Inspection·February 15, 2026

F 0689 Level of Harm - Actual harm Residents Affected - Few support of the sit to stand lift on R1, tightened the belt to fit tightly, connected the hooks on the sit to stand lift, positioned her feet on the base of the list and positioned R1's wheelchair close by in the locked position. V8 stated she pressed the up button on the sit to stand remote and as R1 started to lift up off the bed R1 jerked forward and threw herself toward the sit to stand lift. V8 asked R1, What's going on? Are you okay? V8 stated she started to lower R1 back down to the bed and as she did this R1's buttocks slid off the bed and R1 took her right foot off the base of the sit to stand lift. R1 was still attached to the lift but her toes were touching the floor and R1 was sliding forward. V8 stated she realized she needed help so she had to lower R1 to the floor so she could go get someone to help her. V8 stated when she pressed the down button on the lift to lower R1 to the floor, R1's legs were not out in front of her, they were twisted underneath her body. V8 stated as she lowered R1, her right leg bent inward and was tucked underneath her body, so she was in a seated position on her buttocks with her right leg bent underneath her. V8 stated as soon as she lowered R1 to the floor she went into the hall to get help. V8 asked another CNA (V10) to help her with R1 and when they came back into the room R1 was still in the same seated position on the floor upright with right leg folded underneath her and her left leg was straight out with her back resting on the side of the bed. V8 stated R1 told her that R1's foot hurt and she was in pain. V8 stated she and V10 got on each side of R1 and put their arm under R1's arms with the sit to stand lift to get her up off the floor and put her back into bed (bed was in the lowest position). V8 stated R1 kept saying her right foot was hurting her so V8 ran and told the nurse (V9) to come check R1 out. V8 stated V3 (Registered Nurse) was coming in on duty at that time and she was the one who called the R1's physician. V8 stated R1 kept saying her foot was hurting, her foot was hurting. V8 stayed with her but had to leave before the ambulance arrived to take R1 to the hospital.V8 stated the staff was instructed to use the lifts with two people but she has been using the sit to stand on her own because people are not always available to help her. V8 stated she has never had a problem with doing it on her own before with R1. V8 stated the reason there should be two staff assisting during mechanical lift transfers is so someone can guide the residents and help in case something does happen during the transfer. V8 stated if there were two CNAs there that morning with R1 it could have prevented R1 from getting injured. V8 stated two CNAs could have prevented R1 from sliding off the bed and with two people they would have been able to get R1 back onto the bed instead of having to lower R1 to the floor.On 02/14/26 at 12:57 PM, V10 (Certified Nursing Assistant) stated via telephone interview that she has been working at the facility for one year four months, a CNA for five years. V10 stated she works part-time at the facility on the 11AM-7PM shift. V10 stated she does not use the sit to stand lift by herself, she always goes and gets another CNA to assist her. V10 stated if there is not another CNA available, she leaves the resident in bed because she does not want to risk an injury to the resident or to herself. V10 stated she usually works with V8 and V13 (Certified Nursing Assistant) and V13 asks for her help with transfers but V8 routinely gets R1 up out of bed by herself using the sit to stand lift. V10 stated she knows this because she has never been asked to help V8 transfer R1 using the sit to stand lift. V10 stated on 02/09/26 she was coming out of one of the rooms and V8 asked if she could help her with R1. V10 stated when she came into the room, she saw that R1 was attached to the belt/sling but her butt was on the floor and both of her legs looked twisted underneath her. V10 stated R1 was not suspended in the air she was all the way down on the floor. V10 stated R1 was screaming about her knee and leg. V10 stated it looked like R1 had slipped off the bed maybe when trying to raise the lift R1 slipped off the bed and her legs got caught underneath her. V10 stated R1 does not do well sitting up on her own and does not have good trunk control. V10 stated R1 is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 2 of 4 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 02/15/2026 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 0689 Level of Harm - Actual harm Residents Affected - Few very heavy, like dead weight and cannot bear any weight on her legs. V10 stated R1 is anxious and scared of falling so, V10 thinks R1 slid forward as she was getting ready to go up in the lift. V10 said, R1 was screaming really bad. V10 stated they (V8 and V10) each got under one side of R1 and slid her onto the bed. V10 stated R1 was screaming the entire time I'm in pain! and kept complaining about her knee and leg I'm in so much pain, help me, help me! The nurse (V9) came in to assess R1 and then V10 had to go home because it was the end of her shift. They were sending R1 to the hospital. V10 stated she thinks if there was another CNA in there during the transfer R1 would not have hurt herself. V10 stated if there was another staff behind R1 to support her during the transfer R1 may not have been able to slide off the bed.On 02/14/26 at 1:42 PM, V3 (Registered Nurse) stated on 02/09/26 when she came on shift she observed R1 was lying in the bed and her toes were pronated outward. V3 stated R1 verbally told her that R1 was in pain and the pain was coming from legs. V3 called R1's doctor and told them that R1 went down on her legs while she was in the sit to stand lift and she was complaining of pain. The doctor told V3 to send R1 to the hospital and the ambulance was called. V3 stated when staff is using the sit to stand lift there should be two CNAs during the transfer so one can staff can provide assistance while the other one is moving the lift. V3 stated this is a safety measure so the staff assisting can act quickly in the resident needs help to prevent the resident from getting injured. V3 stated R1 cannot sit on her own because she has poor trunk control and cannot bear weight. V3 stated the injury may have been prevented if two staff were there but because she was not there she does not really know. V3 stated having two staff is a preventative measure to prevent injuries like that from happening.On 02/14/26 at 3:30 PM, V2 (Director of Nursing) stated she called the hospital and was told R1's admitting diagnosis was right periprosthetic femoral shaft fracture and that is why on the initial IDPH reportable she put femur fracture as R1's diagnosis. V2 stated it sounds like when V8 was trying to fix R1's feet they got tangled and when V8 lowered the sit to stand lift R1's legs buckled and that is probably what caused R1's injury. V2 stated V8 should have pulled the sit to stand upwards instead of downwards because that is what caused her weight to be on her legs, tangled underneath her. V2 stated if two staff members were there, they could have potentially pulled R1 back onto the bed and therefore may have prevented her from getting injured. V2 stated a fall is change of plane and therefore by the formal definition R1 had a fall. V2 reviewed R1's most recent MDS assessment and saw that R1 was coded for being dependent for transfers. V2 stated by definition of dependent meaning two-person assistance of two or more helpers required then R1 should have had at least two staff assisting with the sit to stand lift. V2 stated the goal is to keep the residents safe and free from any injury.On 02/14/26 at 3:52 PM, V15 (Therapy Director/Occupational Therapist) stated via telephone interview that when the staff are using any type of mechanical lift there should be two people. V15 stated anything is possible so it is better to have two people with you, even if it is just to have one on standby so they can be there to spot for positioning and safety so they can intervene needed. V15 stated she usually sees two CNAs when they are transferring residents using the sit to stand lift. V15 stated she heard about R1 having a fall while using the sit to stand lift. V15 stated if there had been two staff members present when R1 was being transferred R1 may not have sustained the injury, but she does not know the specifics about the fall. V15 said, the hope is that if someone else was there that would not have happened.On 02/14/26 at 3:40 PM, V16 (Facility Medical Director) stated via telephone interview R1 was admitted to the hospital with a right hip fracture, and it was her understanding that the fracture was caused by R1 falling to the floor during a transfer using the sit to stand lift and tragically R1 was injured. V16 stated if R1 is dependent on staff for mobility and transfers then there should have been two staff members (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145748 If continuation sheet Page 3 of 4 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 02/15/2026 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete present during the transfer.Facility provided a written statement signed by V8 (Certified Nursing Assistant) dated 02/11/26 which reads in part: On 02/09/26 at 6:30AM (V8) was transferring the resident in room (R1's room number) from the bed to her wheelchair in her room using the sit to stand lift. (V8) had properly applied the sling and jacket to the resident. As the lift was transferring the resident from a sitting position to a standing position the resident jerked herself and thru (though) herself forward making her buttocks slide off the bed while still being attached to the lift. (V8) lifted the resident back up the resident removed her right foot from the foot base and (V8) assisted her (R1) with placing her foot back on the base. The resident removed her foot again and positioned her foot in an angle where her toes were touching the floor. As (V8) lowered the resident to the floor her right leg went inwards and the resident sat on her buttocks. Then (V8) and another CNA lifted the resident back up and placed in bed and reported the incident to the nurse.R1's electronic health record (EHR) progress note dated 02/09/26, 7:09 documented by V9 (Licensed Practical Nurse) while transferring on sit to stand and strapped in the resident threw herself forward and took her foot off the base and put one leg behind the other and the CNA had to lower the Mechanical Lift and she sat on her legs and upon laying back in bed both feet were pointed outward and small skin tear was observed on anterior right calf and she complained of pain in right lower extremity.Attempts were made to contact V9 (Licensed Practical Nurse), V11 (Agency Certified Nursing Assistant), V13 (Certified Nursing Assistant) because they were working on 02/09/26 however they were not able to be interviewed as there was no answer and/or returned messages.Facility provided policy titled, Safe Lifting and Movement dated 01/10/26 which documents in part this policy provides guidelines that aim to protect the safety and well-being of the staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.Facility provided policy titled, Fall Policy Overview undated which documents in part,definitions of fall: loss of upright position that results in landing on the floor, ground or an object or furniture, or a sudden, uncontrolled, unintentional, non-purposeful, downward displacement of the body to the floor/ground or hitting another object like a chair or stair; excluding falls resulting from violent blows or other purposeful actions.Any injurious fall is any fall in which physical injury occurs, regardless of severity. Event ID: Facility ID: 145748 If continuation sheet Page 4 of 4