/2022. R29's order for weights are to monitor fluid retention. On 07/20/22 at 02:44 PM, V2 (DON) stated, R29 should be weighed to monitor him for fluid retention. R29's physician order dated 06/30/2022 reads: Weights Monday, Wednesday one time a day every Mon, Wed for fluid retention. Record review of R29's weights show missing weights for following dates: 7/4/22, 7/6/22, 7/11/22, 7/13/22, 7/18/22 Record review of R29's weights: On 07/01/2022, R29 weighed 131.8 lbs. On 07/20/2022, the resident weighed 135.2 pounds which is a 2.58 % Gain. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 7 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145748 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Place 5550 South Shore Drive Chicago, IL 60637 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to apply ordered heel protector boots for 1 (R12) out 1 resident reviewed for pressure ulcers in a sample of 14 residents. Residents Affected - Few Findings include: R12 was admitted to the facility on [DATE] with diagnosis, not limited to, Pressure Ulcer of Right Heel, Unspecified Stage. R12 has mild cognitive impairment, according to R12's most recent minimum data set (MDS). R12's care plan with an initiation date of 07/12/2022 reads: R12 has pressure ulcers with risk for further skin breakdown due to impaired mobility/transfers, incontinence, and malnutrition. R12's care plan intervention with an initiation date of 07/11/2022 reads: heel protector boots per order. R12 physician order dated 07/11/2022 reads: Ensure patient is wearing heel protector boots when in bed or chair. On 07/19/22 at 11:45 AM, R12 was observed sitting in wheelchair in R12's room. [NAME] socks were observed on R12's feet. No heel protector boots observed on R12's feet. On 07/20/22 at 11:02 AM, R12 was observed sitting in wheelchair in R12's room. No sock or shoe observed on R12's left foot. [NAME] sock observed on R12's right foot. No heel protector boots observed on R12's feet. R12 stated, I have boots for my feet, but I do not wear them all the time. I do not know when the last time I had the boots on. I do not know where they are. I think they are in my room. On 07/20/22 at 12:20 PM, V8 (Registered Nurse/RN) searched R12's room and the heel protector boots found in R12's closet. On 07/20/22 at 12:23 PM, V8 (RN) stated R12 does have heel protector boots for his heels in his room. R12 has a wound on his right heel and the heel protector boots are used to relieve pressure. Sometimes R12 does not want to wear his boots. If R12 refuses to wear his boots it should be documented. On 07/20/22 at 12:20 PM, V2 (DON) stated if R12 refuses to wear his heel protector boots it should be documented and care planned. R12 has heel protector boots to protect his heels from skin breakdown. Facility policy titled, Skin and Wound Care Policy, reads: All residents and patients will receive appropriate care to decrease the risk of skin breakdown. For residents who are bed or chair bound consider using a pressure-reducing device. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 8 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145748 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Place 5550 South Shore Drive Chicago, IL 60637 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure oxygen tubing was labeled for 2 (R4, R133) of 3 (R5) reviewed for oxygen therapy in a sample of 14. Residents Affected - Few Findings Include: R133 was admitted to the facility 07/12/22 with diagnosis not limited to Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Obstructive Sleep Apnea, Heart Failure and Atrial Fibrillation. On 07/19/22 at 11:54 AM R133 was observed in bed with oxygen at 3 liter per nasal cannula in use. The oxygen tubing was observed without any labeling. R4 has diagnosis not limited to Acute on Chronic Diastolic (Congestive) Heart Failure, Chronic Obstructive Pulmonary Disease, Dependence on supplemental Oxygen and Primary (Essential) Hypertension. On 07/19/22 at 12:01 PM R4 was observed in bed with oxygen at 2 liter per nasal cannula in use. The oxygen tubing was observed without any labeling. On 07/19/22 at 12:07 PM V6 (Agency Registered Nurse) stated I do not know the policy for labeling and dating the oxygen tubing. On 07/19/22 at 12:37 PM V7 (Unit Coordinator) stated labeling the oxygen tubing is the nurse responsibility. The oxygen tubing is changed every 72 hours and is labeled and dated so they can when it is time for the tubing to be changed. On 07/20/22 at 12:58 PM V3 (Director of Nursing) stated the oxygen tubing is to be labeled and dated when it is started and changed. The oxygen tubing is changed every 72 hours. Policy: Titled Oxygen Administration dated 07/01/18 document in part: The purpose of this procedure is to provide guidelines for safe oxygen administration. Documentation: The date and time that the procedure was performed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 9 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145748 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Place 5550 South Shore Drive Chicago, IL 60637 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a.) medications were labeled after opening b.) stored to prevent the potential for cross contamination and c.) discarded when expired in 1 of 2 medication carts and 1 of 2 medication storage rooms being reviewed for medication labeling and storage. Findings Include: On [DATE] at 11:28 AM the west medication cart was reviewed with V6 (Agency Registered Nurse). During review of the west medication cart, R133's Symbicort Aerosol 160-4.5 MCG (Microgram)/ACT (Activated Clotting Time), Albuterol Sulfate Aerosol Solution 108 (90 Base) MCG/ACT, R21's Albuterol Sulfate HFA ((Hydrofluoroalkane) 108 (90 Base) and Symbicort Aerosol 80-4.5 and R4's Two Advair 500-50 Diskus, were observed in the medication cart unlabeled with no open date. R133's Idosorb Gel 0.9%, R4's Spiriva 18 MCG Handihaler -30 capsule, R28's Dry Eye Relief eye drops labeled Home Med and R8's Voltaren Gel 1% were observed in the medication drawer not stored in a bag. On [DATE] at 11:37 AM V6 (Agency Registered Nurse) stated the medications should be stored inside of bags with Identification and dosage written on it to prevent cross contamination. On [DATE] at 11:46 AM the west medication storage room was reviewed with V6 (Agency Registered Nurse). During review of the west medication storage room two 1000 ml (Milliliter) bottles of Promote with fiber with expiration date 11/21, Milk of Magnesia 16 fluid ounces with expiration date 11/21, Box of 33 Xeroform Occlusive Gauze with expiration date [DATE] and 5% Dextrose and 0.9% Sodium Chloride 1000 ml with expiration date 06/22 were observed in the cabinets. Lispro with open date [DATE] with no name and not in a storage bag, R8's Aspart 100 unit/ml 3 units before meals with and open date of [DATE] and R132's Insulin Glargine Solution100 unit/ml dated [DATE] not in a storage bag were observed in the west medication storage room refrigerator. V6 (Agency Registered Nurse) stated the insulin should be in a bag to precent cross contamination. If the medication does not have a name, we will not know who it belongs to. On [DATE] at 09:42 AM V9 (Registered Nurse) left the Medication cart keys on top of the medication cart, entered R33 room. On [DATE] at 09:46 AM V9 (Registered Nurse) proceeded down the hallway to retrieve medications from the Medication dispenser leaving the medication cart keys on top of the medication cart then entered R1 room before returning to the medication cart. On [DATE] at 09:48 AM V9 (Registered Nurse) returned to the medication cart, unlocked the controlled substance drawer leaving the keys hanging in the lock then stated I have to go on the other side and get Acetaminophen. V9 proceeded down the hallway then returned to the medication cart with a bottle of Acetaminophen. V9 entered V33 room without knocking, leaving the computer screen open, the medication cart unlocked with the keys hanging from the control substance drawer lock. On [DATE] at 10:06 AM V9 (Registered Nurse) stated the medication cart keys should be on me at all times to safe-guard the integrity of the medications. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 10 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145748 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Place 5550 South Shore Drive Chicago, IL 60637 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On [DATE] at 02:18 PM V3 (Director of Nursing) stated we have never given expired enteral feeding before. If the enteral feeding is expired, it is supposed to be tossed away. I cannot be used because each resident has enteral feeding specific to them. The expired Xeroform gauze should have been tossed. The expired IV (Intravenous) fluid should be discarded. If the expired IV fluid is used it would be a medication error. The inhaler Advair is good for 6 weeks after opening. If the Advair and Diclofenac is out of the storage bag it could cause cross contamination. Spiriva should have an open date. The eye drops not stored in a bag is a potential for contamination. Insulin is house stock and may not have a resident name on it. If the insulin does not have a name on it, it should be tossed. The insulin is good for 28 days after opening. The insulin that was open and dated on [DATE] should have been discarded by [DATE]. If the insulin had been given that is a medication error and could have been less effective. R9 insulin that was not stored in a bag has a potential for cross contamination. On [DATE] at 03:59 PM V3 (Director of Nursing) stated I called to replace the medications and get the guidelines for the inhalers. Document titled Inhaled Medications dated 03/20 document in part: Advair Diskus, date the Diskus when removed from the foil pouch and discard on month after removal from the foil pouch. Symbicort Inhalation Aerosol, date after opening the foil pouch. Discard after 3 months. Ventolin HFA Inhalation Aerosol (Albuterol), date after opening the foil pouch and discard after 12 months. Policy: Titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles undated document in part 3.3 The community should ensure that all medications and biologicals, including treatment items are securely stored in a locked cabinet/cart or locked medication room, inaccessible by residents and visitors. 4. The community should ensure that medications and biologicals: 4.4 have an expiry date on the label; 4.2 Have not been retained longer than recommended by manufacturer or supplier guidelines; and 4.3 Have not been contaminated or deteriorated. 6. The community should destroy and reorder medications and biologicals with soiled, illegible, worn, makeshift, incomplete, damage or missing labels. 11. Controlled substance storage: 11.1 The community should ensure that Schedule II-V controlled substances are only accessible to licensed nursing, pharmacy and medical personnel designated by the community. 11.3 The community should ensure that all controlled substances are stored in a manner that maintains their integrity and security. 14. The community should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Applicable law. Titled Medication Administration undated document in part: 13. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 11 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145748 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Place 5550 South Shore Drive Chicago, IL 60637 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure reusable equipment was cleaned and disinfected between resident use and medications were administered under sanitary conditions for 3 of 3 (R33, R34 R134) reviewed for medication administration to prevent cross contamination in a sample of 14. Residents Affected - Few Findings Include: On 07/20/22 09:17 AM V5 (Agency Licensed Practical Nurse) place a wrist blood pressure cuff in her (V5) pocket. V5 entered R34 room without knocking, removed the blood wrist pressure cuff from her pocket and placed it on R34 wrist. On 07/20/22 at 09:19 AM V5 (Agency Licensed Practical Nurse) removed the wrist blood pressure cuff from R34 wrist, placed it in her (V5) pocket, exited the room, returned to the medication cart, removed the wrist blood pressure cuff from her (V5) pocket, placed it in the pouch on the medication cart then prepared R34 medications. On 07/20/22at 09:36 AM V5 (Agency Licensed Practical Nurse) removed the wrist blood pressure cuff from the pouch and placed it in her (V5) pocket. On 07/20/22 at 09:38 AM V5 (Agency Licensed Practical Nurse) entered the dining room to take R134 blood pressure. V5 removed the wrist blood pressure cuff from her (V5) pocket and placed it on the table. On 07/20/22 at 09:40 V5 (Agency Licensed Practical Nurse) applied the wrist blood pressure cuff to R134 right wrist then removed and applied it to the left wrist. V5 removed the wrist blood pressure cuff, placed it in her (V5) pocket, exited the dining room and returned to the medication cart to prepare R134 medications. On 07/20/22 at 12:29 PM V5 (Agency Licensed Practical Nurse) stated I use my personal wrist blood pressure cuff. After taking the blood pressure, I put it in my pocket then put it back in the pouch. I removed it from the pouch to go to the next resident. The wrist blood pressure cuff should be cleaned before and after use. Ideally, I would use sanitizing wipes to clean it after using the wrist blood pressure cuff on each resident to prevent germs and cross contamination. On 07/21/22 at 09:36 AM V9 (Registered Nurse) was observed standing at the medication cart. V9 removed the bottle of house stock Vitamin B12 from the medication cart, removed the top and poured a tablet into her hand before placing it into the medication cup. V9 continued to prepare R33 medications pushing the pills from the bingo cards into her (V9) hand before placing them in the medication cup. V9 dropped an Acetaminophen tablet on top of the medication cart, picked the tablet up with her (V9) hand and placed it in the medication cup. On 07/21/22 at 09:48 AM V9 (Registered Nurse) placed the Enoxaparin 40 MG/0.4 ML, Ciprofloxacin-Dexamethasone Suspension 0.3-0.1% and the Insulin Lispro 100 Unit/ML syringe in her pocket then entered V33 room. On 07/21/22 at 10:06 AM V9 (Registered Nurse) stated medications should be poured directly into the medication cup and not in my hand. I try to do that, but I don't always do it. There is a potential (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 12 of 13 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145748 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Montgomery Place 5550 South Shore Drive Chicago, IL 60637 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 for contamination. Level of Harm - Minimal harm or potential for actual harm On 07/21/22 at 10:21 AM V3 (Director of Nursing) stated reusable equipment should be cleaned between residents. It can be wiped with alcohol or the bleach wipes and allowed to air dry to avoid cross contamination. That is an infection control issue. Medications should be poured into the medication cup from the bingo card or medication bottle. If the medication is poured into the nurse hand it is contaminated. The nurse should have discarded the medication and gotten another one. Residents Affected - Few Policy: Titled Medication Administration undated document in part: 4.a. avoid contact with tablets. Titled Reusable Equipment Policy undated document in part: to reduce the transmission of microorganisms and prevent cross contamination of infections. The facility is committed to prevent the transmission and cross contamination of infection that can occur as a result of reusable equipment. 1. Nursing staff will use appropriate cleaning agent to sanitize all reusable equipment (E.G (Example) blood pressure, glucometer) before and after each use. 2. The nursing staff will clean the reusable equipment in between patient use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 13 of 13