Montgomery Place

Inspectors wroteBased on interviews and record reviews, the facility failed to assess one [R1] resident risk of an accident, identify, implement interventions measures to reduce the hazards or risk as much as possible consistent with R1's needs, goals, care plans and current professional standards of practice to reduce the risk of an accident out of four residents reviewed. These failures resulted in R1 sustaining a right elbow dislocation with mildly displaced fracture of the tip of the coronoid and olecranon process from an unknown origin. Findings Include R1's clinical record indicates the following in part. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their Injury of Unknown Origin Policy and report an injury of unknown origin within two hours of the incident to IDPH [Illinois Department of Public Health] for one [R1] out of four residents reviewed. Findings Include R1's clinical record indicates the following in part. R1 is a ninety-five-year-old admitted [DATE] with the following medical diagnosis of dementia with mood disturbance, major depression disorder, anxiety disorder, Alzheimer's disorder dislocation of right ulnohumeral joint, subsequent encounter, essential hypertension, overactive bladder, and chronic kidney disease. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect a resident's right to be free from physical abuse by a staff member and failed to immediately report an allegation of abuse to the designated abuse coordinator. As a result, Resident (R1) remained fearful, and the alleged perpetrator continued to be assigned to provide care after the allegation was reported to the nurse. The failure to promptly report the allegation had the potential to delay the investigation and place residents at risk for further abuse. This deficient practice affected one (R1) of three residents reviewed for abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure that one resident R2 was free of medication error. This failure affected 1 of 3 residents reviewed in the facility. On 06/22/2026 at 1:55 PM, R2 was observed in bed. On the door the names that were labeled read R5(A), R2(B). When surveyor entered the room and observed the bed B empty, the resident in the first bed asked me who I was looking for and stated she was R2 and that R5 had discharged home. R2 stated she feels safe in the facility despite receiving the wrong medication from a nurse a few weeks ago. R2 stated that the nurse entered her room and gave her a cup of pills that she took. Then a few moments later the nurse returned back and said that she had pills for R2, when I stated to the nurse that you already gave me pills that is when the nurse said oops, I thought you were R5 because the way the door is labeled. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident (R1) remain free from physical abuse and verbal abuse. This failure affected R1 who was physically (aggressively bear hugged and pushed) abused by V7 (Registered Nurse, RN) and verbally abused (aggressively yelled at) by V7 out of a sample size of 3.

Inspectors wroteBased on interview and record review, the facility failed to timely submit an initial abuse report to the state agency within 2 hours which affected one resident (R1) in the sample of 3 residents reviewed for abuseFindings include: On 5/15/26 at 1:50 PM, V4 (Registered Nurse) stated that she has worked at the facility for 11.5 years, and V4's regular work area is R1's floor and hallway. V4 stated that last 5/12/2026 at 7:17 PM that she immediately reported to V5 Health Services Executive Assistant via phone call the abuse incident she witnessed between V7 and R1. V4 stated that V7 pulled R1's arms behind his back and started to push R1 back to the hallway towards R1's bedroom. V4 stated that it is not a form of redirection and V7's voice was loud telling R1 to go back to his room. [...]

Inspectors wroteBased on interviews and records review, the facility failed to keep protected health information secure for one (R4) of three residents reviewed in a sample of 9.

Inspectors wroteBased on interview and record review, the facility failed to maintain resident safety during a mechanical sit to stand lift transfer and failed to use a two person assist when transferring a dependent resident at high fall risk for one (R1) of three reviewed for safety and mechanical lift transfer. This failure resulted in R1 sustaining a right femoral fracture. Findings Include:R1 is a [AGE] year-old initially admitted to the facility on [DATE] with a diagnosis of fractured tibia/fibula after sustaining a fall. [...]

Inspectors wroteBased on observations, interviews and records review, the facility failed to follow their food storage and labeling policy and failed to follow kitchen dress code to prevent food contamination. This failure has the potential of affecting all 31residents receiving food from the facility's kitchen. On 09/02/2025 at 10:20AM, during tour of the kitchen, V4 ([NAME] Director for Dinning) and surveyor observed an opened bag of carrots and an opened bag of peeled garlic in the cooler with no opened-on date. V4 stated all opened foods should be labeled with date when opened to notify kitchen staff which items to use first. V4 stated this is to prevent stale food that can cause foodborne illnesses being served to residents. [...]

Inspectors wroteBased on interview and record review, facility failed to follow their policy to provide pneumococcal vaccination with its education and their consent for 4 residents (R4, R6, R8 and R21) out of 5 reviewed for immunizations in a sample of 13.

Inspectors wroteBased on observations interviews and records review, the facility failed follow their policy to prevent aspiration during feeding for one (R1) of 13 residents reviewed in a sample of 31. R1's current face sheet document's R1's medical diagnosis to include but not limited to: Dysphagia, oropharyngeal phase, Parkinson's disease with dyskinesia, without mention of fluctuations, muscle weakness (generalized). MDS (Minimum Data Set) Section C - Cognitive Patterns dated [DATE], documents R1's Brief Interview for Mental Status (BIMS) as 12/15, indicating R1 has moderately impaired cognation. Section K - Swallowing / Nutritional Status documents R1 Coughing or choking during meals or when swallowing medications and Complaints of difficulty or pain when swallowing. On 09/02/2025 at 1:00PM, V5(Certified Nursing Assistant-CNA) was observed by R1's bed side assisting R1 with eating his lunch. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow their infection control policies and procedures by ensuring appropriate hand hygiene was completed by staff upon exiting and entering a residents' rooms for 2 (R4, R8) out of 6 residents reviewed for infection control out of sample of 13.

Inspectors wroteBased on review of records and interviews the facility failed provide ostomy plan of care to 1 out of 4 residents (R1) reviewed for person centered care plan. This failure is not in accordance with professional standards guidelines. And has a potential to affect 1 resident (R1) ostomy quality of care needs.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident right to receive services in the facility with reasonable accommodation of resident's needs in 1 (R1) of 3 residents in a sample of 8.

Inspectors wroteBased on interview and record review, the facility failed to ensure to have a Registered Nurse (RN) staffed 8 hours with a 24 hour period on weekends to care for residents'needs based on the staffing scheduling and PBJ (Payroll Based Journal) staffing data report. This failure could potentially affect all 28 residents residing in the facility as of census 11/12/24.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to follow their policy and procedure for food and supply storage to ensure foods in the walk-in coolers, walk-in freezer and dry storage were properly covered, labeled and dated when they were opened and prepared, and discarded on the discard by date. The facility also failed to ensure kitchen staff was wearing hair restraint while in the kitchen, failed to ensure frozen foods were stored six inches above the floor in the walk-in freezer, failed to obtain temperature checks prior to serving the food to the residents, and failed to sanitize and air dry the blender and lid after staff washed during pureed preparation. These failures have the potential to affect 26 residents in the facility who are receiving oral diet. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the dumpster was properly covered and not overflowing to prevent the harborage and feeding of pests. This deficient sanitation practice has the potential to affect all 28 residents residing in the facility.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow their infection control procedures. The facility failed to: 1. Handle linen in a manner to prevent cross contamination. 2. Have measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems. These failures could potentially affect all 28 residents residing in the facility. Findings Include: On 11/12/24 at 12:55 PM, the laundry room was reviewed with V13 (Facilities Director) and V14 (Environmental Services Manager). Surveyor observed V14 and V17 handling clean linens on the folding table without proper hand hygiene. V13 stated V13 should have sanitized V13's hand and wear a pair of gloves before handling clean linens. V14 stated that the policy is to sanitize hands and put on gloves when handling clean linens. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their policy to develop and implement a comprehensive person-centered care plan to meet preferences and goals and address the resident's needs that include measurable objectives and timeframes for 5 (R6, R17, R21, R22, R29) of 5 residents reviewed for comprehensive care plan in the sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures by NOT (a) attempting to use appropriate alternatives prior to installing a side or bed rail, (b) assessing the resident for risk for entrapment from bed rails prior to installation, (c) reviewing the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation and (d) developing and implementing a comprehensive person-centered care plan for 4 (R1, R17, R29 and R132) out of 4 residents reviewed for accidents and hazards in a sample of 15.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to account for and dispose of controlled medications in a manner that would decrease the possibility of loss or diversion and failed to dispose expired controlled medication for 1 (R1) resident. These failures could potentially affect 12 residents assigned to the west medication cart as of census dated [DATE].

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy by not ensuring that medications are stored in original containers, properly labeled, and separate from food for one out of 2 medication carts and storage rooms reviewed for the medication storage and labeling. These failures could potentially affect 12 residents assigned to the west medication cart as of census dated 11/12/24.

Inspectors wroteBased on interview and record reviews, the facility failed to provide eligible residents and/or resident representatives education regarding the benefits and potential side effects of all available pneumococcal vaccination and assess eligibility and offer pneumococcal vaccination to four (R9, R11, R12, and R18) of six residents reviewed for pneumococcal and influenza vaccinations. Findings Include: 1. R9's electronic medical record (EMR) revealed R9 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: Unspecified Asthma, type 2 diabetes mellitus with diabetic polyneuropathy, other specified disease of pancreas, chronic embolism and thrombosis of unspecified vein, and bullous pemphigoid. [...]

Inspectors wroteBased on interview and record review the facility failed to determine, establish, obtain or discuss code status of 1 (R133) out of 4 residents reviewed for Advance Directives in a sample of 15.

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit MDS (Minimum Data Set) records to CMS system using the CMS-specified Resident Assessment Instrument (RAI) process within the regulatory timeframes for 1 (R18) of 1 resident reviewed for resident assessment in a sample of 15.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow dietary recommendation and physician order to ensure nutritional supplement was provided to a resident with weight loss for one (R3) out of two residents reviewed for nutrition in a final sample of 28. Findings Include: On 11/12/24 at 11:30 AM, R3's electronic health records were reviewed. R3's Minimum Data Set, dated [DATE] shows R3 has severely impaired cognition. R3's physician orders have an order for Magic Cup two times a day for supplement Magic Cup or similar product w/L + D (ordered 3/21/2024) and Regular diet, Regular texture, Regular/Thin consistency (ordered 3/15/2022). R3's weight records documented the following weights: 153.2 pounds (lbs) on 11/5/24, 155 lbs on 8/15/24, 157.8 lbs on 7/17/24, and 159 lbs on 6/14/24. There were no weights recorded for the months of September and October. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility: 1. Failed to date and store oxygen tubing in a plastic bag when not in use for 1 (R15) resident. 2. Failed to date and label nebulizer mask for 1 (R26) resident. These failures could potentially affect 2 (R15, and R26) residents in a sample of 15. Findings Include: 1. R15's electronic medical record (EMR) revealed R15 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: Respiratory failure unspecified with hypoxia, essential hypertension, and chronic kidney disease. 2. R26's electronic medical record (EMR) revealed R26 was admitted to the facility on [DATE] and is [AGE] years of age with diagnoses that included but were not limited to: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure menu was followed for a resident (R9) receiving a mechanical soft diet and failed to ensure standardized recipes were followed during pureed food preparation. This failure has the potential to affect 2 residents on pureed diet (R1, R32) out of 26 receiving foods prepared in the facility's kitchen. Findings Include: On 11/12/24 at 12:36 PM, V24 (Certified Nursing Assistant) was feeding R9 for lunch. Observed R9 receive a glass of juice, apple sauce, mashed potatoes, ground corned beef sandwich, chicken noodle soup, ground zucchini, and a glass of water. At 12:54 PM, R9 ate 100% of R9's lunch. R9's physician orders with active orders as of 11/13/24 show a diet order of NAS (No Added Salt) Mechanical Soft Texture, Regular/Thin consistency (order date 3/16/22). [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).