Montgomery Place

Penalties

• Feb 15, 2026 — IDPH fine (Nursing Home Care Act) ($25,000)
• Nov 15, 2024 — IDPH fine (Nursing Home Care Act) ($500)
• Feb 20, 2024 — Fine ($4,938)
• Jan 30, 2024 — Fine ($14,814)
• Sep 21, 2023 — IDPH fine (Nursing Home Care Act) ($500)

Inspection findings

1. Jun 25, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Jul 13, 2026 · CMS health inspection

2. May 20, 2026 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected Jun 4, 2026 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Jun 4, 2026 · CMS health inspection

3. Apr 10, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected May 14, 2026 · CMS health inspection

4. Feb 15, 2026 Health · 2 findings
   • Serious Scope/severity G Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Feb 26, 2026 · CMS health inspection

   • Serious Scope/severity A

     Type A Illinois Nursing Home Care Act violation

     Type A: substantial probability of death or serious harm, or actual harm (1-129). Sections of the Illinois Administrative Code cited: 300.610a), 300.1210b), 300.1210c), and 300.1210d)6). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation:300.1210b) and 300.1210d)6).

     Statement of deficiencies (PDF)

5. Sep 5, 2025 Health · 4 findings
   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Sep 19, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Sep 19, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Sep 19, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Sep 19, 2025 · CMS health inspection

6. Aug 6, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Aug 22, 2025 · CMS health inspection

7. Apr 29, 2025 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected May 2, 2025 · CMS health inspection

8. Nov 15, 2024 Fire Safety · 26 findings
   • Not serious Scope/severity F

     E0037 Emergency Preparedness Deficiencies

     Establish staff and initial training requirements.

     Corrected Dec 12, 2024 · CMS fire safety

   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Jan 17, 2025 · CMS fire safety

   • Not serious Scope/severity D

     F0578 Resident Rights Deficiencies

     Honor 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.

     Corrected Dec 5, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0640 Resident Assessment and Care Planning Deficiencies

     Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

     Corrected Nov 30, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Nov 30, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Dec 5, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Dec 5, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0727 Nursing and Physician Services Deficiencies

     Have 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.

     Corrected Nov 30, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Dec 5, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     Ensure 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.

     Corrected Dec 5, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0803 Nutrition and Dietary Deficiencies

     Ensure 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.

     Corrected Dec 6, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Nov 30, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Nov 30, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Nov 30, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0883 Infection Control Deficiencies

     Develop and implement policies and procedures for flu and pneumonia vaccinations.

     Corrected Nov 30, 2024 · CMS health inspection

   • Not serious Scope/severity F

     K0133 Construction Deficiencies

     Install a two-hour-resistant firewall separation.

     Corrected Mar 7, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0222 Egress Deficiencies

     Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

     Corrected Jan 14, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Dec 12, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Dec 12, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Dec 12, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Feb 20, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Feb 10, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0911 Gas, Vacuum, and Electrical Systems Deficiencies

     Meet requirements for the installation and maintenance of electrical systems.

     Corrected Dec 12, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0926 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

     Corrected Dec 12, 2024 · CMS fire safety

   • Not serious Scope/severity C

     Type C Illinois Nursing Home Care Act violation

     Type C: less than minimal harm (1-132). Sections of the Illinois Administrative Code cited: 300.615e). This instance in accordance with 300.282f) and j) of the Code is assessed a fine due to the violation of the sections of the Code with a high-risk designation: 300.615e).

     Statement of deficiencies (PDF)

9. Sep 21, 2023 Health · 10 findings
   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected Oct 8, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Oct 8, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Oct 8, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Oct 8, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Oct 8, 2023 · CMS health inspection

   • Not serious Scope/severity F

     K0133 Construction Deficiencies

     Install a two-hour-resistant firewall separation.

     CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Nov 5, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Nov 5, 2023 · CMS fire safety

   • Not serious Scope/severity F

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Nov 5, 2023 · CMS fire safety

   • Not serious Scope/severity C

     Type C Illinois Nursing Home Care Act violation

     Type C: less than minimal harm (1-132). Sections of the Illinois Administrative Code cited: 300.615e). The fine was doubled in this instance in accordance with 300.282i) and j) of the Code due to the violation of the sections of the Code with a high-risk designation: 300.615e).

     Statement of deficiencies (PDF)

10. Jul 22, 2022 Fire Safety · 7 findings
    • Not serious Scope/severity F

      E0006 Emergency Preparedness Deficiencies

      Conduct risk assessment and an All-Hazards approach.

      Corrected Sep 2, 2022 · CMS fire safety

    • Not serious Scope/severity F

      E0015 Emergency Preparedness Deficiencies

      Address subsistence needs for staff and patients.

      Corrected Aug 15, 2022 · CMS fire safety

    • Not serious Scope/severity F

      E0037 Emergency Preparedness Deficiencies

      Establish staff and initial training requirements.

      Corrected Sep 2, 2022 · CMS fire safety

    • Not serious Scope/severity F

      E0041 Emergency Preparedness Deficiencies

      Implement emergency and standby power systems.

      Corrected Aug 12, 2022 · CMS fire safety

    • Not serious Scope/severity E

      K0311 Smoke Deficiencies

      Have an enclosure around a vertical opening shaft.

      Corrected Sep 12, 2022 · CMS fire safety

    • Not serious Scope/severity F

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Aug 31, 2022 · CMS fire safety

    • Not serious Scope/severity F

      K0918 Gas, Vacuum, and Electrical Systems Deficiencies

      Have generator or other power source capable of supplying service within 10 seconds.

      Corrected Sep 16, 2022 · CMS fire safety

Owners and managers (as published by CMS)

• BONBREST, CONSTANCE — corporate officer, NOT APPLICABLE, since 01/01/2016
• BROOKS PUGH, MARGO — corporate director, NOT APPLICABLE, since 01/01/2009
• HART, DEBORAH — w-2 managing employee, NOT APPLICABLE, since 06/06/2016
• HART, DEBORAH — corporate officer, NOT APPLICABLE, since 06/06/2016
• JUROE, JOHN — corporate officer, NOT APPLICABLE, since 01/28/2016
• LEVY, SUSAN — corporate officer, NOT APPLICABLE, since 02/01/2016
• MCGARRY, MICHAEL — corporate officer, NOT APPLICABLE, since 10/03/2011
• ZAPPOLI, PAUL — corporate officer, NOT APPLICABLE, since 02/12/2017
• MONTGOMERY PLACE — 5% or greater mortgage interest, NOT APPLICABLE, since 12/06/2006