Inspection visit

InspectionSeptember 21, 2023

MONTGOMERY PLACECMS #1457489 citations on this visit

9 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record review, the facility failed to ensure that residents' call devices were within reach. This failure affected 3 out of 28 residents reviewed for call devices (R3, R4 and R29). Residents Affected - Few Findings include: 1.) R29's diagnosis includes but not limited to: Chronic pain, Anemia, Type 2 Diabetes Mellitus and Hypertension. 09/18/23 during survey, R29 was observed in bedroom sitting in wheelchair. R29's call device was observed on the opposite side of R29's bed. R29 attempted to retrieve call light but was unsuccessful. On 9/18/23 at 11:06 AM, R29 said, I cannot reach my call light. Can you please hand it to me? On 9/18/23 at 11:08 AM, V12 (Licensed Practical Nurse) said, It looks like somebody probably just forgot to put her (R29's) call light back after getting her out of bed. I will move it for her that so she can reach me when she needs me. Surveyor inquired about the importance of having the resident's call device within reach. V12 said, It's good to have the call device within reach just because it is a safety measure for the residents. You never know what they may need, so they (residents) should be able to call for help at any given time. 2.) R3's diagnosis includes but not limited to: History of falling, Anxiety disorder, Abnormality of gait and mobility and overactive bladder. On 9/18/23 during investigation, R3 was observed in bed awake. R3's call device was observed on the floor. R3 attempted to reach for the call light but could not reach the call light. On 9/18/23 at 11:33 AM, V4 (Unit Manager) said, R3 cannot reach the call light. I will get it off the floor. It is expected that all resident's call devices are within reach of the resident. 3.) R4's diagnosis includes but not limited to: Major depressive disorder, Osteomyelitis, Pressure ulcer and malignant neoplasm of colon. On 9/18/23, during investigation, R4 was observed lying in bed. R4's call device was observed wrapped around the bed side rail, out of reach of resident. On 9/18/23 at 11:50 AM, V8 (Certified Nurse Assistant) said, R4 can't reach the call light. If R4 needs help, R4 can ask her roommate to get help for her. If R4's roommate is not available, I don't (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 8 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 09/21/2023 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)

F 0558 know. Level of Harm - Minimal harm or potential for actual harm Facility policy titled Resident Call System documents, ensure that residents have a means of direct communication between the resident and his/her caregivers. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 2 of 8 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 09/21/2023 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview and record review, the facility failed to maintain shift change accountability records for controlled substances for residents'-controlled medications. This failure has the potential to affect all 36 residents on the second floor of the facility. Findings include: On 9/18/23 at during the facility's entrance conference, the facility census shows that there are 36 residents on the second floor of the building. On 9/21/23 at 12:50pm on the second floor during medication storage observation with V5(Licensed Practical Nurse), the shift change accountability record for Controlled Substances on the second floor shows several missing entries of nurses' signatures, interpreted to mean that there were some shifts that no nurse was accountable or responsible for the narcotics on the floor. The missing entries for August 2023 are 8/1/23, 8/4/23, 8/29/23, and 8/30/23. The missing entries for September 2023 are: 9/5/23, 9/12/23, 1/9/23, and 9/16/23. V5 was asked why some nurses did not sign the records and if they counted the narcotics before taking over from the previous nurse. V5 stated that she sometimes works on another floor. On 9/21/23 at 12:09pm, V2(Director of Nursing) was interviewed regarding this. V2 stated that her expectation is that every nurse will sign the accountability sheet at the beginning and at the end of their shifts. Facility's policy titled Routine Reconciliation of Controlled Substances dated 1/1/22 states in part: This policy is set up for routine reconciliation of controlled substances. Facility should routinely reconcile controlled substances stored in medication carts, emergency supplies and should reconcile controlled substances waiting to be destroyed. The reconciliation should be performed by two licensed nurses or a licensed nurse and an authorized licensed healthcare professional. #6.8 states: Both nurses should sign the reconciliation sheet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 3 of 8 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 09/21/2023 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)

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record review, the facility failed to ensure that the steam table that hold meals was working properly. This failure affected two residents, R26 and R32 who stated that the food served was not at the preferred temperature and has the potential to affect all 36 residents that reside on that unit and receive meals from the steam table. Residents Affected - Many Findings include: 1.) R32's diagnosis includes but not limited to: Muscle weakness, Chronic Kidney Disease, Vitamin D deficiency, Anemia and Prediabetes. R32 has a BIMS (Brief Interview for Mental Status) score of 13, which indicates cognitively intact. On 9/18/2023 at 11:15 AM R32 was observed on second floor near the Nurse's station. Surveyor inquired about R32's care. R32 said, I am ok. The food that they give us could be a little warmer. Often times, I have to ask staff to warm my food up for me. 2.) R26's diagnosis includes but not limited to: Anxiety disorder, Malignant Neoplasm of Overlapping sites of urinary organs, Hypertension and Constipation. R26 has a BIMS (Brief Interview for Mental Status) score of 15, which indicates cognitively intact. On 9/18/23 at 11:42 AM R26 was observed lying in bed with V6 (R26's caretaker) sitting at the bedside. R26 said, The food is ok but is sometimes cold. I have to ask staff to warm it up often or I will have my caretaker warm it up. On 9/18/23 at 11:42 AM, V6 said, I am here three days per week. R6 asks me to warm his food up at least once or twice per week. On 9/18/23 at 12:35 PM, Surveyor observed meal cart with 6 room trays. Staff began setting up the room trays with soup at that time (12:35 PM). Dietary staff were observed serving residents in the dining room and making room trays (alternating between the two tasks). The room trays were complete and taken from dining area via cart at 12:53 PM by V21 (Dietary Aide) to be delivered to residents' rooms. Surveyor inquired about the temperature on one of the meal trays. On 9/18/23 at 12:35 PM, V9 (Dietary Aide) took the temperature of a serving of spaghetti on a resident's tray. The thermometer read, 49 degrees Fahrenheit for the spaghetti. At that time, V11 (Dietary Manager) said, The thermometers are new. I don't know why they are not working properly, but the temperatures are not correct. On 9/18/23 at 12:37 PM, V9 said, The steam table is broken. Only one of the three wells work on the steam table. We do that best we can, but it is hard to keep everything warm with only one working well. Surveyor observed steam coming from one well on the steam table and the other two wells did not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 4 of 8 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 09/21/2023 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)

F 0804 have steam coming from them. All three wells had pans of food in them. Level of Harm - Minimal harm or potential for actual harm On 9/18/23 at 12:40 PM, V11 (Dietary Manager) said, I put in a work order for the steam table. There is only one well working on the steam table. Residents Affected - Many On 9/20/23 during investigation, Surveyor asked if all residents were served from the steam table. On 9/20/23 at 12:15 PM, V10 (Dietary Aide) said, All food come up from the kitchen on a hot box between 12:00 PM and 12:15 PM. Once the food is sent up, we transfer the food to the steam table to be served. We serve room trays and from the steam table and trays for residents in the dining room. On 9/20/23 at 10:20 AM, V11 (Dietary Manager) said, The steam table is not repaired as of today. I put in a work order last month and believe we are waiting on parts. On 9/20/23 2:38 PM, V1 (Administrator) said, I am aware of the steam table not working properly. We are waiting on parts for it to be repaired. Facility policy titled Infection control- Food Handling documents, Food is to be held at appropriate temperatures while being served. Monitoring of food temperatures using food thermometer should be performed regularly. Facility policy titled Food and Nutrition Services- Sanitation and Food Safety documents, to ensure food safety, hot food is cooked to a minimum safe temperature and is held at no lower than 135 degrees Fahrenheit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 5 of 8 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 09/21/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to date refrigerated food items when opened; failed to ensure that food is not stored on the floor of the walk-in freezer; failed to ensure that dented cans are stored in a designated area; and failed to serve food in a sanitary manner. These failures have the potential to affect all 36 residents receiving oral foods from the facility's kitchen. Findings include: On 9/18/23 at 9:40am during the entrance conference, V1(Administrator) presented the facility's census as 36, and that all the residents are on the second floor. On 9/18/23 between 10:20am and 10:40am during observation in the kitchen with V13(Director of Dining Services), the following refrigerated food items were observed opened in the walk-in cooler without open dates: A five-pound container low fat cottage cheese that was less than one-quarter full. A five-pound container of strawberry nonfat yogurt that was one-third full. A five-pound container of sour cream that was one-quarter full. V13 was asked why the foods were not labeled with the open dates when they were opened. V13 responded that she knew the foods should have been dated when opened, but was not sure who opened them, but that she could remove them from the walking cooler and toss them. In the dry storage area, two #10 cans of baked beans (117 ounces each) were observed in the storage shelves with other canned food items. V13 stated that there is no designated separate place for dented cans pick-up because they usually send the dented cans back to the supplier immediately. In the walk-in freezer, two racks of bread loaves were observed on the floor. V13 stated that the bread should have been put in the shelves and not on the floor. V13 stated that staff will be educated about these. On 9/19/23 at 10:55am, V14(Executive Chef) stated I was off yesterday and was told you were here. The surveyor explained the above listed observations to V14 and V14 stated that he(V14) would ensure that staff follow the policy. Facility's policy on Storage of refrigerated foods with latest revision date 2017 states in part that refrigerated food is stored in a manner that ensures food safety and preservation of nutritive value and quality. Refrigerated food is covered, labeled, and dated with a use by date. Opened products that have not been properly sealed and dated are discarded. Facility's policy on storage of frozen foods with revision date 2017 says and part: Frozen food are placed in the freezer as quickly as possible after receipt. Food is stored 6 inches above the floor. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 6 of 8 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 09/21/2023 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Facility's policy on storage of dry foods with revision date 2017 states in part: Dented Cans are stored in a designated area to be returned to vendors. On 9/18/23 during investigation, Surveyor observed staff setting up dining room for lunch in the 2nd floor dining room. Residents Affected - Many On 9/18/23 at 12:35 PM, Surveyor observed V9 (Dietary Staff) grabbing a handful of spaghetti noodles with a gloved hand and placing the noodles on a plate. V9 then grabbed a ladle with the opposite hand to scoop spaghetti sauce on top of the noodles, and finally grabbing plates with the same gloved hand used to pick up the noodles. V9 was observed repeatedly grabbing spaghetti noodles and plates with the same hand without changing gloves or using a utensil. Surveyor inquired about the protocol when serving meals. On 9/18/23 at 12:38 PM, V9 said, We are supposed to use tongs for sanitary purposes. When we touch the food, we should not touch other things without changing gloves. On 9/18/23 at 12:40 PM, V11 (Dietary Manager) said, Grabbing food with a gloved hand and touching other things could be a hazard. The food can get contaminated. We are expected to pick the spaghetti up with the tongs or another utensil. Facility policy titled Infection Control- Food Handling documents, Single-use gloves are not to be used for more than one task. Change gloves and perform hand hygiene between tasks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 7 of 8 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 09/21/2023 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)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure that the outside dumpster was covered, and failed to ensure that the overflowing garbage on the floor by the dumpster was picked up. This failure has the potential to affect all 36 residents in the facility. Residents Affected - Many Findings include: On 9/18/23 at 10:45am during observation of the facility, the outside dumpster was observed to be full of garbage overflowing to the floor and without a lid or cover. On 9/18/23 at 3:55pm, V16 (Director of Facility) was notified. Again on 9/19/23 at 9:30am and at 11am, the outside dumpster was still in the same condition. On 9/19/23 at 12:33pm, V1(Administrator) was notified that the outside dumpster was left open with garbage overflowing. V1 stated that it's mostly the Dietary Department that puts garbage in the outside dumpster and he(V1) would ensure that the garbage is closed and picked up. On 9/19/23 at 1:22pm, V16 stated that the outside dumpster had been picked up by the vendor. V16 added I had to talk to the vendor that it was unsightly, and now, the vendor removed it. I can show you the picture. On 9/20/23 at 9:40am, V1 presented a facility's document titled Trash Removal. This document dated 9/20/23 states that the regular contract pick-ups (recycle and trash) is Tuesdays and Fridays. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 8 of 8

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Citations

9 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0814GeneralS&S Fpotential for harm
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
0558GeneralS&S Dpotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0804GeneralS&S Fpotential for harm
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0133GeneralS&S Fpotential for harm
Install a two-hour-resistant firewall separation.
0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
0521GeneralS&S Fpotential for harm
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

FAQ · About this visit

Common questions about this visit

What happened during the September 21, 2023 survey of MONTGOMERY PLACE?

This was a inspection survey of MONTGOMERY PLACE on September 21, 2023. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at MONTGOMERY PLACE on September 21, 2023?

Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Dispose of garbage and refuse properly."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 8, 2026. If you believe any information is inaccurate, report it here.

Inspection·September 21, 2023