Montgomery Place
5550 South Shore Drive, Chicago, IL 60637 · Non profit - Corporation · 40 certified beds · (773) 753-4100 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- a high payroll-based staffing rating (4/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited May 2026
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $19,752 in federal fines (most recent 2024-02-20)
- its facility-reported quality-measure score sits well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 5 of 5 |
| Short-stay residentsrehab / post-hospital | 4 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 2 to 3 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 15.5% | 13.4% | 15.4% | typical |
| Long-stay residents who lose too much weight | 1.3% | 6.3% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 1.0% | 0.9% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 10.3% | 54.2% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.1% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.0% | 3.1% | 3.3% | check this* — see note marked star below the table |
| Long-stay residents on antianxiety or hypnotic medication | 6.6% | 18.3% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 81.0% | 91.8% | 95.3% | worse |
| Long-stay residents with pressure ulcers | 1.4% | 4.8% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.4% | 20.6% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.8% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.4% | 2.2% | 1.4% | typical |
| Short-stay residents given the seasonal flu vaccine | 40.0% | 63.1% | 79.4% | worse |
| Short-stay residents rehospitalized after admission | 27.4% | 26.1% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 7.8% | 13.9% | 12.0% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
60.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 208 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 62 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.61 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 15% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 60.6%CMS range 54.6–66.3 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.8%CMS range 7.8–14.7 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 58.1% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 72.6% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 61.3% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 85.6% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 98.2% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.8%CMS range 3.1–9.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 40 beds and averages 33.4 residents a day — about 84% occupied, or roughly 7 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.82 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.85 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.71 hrs/resident/day on weekends vs 3.87 on weekdays — 4% thinner on weekends. RN hours go from 0.88 to 0.78 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · Gcited before2026-02-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. R1's diagnosis include but not limited to Unspecified Fracture of Shaft of Left Tibia, Subsequent Encounter for Closed Fracture with Routine Healing, Fall From or Off Toilet Without Subsequent Striking Against Object, Subsequent Encounter, History of Falling, Pain in Left Lower Leg, Spinal Stenosis, Cervical Region, Polyosteoarthritis, Pain In Left Shoulder, Presence of Artificial Knee Joint, Bilateral, Unspecified Urinary Incontinence, Muscle Weakness (Generalized), Other Reduced Mobility, Need For…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-06-25 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. R2 states she is only here temporarily for therapy and will be going back home and she has not seen that nurse since.R2 stated after receiving the wrong medications she was feeling tried and drowsy…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-20 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Finding include:R1 had diagnosis of but not limited Cerebral Infarction, Acute Respiratory Failure with Hypoxia, Pneumonia, Aphasia, Chronic Kidney Disease, Stage 4 (Severe), Hypertension, Dementia and Alzheimer's Disease.R1 has a Brief Interview of Mental Status Score of 07 that indicates severe cognition impairment. R1's Care Plan focus titled Altered Neurological Status, dated 4/08/2025, documents, in part, Interventions: Monitor for behavioral changes.R1's Care Plan focus titled Elopement risk/wanderer, dated 4/08/2026, documents, in part, Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book.R1's Care Plan focus titled Impaired Cognitive Function/dementia or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-05-20 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. V4 stated that's the reason the incident was reported immediately due to aggressive actions by V7 towards R1. V4 stated that on the next day, 5/13/26, she reported the incident again to V1 (Administrator), and V4 provided a signed witness statement to V1. On 5/19/2026 at 2:53 PM V1 (Executive Director)…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-04-10 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include:R4's medical diagnosis includes but is not limited to mixed hyperlipidemia, dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R4's MDS (Minimum Data Set) section C-Functional Abilities dated [DATE], documents R4's Brief Interview for Mental Status as 7/15, indicating severe cognitive impairment.R4's Physician Order Sheet (POS) dated 12/30/2025 documents: Atorvastatin Calcium Oral Tablet 20 MG (Atorvastatin Calcium). Give 20 mg by mouth one time a day for antihyperlipidemia.R2's Physician Order Sheet (POS) dated 11/15/2025 documents: Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth at bedtime for LIPITOR.On 04/07/2026 at 11:26AM, V3 (R2's family member/Power of power of attorney -POA) stated via…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-09-05 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Observed an open bag of vanilla wafers (Cookies), a 25 pounds (lb.) bag of breadcrumbs, 25lbs bag of cake mix open to air and not label with opened on date in the dry food storage room. V4 stated this is not our standard. V4 further stated all opened dry foods should be transferred to a self-sealing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-05 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings include: On 09/03/2025 at 12:15 PM, V2 (Director of Nursing) stated that she is currently the Infection Preventionist.On 09/03/2025, V2 stated that the facility has not ordered the pneumococcal vaccinations yet. V2 stated pneumococcal vaccine is offered all year around. We order the pneumococcal vaccine with influenza for this year. V2 stated that the facility orders it together when they order the influenza vaccine to save on costs. V2 stated that flu season begins in October till April. V2 stated that they screen residents for the influenza immunization in September and administer the vaccine in October. V2 stated that she has not screen or educated R4, R8 or R21 for their pneumococcal vaccination. V2 stated that R4, R8 and R21 do not have their pneumococcal vaccine, nor do they have education or consent. V2 stated that it is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-09-05 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. R1 was observed with food in his mouth trying to eat. R1's bed was observed to be slightly elevated. V5 stated the bed is elevated at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-09-05 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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.Findings include: On 09/02/2025 at 11:30 AM, surveyor observed V10 (Housekeeper) clean R8's bathroom. V10 then came out of the bathroom, exited R8's room without removing her gloves or washing her hands. Immediately right after surveyor observed V10 enter R4's room without sanitizing her hands and enter R4's bathroom. On 09/03/2025 at 12:48 AM, V2 (Director of Nursing) stated all staff members including housekeepers are expected to sanitize their hands and wear gloves prior to entering a resident's room. V2 stated that prior to exiting the room the staff member is expected to remove their gloves in the room and wash their hands. This prevents the spread of infection. V2 stated housekeepers should not go from room to room wearing the same gloves because this can…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-08-06 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include: R1 is [AGE] years old, initial admission date 05/11/2024. R1 was seen able to express clearly her thoughts during conversation. On 08/05/2025 at 10:55 AM, R1 stated that V3 (Registered Nurse/Agency) came to her room took her ostomy supplies and ran out of her room. At 12:18 PM, V1 (Administrator) clarified that R1 went for an appointment for her ostomy and came back with change or new ostomy size. After ostomy supplies for new size were used. R1 does not want to use her old ostomy supplies although R1 kept on asking for her ostomy to be changed multiple times a day. V1 stated that Medicare Part B will not cover premature order of supplies. Per V1, R1 was informed that she can go to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-29 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R1 is a [AGE] year old male with a diagnosis including Heart Failure, Obesity and Multiple Myeloma. R1 was first admitted to the facility on [DATE]. R1 has a BIMS (Brief Interview for Mental Status) 10/15, moderate cognitive impairment. On 4/28/25 at 12:30PM R1 stated they run out of the proper size diapers for me on the weekends and night shift. The CNAs put a small size diaper on me, and it is very uncomfortable. My wife had to go to the store on several occasions to buy the right size diaper for me to wear. This has happened several times. The CNAs just say they are out of the extra large size. On 4/28/25 at 12:50PM V6 (family member) stated two times I had to buy diapers for R1 because they ran out of size 3XL. The CNAs used the diapers I purchased. On 4/28/25 at 12:41PM V5 (CNA,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 19 citations
- Potential for harm · F2024-11-15 · tag F0727 — failed to provide required RN coverage — widespreadHave a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. The findings include: On 11/14/24 at 10:40 am V2 (Director of Nursing/DON) stated that it is V2's expectation that there shall be a minimum of one Registered Nurse (RN) on duty in the facility for eight hours, seven days a week. V2 stated that V2 has four RNs and two of the RNs are as needed. V2 stated that V2 does not have a RN on duty some days and weekends especially in the month of April, May, and June, and V2 is interviewing more RNs for this position. V2 stated that the potential problem of not having RNs to take care of residents could result in poor outcomes to residents requiring specialized care that is beyond the scope of the Licensed Practical Nurse (LPN). On 11/14/24 at 12:15 PM, V1 (Administrator) stated V1…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-11-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: On 11/12/24 at 9:36 AM, during the initial kitchen observation conducted with V3 (Director Dining Services), the following were found in the main cooler for meat and dairy: opened foods with no labels when…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-11-15 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. Findings include: On 11/12/24 at 9:36 AM, during the initial kitchen observation conducted with V3 (Director Dining Services), observed 3 garbage bins with no covers filled with waste from the kitchen. V3 stated they all should be covered. On 11/12/24 at 9:55 AM, V3 (Director of Dining Services) brought surveyor outside to inspect the facility's dumpsters. Surveyor observed one dumpster with the lid not fully closed due to overflowing of garbage. V3 stated that all dumpsters should be fully closed to prevent rodents and other pests' infestation. On At 10:14 AM, V12 (Maintenance Director) that the lids of the dumpster should be closed when not in used so no rodents get in there and no debris would fly out. V12 stated that the lids should be closed for pest control, and if it's open the garbage would…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-11-15 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. V14 stated that touching clean linens with dirty hands can result in cross contamination, spreading of bacteria to residents, and increase the risk for infection. On 11/12/24 at 1:05 PM, surveyor reviewed the water management area with V13.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-15 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include: R17's admission record showed admission date on 8/30/2024 with diagnoses not limited to Unspecified fracture of shaft of left tibia, Anemia, Spinal stenosis cervical region, Essential (primary) hypertension, Polyosteoarthritis, Pain in left shoulder, Presence of artificial knee joint bilateral, Unspecified fracture of upper end of right tibia, Unspecified glaucoma. R22's admission record showed admission date on 5/11/2024 with diagnoses not limited to Other nontraumatic intracerebral hemorrhage, Malignant neoplasm of colon, Essential (primary) hypertension, Unspecified convulsions, Malignant neoplasm of bladder, Gastrostomy status,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The findings include: R1's admission record showed admission date on 10/4/2019 with diagnoses not limited to Cerebral infarction, Vascular dementia, other seizures, Essential (primary) hypertension, Unspecified osteoarthritis, anxiety disorder. R17's admission record showed admission date on 8/30/2024 with diagnoses not limited to Unspecified fracture of shaft of left tibia, Anemia, Spinal stenosis…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-15 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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]. The findings include: On [DATE] at 12:07 PM V10 (Licensed Practical Nurse / LPN) stated she has been working in the facility since [DATE]. The west side medication cart was inspected and the controlled medications counted with V10. She said outgoing and incoming nurses are counting the narcotic medications and signing off in the controlled medication sheet after every count. R11's Tramadol with remaining 2 half tablets, blister packet / slots were compromised or broken and had a piece of transparent tape over the back. At 12:28 PM The west side medication room was inspected with V10 and observed R1's Hydromorphone concentrates about…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-11-15 · tag F0761 — failed to label and store drugs safely — patternEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. The findings include: On 11/12/24 at 12:07 PM V10 (Licensed Practical Nurse / LPN) stated she has been working in the facility since November 2018. [NAME] side medication cart inspected with V10 and found about 20 loose yellow capsules and white tablets inside plastic container covered with tape and with no label, kept inside the narcotic box. V10 unable to determine the name of the medications and for whom they belonged to. V10 stated these loose medications should have been disposed or discarded. At 12:28 PM the west side medication room inspected with V10. Observed the locked refrigerator with medications such as insulin, flu vaccine, acetaminophen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2024-11-15 · tag F0883 — failed to offer flu and pneumonia vaccines — patternDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. R9's EMR revealed no documentation indicating the facility assessed R9's eligibility to receive the pneumococcal vaccination and/or that R9 was provided education related to the pneumococcal vaccination. There were no signed consents for pneumococcal immunizations…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-15 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. The findings include: R133's admission record showed admission date on 11/6/2024 with diagnoses not limited to Unspecified displaced fracture of sixth cervical vertebra,Unspecified fracture of first thoracic vertebra, Fall on same level, Unspecified abnormalities of gait and mobility, Problem related to care provider dependency, Encounter for other orthopedic aftercare, Muscle weakness (generalized), Unsteadiness on feet, History of falling, Obesity. MDS (Minimum Data Set) dated 11/12/2024 showed R133 with intact cognition. At 10:09am V2 (DON / Director of Nursing) stated she started working in the facility March 2024. V2 stated residents should have an advance directive / code status ordered or documented in resident's record whether a DNR (Do Not Resuscitate) or Full code and should be care planned. Resident's code status is important during an emergency. The care plan serves as a guidance…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-15 · tag F0640 — isolatedEncode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based 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. The findings include: R18's admission record showed admission date on 6/21/22 with diagnoses not limited to Malignant neoplasm of prostate, Spinal stenosis, Anemia, Atherosclerosis, Chronic kidney disease, Essential hypertension. R18's Quarterly MDS (Minimum Data Set) ARD (Assessment Reference Date) 10/4/24 was completed on 10/14/24. Final validation report dated 11/11/24 showed record submitted late. The submission date is more than 14 days after the completion date. On 11/14/24 at 9:50 AM V19 (MDS manager) stated they are an outside company hired by facility and completing some sections of the MDS. V19 stated she is working remotely and coordinating with V2 (DON / Director of Nursing) to let her know what needs to be done for MDS completion. She said the MDS assessment is a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-15 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. R3's progress notes documented by V7 (Registered Dietitian/RD) reads in part: continue magic cup with lunch and dinner; provides 580…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-15 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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: Chronic obstructive pulmonary disease with acute exacerbation, essential hypertension, and nontraumatic intracerebral hemorrhage in hemisphere subcortical. On 11/12/24 at 11:35 AM, R15 received in bed, oxygen tubing hanging on the oxygen tank, not…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-11-15 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). R9's Minimum Data Set, dated [DATE] shows R9 is cognitively impaired. The facility's menu spreadsheet for August 2024 - Week 3 Mechanical Soft indicates minestrone soup, ground…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2023-09-21 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
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. 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,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-09-21 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2023-09-21 · tag F0814 — failed to dispose of garbage properly — widespreadDispose of garbage and refuse properly.
What the surveyor found here — an excerpt from the official record, may be distressing
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. 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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2023-09-21 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-09-21 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
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). 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…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$19,752 in federal fines across 2 penalties.
- $4,938 — penalty dated 2024-02-20
- $14,814 — penalty dated 2024-01-30
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MONTGOMERY PLACE | Organization | 5% OR GREATER MORTGAGE INTEREST | since 12/06/2006 |
| HART, DEBORAH | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | since 06/06/2016 |
| BROOKS PUGH, MARGO | Individual | CORPORATE DIRECTOR | since 01/01/2009 |
| BONBREST, CONSTANCE | Individual | CORPORATE OFFICER | since 01/01/2016 |
| JUROE, JOHN | Individual | CORPORATE OFFICER | since 01/28/2016 |
| LEVY, SUSAN | Individual | CORPORATE OFFICER | since 02/01/2016 |
| MCGARRY, MICHAEL | Individual | CORPORATE OFFICER | since 10/03/2011 |
| ZAPPOLI, PAUL | Individual | CORPORATE OFFICER | since 02/12/2017 |
CMS files one row per role, so the 9 rows in the source record cover these 8 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in IL
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145748. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-09-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.