Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Montgomery Place during CMS and state inspections, most recent first.
A resident received another resident’s medications after an LPN misidentified the resident because of confusing door labels and gave the pills before realizing the error. The resident later reported feeling tired and drowsy for several days. Staff stated the nurse monitored the resident, but the record showed no documented vitals, no documented physician notification, and no medication error report, despite facility policy requiring resident identification before med pass and documentation/notification after a med error.
Physical and Verbal Abuse of a Cognitively Impaired Resident: A resident with dementia, Alzheimer’s disease, aphasia, and severe cognitive impairment was physically handled and verbally yelled at by an RN during an elopement-related incident. Witnesses reported the RN bear hugged the resident, pulled his hands behind his back, pushed him into his room, and told him not to come out, while the RN admitted shouting at the resident.
Failure to Timely Report Alleged Abuse: A RN witnessed another RN pull a resident’s arms behind his back and push him toward his room while speaking loudly to him, and the incident was immediately reported to facility leadership. The ED later acknowledged the abuse report was not submitted to IDPH within the required 2 hours, and the preliminary report was not faxed until several days later.
The facility failed to protect PHI when a resident was discharged home with their own medications and an additional Bingo card of Atorvastatin 20 mg labeled for another resident, including that resident’s name, date of birth, and dosing instructions. The discharging agency RN reported sending all medications as ordered and acknowledged that Bingo cards contain PHI, while the DON stated nurses are expected to verify discharge medications and confirmed that sending one resident home with another resident’s labeled medications is a HIPAA violation under the facility’s privacy policy.
A dependent, high fall‑risk resident with multiple fractures, severe mobility limitations, poor trunk control, and generalized weakness was transferred from bed to wheelchair using a mechanical sit‑to‑stand lift by a single CNA, despite facility expectations and documentation indicating two‑person assistance was required. During the lift, the resident jerked forward, slid off the bed while still attached to the lift, and her feet came off the foot base, leading to her being lowered to the floor with her legs twisted underneath her. The resident screamed in pain, was manually lifted back to bed by two CNAs, and was later sent to the hospital, where she was diagnosed with a right periprosthetic femoral shaft/hip fracture. Staff interviews, including from CNAs, an RN, the DON, therapy director, and medical director, confirmed that two staff should have been present for mechanical lift transfers and that the event met the facility’s definition of a fall.
Food storage and kitchen dress code deficiencies were observed when opened refrigerated and dry food items were left unlabeled with no opened-on date, several dry goods were left open to air instead of being stored in sealed containers, and a dented can of pumpkin puree was kept on the regular can rack rather than in the designated damaged-item area. In addition, a server was observed in the kitchen without a hair net while handling food items, contrary to facility policy requiring food items to be covered, labeled, and dated and staff to wear approved hair restraints.
Failure to provide required vaccine education and consent documentation for several residents. The DON, who was also the IP, stated the facility had not yet ordered the pneumococcal vaccine and had not screened or educated three residents for it; those residents had no pneumococcal vaccine, education, or consent documented. Another resident received the flu vaccine without education. The facility policy required education on the benefits and potential side effects before offering pneumococcal and influenza immunizations, with documentation of consent, refusal, or contraindication.
A resident with dysphagia, Parkinson's disease, and generalized weakness was fed lunch while the bed was only elevated about 30-40 degrees instead of the required 90-degree upright position. A CNA stated she knew the resident should be upright to prevent choking, but after the resident complained of pain when the bed was raised, she continued feeding without notifying the LPN. The LPN and DON confirmed the resident should have been positioned at 90 degrees during meals, and the facility feeding policy required an upright 90-degree position.
Failure to perform hand hygiene between resident rooms. A housekeeper was observed cleaning one resident’s bathroom, exiting without removing gloves or washing hands, and then entering another resident’s room without sanitizing hands. The DON stated staff, including housekeepers, are expected to sanitize hands before entering a room, remove gloves in the room, and wash hands before exiting; the facility’s infection control policy states glove use does not eliminate the need for hand hygiene.
A resident with a urostomy did not have an individualized care plan addressing her ostomy care needs, despite documented changes in her ostomy size and repeated requests for supply changes. Staff confirmed the absence of a care plan in the electronic health record, even though physician orders and assessments indicated the need for scheduled ostomy care.
A resident with heart failure, obesity, and multiple myeloma repeatedly did not receive the correct size incontinence products due to supply shortages. Staff used smaller, uncomfortable sizes, and the resident's family had to purchase the correct size. CNAs confirmed the lack of proper supplies and were unaware of additional stock in the basement, leading to unmet resident needs.
The facility failed to maintain RN staffing for at least eight hours on weekends, as required by policy. Interviews and records showed that on several weekends, only LPNs were on duty, with no RN coverage. The DON and Administrator acknowledged the issue, citing challenges in staffing and efforts to hire more RNs. This deficiency was documented in the CMS report and the facility's policy, potentially affecting the care of all 28 residents.
The facility failed to follow its food storage and handling policies, with opened and unlabeled food items found in storage, improper hygiene practices by kitchen staff, and failure to check food temperatures before serving. These deficiencies potentially affect 26 residents receiving oral diets.
The facility failed to properly dispose of garbage, with uncovered bins and an overflowing dumpster observed during a survey. The Director of Dining Services and other staff confirmed that dumpsters should be closed to prevent pest infestations. The facility's policy requires garbage containers to be covered at all times.
The facility failed to follow infection control procedures, with staff handling clean linens without proper hand hygiene, risking cross-contamination. Additionally, there were no measures in place to prevent Legionella growth in water systems, with no testing conducted for two years.
The facility failed to implement comprehensive care plans for several residents, neglecting to address advance directives, psychotropic medication use, and specific medical conditions. This oversight affected residents with complex medical histories, including those with fractures, hypertension, intracerebral hemorrhage, and dementia.
The facility failed to follow its bed rail policy, leading to a deficiency related to accident hazards and inadequate supervision. Four residents had bed rails installed without attempts to use alternatives, assessments for entrapment risk, or informed consent. Observations showed residents with various medical conditions had bed rails up without proper documentation or care plans. Interviews with staff revealed a lack of clarity and adherence to the policy, posing potential risks of harm to residents.
The facility failed to properly account for and dispose of controlled medications, affecting 12 residents. An LPN found a compromised Tramadol blister packet and expired Hydromorphone concentrate in the medication room. The DON confirmed that medications should be checked daily, and records showed missing nurse signatures, indicating non-compliance with controlled substances policy.
The facility failed to properly store and label medications, as observed during an inspection of a medication cart and storage room. An LPN found loose, unlabeled medications in a narcotic box, and the DON confirmed that medications were improperly stored with food items in a refrigerator. The facility's policy requires medications to be stored securely, in original containers, and separately from food.
The facility failed to educate and assess four residents for pneumococcal vaccinations, as required by policy. The Infection Preventionist admitted to not providing vaccinations or obtaining consents since March 2024. Residents' EMRs lacked documentation of education, eligibility assessment, and signed consents, despite their medical conditions potentially qualifying them for vaccination.
A facility failed to document a resident's code status and advance directives, despite the resident having intact cognition and multiple health issues. Interviews with the DON and Social Services confirmed the absence of documentation, which is crucial during emergencies. The facility's policy requires discussing and documenting advance directives during admission, but this was not done for the resident.
A facility failed to transmit a resident's MDS records to the CMS system within the required timeframe. The resident, admitted with multiple diagnoses, had their Quarterly MDS completed but submitted late, beyond the 14-day regulatory period. The MDS manager, working remotely for an outside company, coordinated with the DON but acknowledged the delay, indicating non-compliance with the RAI manual and facility policy.
A resident with severe cognitive impairment and significant weight loss did not receive the prescribed nutritional supplement, Magic Cup, due to a lack of stock and communication failures in the facility. Despite physician orders and dietary recommendations, the resident's meal did not include the supplement, contributing to continued weight loss.
The facility failed to date and properly store respiratory equipment for two residents, potentially increasing infection risk. One resident's oxygen tubing was not dated or stored in a plastic bag, while another's nebulizer mask was undated. An LPN was unaware of the facility's policy, which was confirmed by the DON. The policy requires equipment to be dated and stored in a clean bag when not in use.
A facility failed to follow the prescribed menu for a resident on a mechanical soft diet and did not adhere to standardized recipes during pureed food preparation. A resident received a meal that did not match the facility's menu, and the support chef used unmeasured scoops, resulting in improper food consistency. The Director of Dining Services and Registered Dietician confirmed the importance of following recipes to ensure nutritional adequacy.
Medication Error Due to Resident Misidentification and Lack of Required Monitoring
Penalty
Summary
The facility failed to ensure that a resident was free from a significant medication error when the resident received another resident’s medications after staff misidentified the resident in the room. The resident was observed in bed, and the room door labeling was confusing, with the names on the door indicating one resident in bed A and another in bed B. The resident stated that a nurse entered the room and gave her a cup of pills, then returned and said the pills were for the other resident after realizing the mistake. The resident reported feeling tired and drowsy for a few days afterward. The resident involved had diagnoses including anemia, diabetes mellitus, idiopathic aseptic necrosis of the right femur, left rib fracture, pleural effusion, hypertensive heart disease, heart failure, chronic kidney failure, atrial fibrillation, muscle weakness, cognitive communication deficit, history of falls, and obstructive sleep apnea. The resident’s MDS documented a BIMS score of 13, indicating cognitive intactness. The care plan identified the resident as at risk for decreased cardiac output and included monitoring for orthostatic blood pressure, changes in level of consciousness, heart rate, and pulse oximetry. Staff interviews showed that the nurse who administered the medications entered the room, called out the wrong resident’s name, and gave medications before realizing the error after the resident had already swallowed them. The medications given were listed as mirtazapine 15 mg, Azo D-Mannose 500 mg two tablets, carvedilol 6.25 mg, Eliquis 5 mg, and gabapentin 300 mg. The nurse stated she monitored the resident overnight but did not call the physician on call or use the facility’s on-call physician service, and she did not complete a medication error report. The DON stated there was no documentation in the medical record of the medication error or monitoring, and review of the record showed no documented blood pressures or vital signs from the time of the error through the following days. The medical director stated he was not informed until greater than 48 hours later, and the facility’s policies required identification of the resident before medication administration and notification/documentation when a medication error or change in condition occurred.
Physical and Verbal Abuse of a Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment remained free from physical abuse and verbal abuse. The resident had diagnoses including cerebral infarction, acute respiratory failure with hypoxia, pneumonia, aphasia, chronic kidney disease stage 4, hypertension, dementia, and Alzheimer’s disease, and had a BIMS score of 07. The care plan documented altered neurological status, elopement risk/wanderer behavior, and impaired cognitive function, with interventions to monitor behavior, distract from wandering, and cue, reorient, and supervise as needed. Survey findings showed that a RN physically handled the resident in an aggressive manner and yelled at him during an elopement-related incident. One RN reported observing another RN pull the resident’s hands behind his back and aggressively push him into his room. A CNA reported seeing the RN aggressively bear hug the resident, pull him back from the stairwell into the hallway, push him to his room, and yell at him not to come out, while also making statements about being made to hit the resident. The RN acknowledged shouting at the resident and stated the resident was combative and trying to leave, while the DON stated it was not appropriate to aggressively grab, touch, or yell at a resident with dementia or one trying to elope.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to timely submit an initial abuse report to the state agency within 2 hours after an alleged abuse incident involving one resident. A registered nurse stated that on 5/12/26 at 7:17 PM, she immediately reported by phone to the Health Services Executive Assistant that she witnessed another registered nurse pull the resident’s arms behind his back and push him back toward his bedroom while speaking loudly to him. She stated the behavior was aggressive and not redirection, and that she reported the incident again the next day to the Administrator and provided a signed witness statement. The Executive Director stated that when she was notified about the abuse incident, she investigated but did not report it in a timely fashion and acknowledged that she should have reported any abuse incident to IDPH within 2 hours and had 5 working days to submit the final report. A facility document shows the preliminary report was submitted to the state agency by fax on 5/18/26 at 3:30 PM. Facility policy states that abuse includes willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and that allegations or reasonable suspicion of abuse involving serious bodily injury or sexual abuse must be reported to IDPH and local law enforcement within 2 hours of the event.
Failure to Protect PHI When Discharging Medications
Penalty
Summary
The facility failed to protect a resident’s protected health information (PHI) when discharge medications for one resident were sent home with another resident. One resident (R4), who had severe cognitive impairment as evidenced by a Brief Interview for Mental Status score of 7/15 on the MDS, had active orders for Atorvastatin Calcium 20 mg by mouth once daily for antihyperlipidemia. Another resident (R2) had an order for Atorvastatin Calcium 40 mg by mouth at bedtime. Each resident’s medications were supplied on Bingo cards that displayed the resident’s name, date of birth, medication name, dose, and administration time. During R2’s discharge, R2’s family member and POA later reported receiving two packets of medication at home: one packet of Atorvastatin 40 mg correctly labeled for R2, and another packet of Atorvastatin 20 mg labeled with R4’s personal identifying information, including name, date of birth, and dosing instructions. The agency RN who completed the discharge stated she sent all medications as prescribed in the discharge order and acknowledged that Bingo cards contain PHI and that sending another resident’s medication home would be a HIPAA violation. The DON similarly stated that nurses are expected to review discharge medications with the resident to ensure they are correct and confirmed that discharging a resident with another resident’s medication constitutes a HIPAA violation because the Bingo cards contain the other resident’s protected identifying information. The facility’s HIPAA policy required protection of the privacy, security, and integrity of PHI.
Failure to Use Two‑Person Assist During Sit‑to‑Stand Lift Transfer Resulting in Femoral Fracture
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident safety during a mechanical sit‑to‑stand lift transfer and to provide the required two‑person assistance for a dependent resident at high risk for falls. The resident was an older adult with a history of multiple fractures, falls, spinal stenosis, polyosteoarthritis, bilateral artificial knee joints, generalized muscle weakness, reduced mobility, and need for assistance with personal care. The resident’s MDS documented functional limitations in range of motion in one upper extremity and both lower extremities and coded the resident as dependent for transfers, meaning assistance of two or more helpers was required. The care plan and a fall risk evaluation identified the resident as high risk for falls, with impaired physical mobility and prior fall during transfer. On the morning of the incident, a CNA (V8) attempted to transfer the resident from bed to wheelchair using a mechanical sit‑to‑stand lift without a second staff member present. V8 reported that she applied the belt/sling, tightened it, attached the hooks, positioned the resident’s feet on the lift base, and locked the wheelchair nearby. As the lift began to raise the resident from the bed, the resident jerked or threw herself forward, causing her buttocks to slide off the bed while still attached to the lift, and her feet to come off the foot base. V8 attempted to lower the resident back toward the bed, but the resident’s buttocks slid off the bed and one foot came off the base, with toes touching the floor and the resident sliding forward. V8 then lowered the resident fully to the floor while the resident’s legs were twisted underneath her, with the right leg bent inward and tucked under the body as the resident came to rest seated on her buttocks. After lowering the resident to the floor, V8 left to get help and returned with another CNA (V10). Both CNAs observed the resident on the floor in a seated position with legs twisted underneath her, and the resident was screaming and complaining of pain in her leg and knee. They manually lifted and slid the resident back into bed. Nursing documentation by an LPN (V9) noted that during the sit‑to‑stand transfer the resident threw herself forward, removed her foot from the base, placed one leg behind the other, and that the CNA had to lower the mechanical lift, resulting in the resident sitting on her legs, with both feet later observed pointed outward and a small skin tear on the anterior right calf and complaints of right lower extremity pain. The resident was subsequently sent to the hospital, where the admitting diagnosis communicated to the facility was a right periprosthetic femoral shaft fracture/hip fracture, attributed by facility staff and the medical director to the fall to the floor during the sit‑to‑stand transfer. Multiple staff interviews confirmed that facility practice and expectation were that two staff members should assist with mechanical lift transfers, including sit‑to‑stand lifts, particularly for dependent residents. V8 acknowledged that staff were instructed to use two people with lifts but stated she had been using the sit‑to‑stand lift alone with this resident because help was not always available and she had not previously had problems. Other CNAs and the therapy director stated they always or usually used two staff for sit‑to‑stand transfers and believed that having a second staff member present could have helped prevent the resident from sliding off the bed or being injured. The DON reviewed the resident’s MDS coding for dependence in transfers and stated that, by definition, the resident should have had at least two staff assisting with the sit‑to‑stand lift, and that the event met the facility’s definition of a fall as a change in plane resulting in landing on the floor. The DON further stated that, based on her understanding of the incident, the resident’s feet became tangled when V8 was trying to fix their position, and when the lift was lowered, the resident’s legs buckled, likely causing the injury. The DON indicated that V8 should have pulled the sit‑to‑stand lift upward instead of downward, as lowering it placed the resident’s weight on her legs while they were tangled underneath her. The therapy director and medical director both stated that when a resident is dependent for mobility and transfers, two staff members should be present during mechanical lift transfers, and they understood that the resident’s fracture occurred when she fell to the floor during the sit‑to‑stand transfer. The facility’s Safe Lifting and Movement policy stated that it was intended to protect the safety and well‑being of staff and residents and promote quality care through appropriate lifting techniques and devices, and the facility’s fall policy defined falls as downward displacement of the body to the floor or ground, including injurious falls where physical injury occurs.
Food Storage, Labeling, and Hair Restraint Deficiencies
Penalty
Summary
The facility failed to follow its food storage and labeling policy and failed to follow its kitchen dress code during observations in the kitchen and food storage areas. During a tour of the kitchen, an opened bag of carrots and an opened bag of peeled garlic were observed in the cooler without an opened-on date. In the dry food storage room, an open bag of vanilla wafers, a 25-pound bag of breadcrumbs, and a 25-pound bag of cake mix were observed open to the air and not labeled with an opened-on date. A dented can of pumpkin puree was also observed on the can rack in the dry food area. The Director for Dinning stated opened foods should be labeled with the date opened, opened dry foods should be transferred to a self-sealing food container and labeled, and dented cans should be placed in the designated return area. During a separate observation, a server was seen in the kitchen without a hair net while arranging ice-cream/soup cups. The server stated he should have worn his hair net when he returned to the kitchen from break, and that working without a hair net can cause hair to fall into residents' food and contaminate it. The Director for Dinning stated all staff working in the kitchen should wear hair nets to prevent food contamination. Facility policies titled Food and supply storage and Uniform Dress Code required unused portions and open packages to be covered, labeled, and dated, damaged cans to be kept in a designated return area, and associates working with food to wear an approved hair restraint when on duty.
Failure to Provide Required Vaccination Education and Consent Documentation
Penalty
Summary
The facility failed to follow its policy for influenza and pneumococcal vaccinations by not providing pneumococcal vaccine education and consent documentation for 4 residents (R4, R6, R8, and R21) out of 5 reviewed for immunizations in a sample of 13. On 09/03/2025, the DON, who was also serving as the Infection Preventionist, stated that the facility had not yet ordered the pneumococcal vaccinations and that the vaccine is offered year-round. She stated the facility orders pneumococcal vaccine together with influenza vaccine to save on costs, and that residents are screened for influenza immunization in September and vaccinated in October. The DON stated she had not screened or educated R4, R8, or R21 for pneumococcal vaccination, and that these residents did not have the pneumococcal vaccine, education, or consent. She also stated that R6 received the influenza vaccine on 09/01/2025 but no education was provided. The immunization records for R4, R8, and R21 documented no up-to-date pneumococcal vaccine and no documentation of education or consent. R6's record documented influenza vaccine administration without education. The facility's policy required education on the benefits and potential side effects before offering pneumococcal and influenza immunizations, and required documentation that the resident or representative received that education and either received the vaccine or refused it or had a medical contraindication.
Failure to Maintain Upright Position During Feeding
Penalty
Summary
The facility failed to follow its policy for assisting a resident with feeding by not ensuring the resident was positioned upright at 90 degrees during meals. The resident had diagnoses including dysphagia, oropharyngeal phase, Parkinson's disease with dyskinesia, and generalized muscle weakness. The MDS documented a BIMS score of 12/15, indicating moderately impaired cognition, and also noted coughing or choking during meals or when swallowing medications, as well as complaints of difficulty or pain when swallowing. During observation, a CNA was seen feeding the resident lunch while the resident's bed was only slightly elevated, later described as about 30-40 degrees. The CNA stated she knew the bed was supposed to be elevated to 90 degrees to prevent choking, but when the resident complained of pain as the bed was raised, she left the bed at about 40 degrees and continued feeding. The CNA did not notify the resident's LPN about the pain. The LPN later confirmed the bed should have been elevated to 90 degrees during eating and stated that feeding at 40 degrees was a choking hazard. The DON also stated the resident should have been fed with the head of the bed elevated to 90 degrees and that the CNA should have notified the nurse when the resident experienced pain with bed elevation. The facility policy titled Assisting Resident with feeding required checking that the resident was sitting in an upright 90-degree position.
Failure to Perform Hand Hygiene Between Resident Rooms
Penalty
Summary
The facility failed to follow its infection control policies and procedures by not ensuring appropriate hand hygiene was completed when staff entered and exited residents’ rooms. On 09/02/2025 at 11:30 AM, a surveyor observed V10, a housekeeper, clean R8’s bathroom, then exit R8’s room without removing gloves or washing hands, and immediately enter R4’s room without sanitizing hands before going into R4’s bathroom. On 09/03/2025 at 12:48 AM, the DON stated that all staff, including housekeepers, are expected to sanitize hands and wear gloves before entering a resident’s room, remove gloves in the room, and wash hands before exiting; the DON also stated housekeepers should not go from room to room wearing the same gloves. The facility’s infection control policy states handwashing is the single most important means of preventing the spread of infections and that glove use does not eliminate the need for hand hygiene.
Failure to Develop Individualized Ostomy Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to provide an individualized care plan for a resident with a urostomy. The resident, who was able to clearly express her needs, had her ostomy size changed following a medical appointment. After returning, she requested frequent changes of her ostomy supplies and refused to use her old supplies, as the new supplies for the updated size had run out. Staff, including the Administrator and DON, acknowledged that Medicare Part B would not cover premature reordering of supplies and that the resident was informed of her options, including going to the hospital, which she refused. Despite these ongoing issues and repeated requests from the resident, there was no care plan in place addressing her ostomy care needs. Upon review of the electronic health record, the DON confirmed that the care plan for ostomy care was missing, even though the resident's MDS assessment documented the presence of an ostomy and physician orders specified scheduled changes. The lack of a person-centered, individualized care plan for ostomy care was not in accordance with professional standards and guidelines, as required by CMS regulations. This omission was confirmed through record review and staff interviews.
Failure to Provide Proper Size Incontinence Products
Penalty
Summary
A male resident with diagnoses including heart failure, obesity, and multiple myeloma, and with moderate cognitive impairment (BIMS 10/15), experienced repeated instances where the facility failed to provide the correct size incontinence products (3XL diapers) as needed. The resident reported that on weekends and night shifts, the proper size diapers were unavailable, resulting in staff using smaller, uncomfortable sizes. The resident's wife had to purchase the correct size diapers on several occasions due to the facility's lack of supply. This issue was corroborated by both the resident and his family member, who confirmed that the facility ran out of the required size multiple times. Multiple CNAs confirmed that they had to use smaller size diapers for the resident when the correct size was not available, and were unaware of additional supplies in the basement. Documentation from a resident concern form indicated that the resident was told the correct size was not available, and staff did not escalate the issue to supervisors or access the basement storage for additional supplies. The Director of Nursing later acknowledged that staff failed to follow the protocol of notifying security to access the basement storage for the needed supplies, resulting in the deficiency.
Failure to Maintain RN Staffing on Weekends
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was staffed for at least eight hours within a 24-hour period on weekends, as required by their policy. This deficiency was identified through interviews and record reviews, which revealed that the facility did not have an RN on duty on certain days and weekends, particularly in the months of April, May, and June. The Director of Nursing (DON) acknowledged the issue, stating that the facility had four RNs, two of whom were as-needed, and admitted to not having an RN on duty on some days and weekends. The Administrator also confirmed the failure to meet the RN staffing requirement, noting that the facility had been using agency staff or the DON to fill in at times, but was actively seeking to hire more RNs. The facility's daily nursing schedule showed that on several weekends, only Licensed Practical Nurses (LPNs) were on duty for both the day and night shifts, without any RN coverage. This lack of RN staffing was also reflected in the CMS report, which triggered for no RN hours. The facility's policy, dated January 1, 2024, clearly stated the requirement for a minimum of one RN on duty for eight consecutive hours, seven days a week. The absence of RNs on specific dates, including November 11 and 12, 2024, was documented, highlighting the facility's non-compliance with its own staffing policy and potentially affecting the care provided to all 28 residents in the facility.
Deficiencies in Food Storage and Handling
Penalty
Summary
The facility failed to adhere to its policies and procedures for food storage and handling, as observed during a survey. In the main cooler for meat and dairy, several opened food items were found without labels indicating when they were opened or when they should be discarded. These items included canned prunes, cottage cheese, lettuce, chicken salad, olives, coleslaw, pears, grilled chicken, tofu, various types of lettuce, cranberries, nuts, spinach, vanilla pudding, and Monterey jack cheese. Additionally, unwrapped and unlabeled items such as parmesan cheese, carrot cake, and shredded mozzarella cheese were found. In the dry storage area, an opened box of cream of wheat mix was not wrapped or labeled. In the walk-in freezer, boxes of frozen cod, bread buns, and a container of demi-glace were improperly stored on the floor. The facility also failed to ensure that kitchen staff adhered to hygiene and food safety protocols. A dietary aide was observed serving lunch without checking food temperatures, contrary to the facility's policy that requires temperature checks before serving. A cook was seen preparing food without wearing a hair restraint, and a support chef did not properly sanitize and air dry a blender after use, leaving residual food inside before using it again. These lapses in protocol have the potential to affect the 26 residents receiving oral diets at the facility. Interviews with the Director of Dining Services confirmed that the facility's policies require all opened foods to be covered, labeled, and discarded by the date on the label to ensure food safety. The director acknowledged that expired foods should not be stored or served and that food temperatures should be recorded at various stages to prevent bacterial growth. The facility's policies on meal quality, food storage, and infection control emphasize the importance of proper labeling, storage, and hygiene practices to maintain food safety and prevent contamination.
Improper Garbage Disposal and Overflowing Dumpsters
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed during a survey. During an initial kitchen observation, three garbage bins were found uncovered and filled with waste. The Director of Dining Services acknowledged that these bins should have been covered. Additionally, an inspection of the facility's dumpsters revealed one dumpster with a lid that could not be fully closed due to overflowing garbage. This was confirmed by the Director of Dining Services, who stated that dumpsters should be fully closed to prevent pest infestations. Further interviews with the Maintenance Director and Facilities Director corroborated the issue, emphasizing the importance of keeping dumpster lids closed to prevent rodents and pests from entering the facility. The Maintenance Director noted that open lids could lead to debris flying out and attracting flies and rodents, potentially causing pest issues within the building. The Facilities Director also highlighted the safety risks to staff if lids were not closed, as items could be tossed and hit workers. The facility's policy on solid waste disposal mandates that garbage containers be clean, lined, and covered at all times, with lids closed on all outside trash receptacles.
Infection Control Deficiencies in Linen Handling and Water Management
Penalty
Summary
The facility failed to adhere to its infection control procedures, specifically in the handling of linens and the management of water systems to prevent Legionella growth. During an inspection, it was observed that clean linens were handled without proper hand hygiene by staff members, contrary to the facility's policy which requires sanitizing hands and wearing gloves. This lapse in protocol was acknowledged by the Facilities Director and the Environmental Services Manager, who confirmed that such actions could lead to cross-contamination and increase the risk of infection among residents. Additionally, the facility lacked measures to prevent the growth of Legionella and other waterborne pathogens in its water systems. The Facilities Director was unable to provide documentation or confirm any preventive measures in place, and the Administrator admitted that Legionella testing had not been conducted for the current or previous year. The absence of a policy on waterborne pathogen prevention was noted, highlighting a significant gap in the facility's infection control program.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for five residents, as required by their policy. Specifically, the care plans did not include measurable objectives and timeframes to address the residents' medical, physical, mental, and psychosocial needs. For instance, Resident 17, who was admitted with multiple diagnoses including fractures and hypertension, had no care plan for advance directives or code status despite having a Full Code order. Similarly, Resident 22, with conditions such as intracerebral hemorrhage and depression, lacked a care plan for the use of psychotropic medication. Resident 29, admitted with acute respiratory failure and other serious conditions, also had no care plan for advance directives despite having a DNR order. The Director of Nursing (V2) acknowledged that care plans should be developed by the interdisciplinary team and individualized according to each resident's needs. However, the facility's records for Residents 17, 22, and 29 did not include care plans for advance directives or psychotropic medication use. Additionally, Resident 6, who was on anticoagulant medication for stroke, and Resident 21, diagnosed with dementia, did not have care plans addressing these specific needs. The facility's policies on comprehensive care planning and psychotropic medication use were not followed, leading to these deficiencies.
Failure to Follow Bed Rail Policy and Procedures
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding the use of bed rails, resulting in a deficiency related to accident hazards and inadequate supervision. Specifically, the facility did not attempt to use appropriate alternatives before installing side or bed rails, did not assess residents for the risk of entrapment from bed rails prior to installation, and did not review the risks and benefits of bed rails with the residents or their representatives to obtain informed consent. Additionally, the facility did not develop and implement a comprehensive person-centered care plan for the residents involved. The deficiency was observed in four residents, each with various medical conditions. One resident, admitted in 2019, had diagnoses including cerebral infarction and vascular dementia, while another resident, admitted in 2024, had conditions such as unspecified fracture and anemia. The third resident, also admitted in 2024, had acute respiratory failure and suicidal ideations, and the fourth resident had chronic respiratory failure and Alzheimer's disease. Observations revealed that these residents had bed rails up without proper documentation or assessment, and there was no evidence of care plans or informed consent for their use. Interviews with facility staff, including the Director of Nursing, revealed a lack of clarity and adherence to the facility's bed rail policy. The Director of Nursing admitted that side rails were used to aid in mobility and repositioning but was unsure if an order was required for their use. The facility's records lacked documentation of care plans, assessments, and consent for the use of side rails, and there was no evidence of attempts to use alternatives before resorting to bed rails. This lack of documentation and assessment posed potential risks of harm to the residents due to entrapment or other accidents.
Failure to Properly Account for and Dispose of Controlled Medications
Penalty
Summary
The facility failed to properly account for and dispose of controlled medications, which could potentially affect 12 residents assigned to the west medication cart. During an inspection, it was observed that the controlled medications were not consistently counted and signed off by outgoing and incoming nurses, as required. Specifically, a blister packet containing Tramadol for a resident was found to be compromised with transparent tape, indicating tampering. Additionally, expired Hydromorphone concentrate was found in the medication room refrigerator, which should have been returned to hospice care or discarded. The Director of Nursing confirmed that the expiration date for all medications should be checked daily to prevent the administration of expired medications, which could lead to adverse reactions. The facility's records showed multiple instances of missing nurse signatures or initials on the controlled substances record sheet, suggesting that the required counts were not being performed. The facility's policy mandates that expired controlled substances be clearly labeled and separated, but this was not adhered to, as evidenced by the expired Hydromorphone concentrate found during the inspection.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to adhere to its medication storage policy, as observed during an inspection of the west side medication cart and storage room. A Licensed Practical Nurse (LPN) who has been working at the facility since November 2018 was present during the inspection. The surveyor found approximately 20 loose yellow capsules and white tablets inside a plastic container covered with tape and without a label, stored inside the narcotic box of the medication cart. The LPN was unable to identify the medications or determine to whom they belonged, acknowledging that these medications should have been disposed of or discarded. Further inspection of the west side medication room revealed that medications requiring refrigeration, such as insulin, flu vaccine, acetaminophen suppositories, hydrocortisone suppositories, Morphine concentrate, and Hydromorphone concentrate, were stored alongside food items like a carton of Jevity 1.5 and a bottle of Ensure. The Director of Nursing (DON) confirmed that medications should be stored separately from food and that any medications without proper labeling should be discarded to prevent potential hazards. The facility's policy, dated 7/1/18, mandates that all drugs and biologicals be stored securely and in their original containers, with medications requiring refrigeration stored separately from food and properly labeled.
Failure to Provide Pneumococcal Vaccination Education and Assessment
Penalty
Summary
The facility failed to provide education and assess eligibility for pneumococcal vaccinations for four residents, as required by their policy. The electronic medical records (EMR) of these residents showed no documentation of education regarding the benefits and potential side effects of the pneumococcal vaccination, nor any assessment of their eligibility to receive it. Additionally, there were no signed consents for pneumococcal immunizations found in the EMRs of these residents. The residents involved had various medical conditions, including asthma, diabetes, spinal stenosis, and chronic kidney disease, which could potentially make them eligible for the vaccination. The Infection Preventionist (V2) admitted to not having provided any pneumococcal vaccinations, education, or obtained consents since starting in March 2024. V2 was unsure about the process of ordering the pneumonia vaccine and acknowledged that the education should be documented in the progress notes of the residents' EMRs, with consents uploaded accordingly. The facility's policy mandates that each resident or their representative should receive education about the pneumococcal immunization and that the immunization should be offered unless contraindicated or previously administered. However, this policy was not followed, leading to the deficiency noted in the report.
Failure to Document Resident's Code Status and Advance Directives
Penalty
Summary
The facility failed to determine, establish, obtain, or discuss the code status of a resident, identified as R133, who was part of a sample of 15 residents reviewed for Advance Directives. R133 was admitted with multiple diagnoses, including unspecified displaced fractures, gait and mobility issues, and a history of falling. Despite having intact cognition as per the Minimum Data Set, there was no documentation or order regarding the resident's code status or advance directives in their health record. This lack of documentation was confirmed during interviews with the Director of Nursing (V2) and Social Services (V17), who both acknowledged the importance of having a documented code status for residents, especially during emergencies. The facility's policy on advance directives, dated May 5, 2024, requires that during the admission process, the Social Services or a designee should discuss advance directives with the resident or their representative. This includes determining if the resident has a health care surrogate designation, living will, durable power of attorney, or a Do Not Resuscitate (DNR) form. However, the facility was unable to provide any documentation regarding R133's code status or advance directives, indicating a failure to adhere to their own policy and procedure.
Late Transmission of MDS Records
Penalty
Summary
The facility failed to electronically transmit the Minimum Data Set (MDS) records to the CMS system within the regulatory timeframes for a resident, identified as R18, who was part of a sample of 15 residents reviewed for assessment. R18 was admitted on June 21, 2022, with multiple diagnoses including malignant neoplasm of the prostate, spinal stenosis, anemia, atherosclerosis, chronic kidney disease, and essential hypertension. The Quarterly MDS Assessment Reference Date (ARD) for R18 was October 4, 2024, and the assessment was completed on October 14, 2024. However, the final validation report indicated that the record was submitted late, on November 11, 2024, which is more than 14 days after the completion date. The MDS manager, V19, who works remotely for an outside company hired by the facility, stated that they coordinate with the Director of Nursing (DON), V2, to complete the MDS. V19 acknowledged that the MDS assessment should be completed within 14 days from the ARD and transmitted within 14 days from the completion date, as per the Resident Assessment Instrument (RAI) manual. Despite this, the transmission of R18's MDS was delayed, indicating non-compliance with the regulatory timeframes. The facility's policy also documented that the quarterly transmission date should be no later than 14 calendar days from the MDS completion date, which was not adhered to in this instance.
Failure to Provide Nutritional Supplement as Ordered
Penalty
Summary
The facility failed to adhere to dietary recommendations and physician orders for a resident (R3) experiencing weight loss. R3's electronic health records indicated a physician's order for a nutritional supplement, Magic Cup, to be provided twice daily with lunch and dinner. Despite this order, observations revealed that R3 did not receive the Magic Cup during lunch, and the meal ticket did not list the supplement. Interviews with dietary staff confirmed that the facility did not have Magic Cup in stock, and there was a lack of communication regarding the need for this supplement. R3's weight records showed a decline from 159 pounds in June to 153.2 pounds in November, with no weights recorded for September and October. The resident's daughter, who holds power of attorney, expressed concerns about R3's weight loss and confirmed that R3 enjoys sweet foods like the Magic Cup. The Registered Dietitian emphasized the importance of providing the nutritional supplement as ordered to help maintain R3's weight. The facility's policies on receiving orders and nourishment supplements were not followed, contributing to the deficiency.
Improper Storage and Dating of Respiratory Equipment
Penalty
Summary
The facility failed to properly date and store respiratory equipment for two residents, which could potentially affect their health. One resident, who was admitted with respiratory failure, essential hypertension, and chronic kidney disease, was observed with oxygen tubing that was not dated or stored in a plastic bag when not in use. This resident uses oxygen daily, and the improper storage of the tubing was noted during a surveyor's visit. Another resident, admitted with chronic obstructive pulmonary disease, essential hypertension, and a nontraumatic intracerebral hemorrhage, had a nebulizer mask that was not dated. A Licensed Practical Nurse (LPN) at the facility was unaware of the policy regarding the storage and dating of oxygen tubing and nebulizer masks. The Director of Nursing confirmed the deficiencies, acknowledging that undated and improperly stored equipment could increase the risk of infection. The facility's policy requires that such equipment be dated and stored in a clean plastic bag when not in use.
Failure to Follow Prescribed Menus and Standardized Recipes
Penalty
Summary
The facility failed to adhere to the prescribed menu for a resident on a mechanical soft diet and did not follow standardized recipes during the preparation of pureed foods. Specifically, a resident with a diet order of NAS (No Added Salt) Mechanical Soft Texture was observed receiving a meal that did not match the facility's menu for that week. The menu indicated minestrone soup, ground grilled corned beef sandwich, basil roasted zucchini, and blueberry buckle, but the resident was served chicken noodle soup and ground zucchini instead. This discrepancy was noted during an observation of the resident's lunch, where the resident consumed 100% of the meal provided. Additionally, during the preparation of pureed meals, the support chef did not follow the facility's standardized recipes. The chef was observed using a scoop without measurement to puree quinoa stuffed peppers and boiled carrots, resulting in a thin consistency that did not meet the required texture standards. The facility's Director of Dining Services confirmed that recipes should be followed to ensure appropriate texture and nutritional adequacy. The Registered Dietician also emphasized the importance of following menus and recipes to meet nutritional needs. The facility's policy on modified texture foods outlines the need for a standardized process to ensure palatability, flavor, texture, and nutritional value, which was not adhered to in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pavilion Of South Shore | 0 mi | ★★★★★ | 2 | 0 |
| Landmark Of Hyde Park Rehabilitation And Nursing C | 1 mi | ★★★★★ | 14 | 0 |
| Kenwood Vlge Nrsg And Rhb Ctr | 1.8 mi | ★★★★★ | 10 | 0 |
| South Shore Rehabilitation | 2 mi | ★★★★★ | 1 | 0 |
| Elevate Care Windsor Park | 2.6 mi | ★★★★★ | 36 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.