Montgomery Place
5550 South Shore Drive, Chicago, IL 60637 · Cook County · 40 certified beds · avg 33 residents/day · certified since Mar 19, 1993
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 4/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Feb 15, 2026 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Feb 26, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (30)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 25, 2026 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| May 20, 2026 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| May 20, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Apr 10, 2026 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Feb 15, 2026 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 5, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 5, 2025 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Sep 5, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Sep 5, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Aug 6, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Apr 29, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Nov 15, 2024 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Nov 15, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Nov 15, 2024 | F · Potential for harm, facility-wide | The facility did not dispose of garbage and refuse properly. |
| Nov 15, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 15, 2024 | E · Potential for harm, repeated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Nov 15, 2024 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 15, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Nov 15, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Nov 15, 2024 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Nov 15, 2024 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Nov 15, 2024 | D · Potential for harm, one-off | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Nov 15, 2024 | D · Potential for harm, one-off | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. |
| Nov 15, 2024 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Nov 15, 2024 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Sep 21, 2023 | F · Potential for harm, facility-wide | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Sep 21, 2023 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Sep 21, 2023 | F · Potential for harm, facility-wide | The facility did not dispose of garbage and refuse properly. |
| Sep 21, 2023 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Sep 21, 2023 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (14 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | F |
| 2024 | 14 | 0 | F |
| 2025 | 6 | 0 | F |
| 2026 | 5 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
2 fines totaling $19,752.
| Date | Type | Amount / length |
|---|---|---|
| Feb 20, 2024 | Fine | $4,938 |
| Jan 30, 2024 | Fine | $14,814 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Illinois avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.37 | 2.99 | 3.95 | top 13% in Illinois; top 27% in the U.S. |
| Registered Nurse hours | 0.97 | 0.63 | 0.69 | top 14% in Illinois; top 17% in the U.S. |
| Weekend total nurse staffing | 4.25 | 2.67 | 3.50 | top 8% in Illinois; top 17% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.78 | 0.56 | 0.48 | top 19% in Illinois; top 12% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 44.5 | 45.8 | — |
| RN turnover (%) | 0.0 | 41.8 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.82, RN 0.85, weekend 3.71. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bonbrest, Constance | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2016 |
| Brooks Pugh, Margo | Individual | Corporate Director | NOT APPLICABLE | 01/01/2009 |
| Hart, Deborah | Individual | W-2 Managing Employee | NOT APPLICABLE | 06/06/2016 |
| Hart, Deborah | Individual | Corporate Officer | NOT APPLICABLE | 06/06/2016 |
| Juroe, John | Individual | Corporate Officer | NOT APPLICABLE | 01/28/2016 |
| Levy, Susan | Individual | Corporate Officer | NOT APPLICABLE | 02/01/2016 |
| McGarry, Michael | Individual | Corporate Officer | NOT APPLICABLE | 10/03/2011 |
| Montgomery Place | Organization | 5% or Greater Mortgage Interest | NOT APPLICABLE | 12/06/2006 |
| Zappoli, Paul | Individual | Corporate Officer | NOT APPLICABLE | 02/12/2017 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What percentage of your residents and staff are vaccinated against flu and pneumonia, and how do you offer the vaccines?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Pavilion of South Shore | 0.0 mi | Chicago, IL | ★★★☆☆ | 2/5 | |
| Landmark of Hyde Park Rehabilitation and Nursing C | 1.0 mi | Chicago, IL | ★☆☆☆☆ | 1/5 | abuse |
| Kenwood Vlge Nrsg and RHB Ctr | 1.8 mi | Chicago, IL | ★☆☆☆☆ | 1/5 | abuse |
| South Shore Rehabilitation | 2.0 mi | Chicago, IL | ★☆☆☆☆ | 2/5 | |
| Elevate Care Windsor Park | 2.6 mi | Chicago, IL | ★☆☆☆☆ | 2/5 | |
| Aspyre of Bronzeville | 2.8 mi | Chicago, IL | ★☆☆☆☆ | 1/5 | |
| Wentworth Rehab & HCC | 3.1 mi | Chicago, IL | ★★☆☆☆ | 2/5 | abuse |
| Princeton Rehab & HCC | 3.1 mi | Chicago, IL | ★☆☆☆☆ | 2/5 | abuse |
| Ryze on the Avenue | 3.5 mi | Chicago, IL | ★☆☆☆☆ | 1/5 | abuse |
| Kensington Place Nrsg & Rehab | 3.5 mi | Chicago, IL | ★☆☆☆☆ | 2/5 | abuse |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 145748.