Inspection·July 17, 2023

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. 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 implement their Inventory List, Resident's Personal policy for one of three residents (R1) reviewed for theft. This failure resulted in money and credit cards being stolen from R1's purse. Residents Affected - Few Findings include: Facility's incident report of 5/8/2023 documents in part, CNA (Certified Nurse Assistant) notified Executive Director (V1 Administrator) that patient (R1) requested to meet. (V1) met with (R1) at approximately 8:45 AM on 5/1/2023. (R1) told (V1) that she realized on Sunday evening (4/30/2023) that some cash ($24.00) and her five credit cards were missing from her wallet and purse. (R1) does not remember looking in her wallet since Wednesday, 4/26 at about 12 noon. (R1's) wallet was in her purse-and the purse (was) hanging on the chair next to her bed. Investigation included a questionnaire being completed by department staff. No significant findings surfaced to help us identify the person that took the money and credit cards. (V1) also met with (R1's) roommate. Other resident interviews were conducted. No useful information was obtained from these interviews. We identified an Inventory List of Resident Personal Belongings upon admission that did not get completed for (R1) by the CNA or Nurse. This is required per policy to protect the resident('s) personal property and valuable items during their stay at the community. Investigation found evidence of financial exploitation. This was due to our non-compliance related to not completing the resident's Inventory of Personal Belongings-and then securely storing those valuable items. On 7/15/2023 at 2:00 PM, V1 (Administrator) said he was informed on 5/1/2023 by a CNA that R1 wanted to speak with him but did not offer any other information. V1 said he spoke with resident, who informed him that she was missing $24 and five credit cards from her purse which she kept at her bedside hanging on a chair. V1 said R1 told him that she realized on 4/30/2023 that the cash and credit cards were missing from her purse; the last time she had looked in her purse was four days earlier. V1 said R1 was reimbursed $24. On 7/17/2023 at 9:58 AM via telephone, R1 said she discovered money and credit cards missing from her wallet on 4/30/2023. R1 said she reported this to the V1 (Administrator). R1 said she was re-imbursed $24 by V1. R1 also said when she was admitted to the facility, no one asked her about her valuables or inventoried her belongings. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145748 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 07/17/2023 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)