Cycle 1
Health 2025-04-11 · Fire 2025-04-11
18 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
4 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Chicago, IL
Carlton At The Lake, The
2-star overall rating with 2-star inspections with $241,131 in total fines with 18 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
725 West Montrose Avenue, Chicago, IL
(773) 929-1700
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
244
Certified beds
Average residents
168
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Legacy Healthcare
Operator or chain grouping
Approved since
1990-06-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.76
Registered nurse staffing
LPN hours / resident day
0.71
Licensed practical nurse staffing
Aide hours / resident day
1.81
Nurse aide staffing
Weekend hours
3.11
Weekend nurse staffing
RN turnover
31%
Annual RN turnover
Total nurse turnover
36%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.0
0.6 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
2.3
0.3 pts better
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
89.6%
3.1 pts better
|
93.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
91.6%
5.6 pts better
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.5% |
3.3%
1.8 pts better
|
3.3%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 99.5% |
50.3%
49.2 pts worse
|
11.4%
88.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.8% |
6.5%
1.3 pts worse
|
5.4%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.9% |
18.5%
7.6 pts better
|
19.6%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 26.6% |
22.8%
3.8 pts worse
|
16.7%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 3.5% |
0.1%
3.4 pts worse
|
0.1%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.5% |
17.2%
13.7 pts better
|
16.3%
12.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.3% |
15.0%
11.7 pts better
|
14.9%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.2% |
1.1%
2.1 pts worse
|
1.0%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 2.2% |
21.3%
19.1 pts better
|
19.8%
17.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 8.1% |
5.2%
2.9 pts worse
|
5.1%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 39.6% |
68.8%
29.2 pts worse
|
81.7%
42.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.6% |
14.0%
7.4 pts better
|
12.0%
5.4 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
2.3%
0.7 pts better
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 70.5% |
63.0%
7.5 pts better
|
79.7%
9.2 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.8% |
26.2%
5.6 pts worse
|
23.9%
7.9 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-15 · Fire 2024-03-15
17 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-02-03 · Fire 2023-02-03
25 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-11
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-04-16
F · Potential for more than minimal harm
2025-04-11
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2025-05-14
F · Potential for more than minimal harm
2025-04-11
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2025-04-16
E · Potential for more than minimal harm
2025-04-11
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-04-16
F · Potential for more than minimal harm
2024-03-15
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Not marked corrected
F · Potential for more than minimal harm
2024-03-15
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-03-14
E · Potential for more than minimal harm
2024-03-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-14
C · Minimal harm
2024-03-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-14
F · Potential for more than minimal harm
2023-02-03
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2023-02-09
F · Potential for more than minimal harm
2023-02-03
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Not marked corrected
F · Potential for more than minimal harm
2023-02-03
K531 · Services Deficiencies
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2023-02-09
F · Potential for more than minimal harm
2023-02-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-09
F · Potential for more than minimal harm
2023-02-03
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2023-02-09
E · Potential for more than minimal harm
2023-02-03
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-02-09
E · Potential for more than minimal harm
2023-02-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-09
E · Potential for more than minimal harm
2023-02-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-02-09
E · Potential for more than minimal harm
2023-02-03
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-02-09
E · Potential for more than minimal harm
2023-02-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-02-09
D · Potential for more than minimal harm
2023-02-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-02-09
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-21
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-11-22
D · Potential for more than minimal harm
2025-11-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-11-22
D · Potential for more than minimal harm
2025-11-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-11-08
D · Potential for more than minimal harm
2025-09-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-09-09
D · Potential for more than minimal harm
2025-09-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-09
F · Potential for more than minimal harm
2025-08-25
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-08-26
D · Potential for more than minimal harm
2025-08-25
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-08-26
G · Actual harm
2025-05-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-03
D · Potential for more than minimal harm
2025-05-02
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-03
E · Potential for more than minimal harm
2025-04-11
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-04-12
E · Potential for more than minimal harm
2025-04-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-12
E · Potential for more than minimal harm
2025-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-04-11
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-04-11
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-04-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-04-11
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-04-11
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-04-12
D · Potential for more than minimal harm
2025-04-11
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-04-12
D · Potential for more than minimal harm
2024-11-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-11-07
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-08-05
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-08-05
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-04-15
F761 · Pharmacy Service Deficiencies
Health
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 2024-04-16
D · Potential for more than minimal harm
2024-04-15
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2024-04-16
D · Potential for more than minimal harm
2024-04-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-04-16
G · Actual harm
2024-03-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-03-16
E · Potential for more than minimal harm
2024-03-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-16
E · Potential for more than minimal harm
2024-03-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-16
E · Potential for more than minimal harm
2024-03-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-16
E · Potential for more than minimal harm
2024-03-15
F761 · Pharmacy Service Deficiencies
Health
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 2024-03-16
E · Potential for more than minimal harm
2024-03-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-03-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-03-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-03-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-03-16
D · Potential for more than minimal harm
2024-03-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-16
G · Actual harm
2024-01-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-03
D · Potential for more than minimal harm
2024-01-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-02-03
D · Potential for more than minimal harm
2023-12-08
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-12-20
G · Actual harm
2023-11-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-03
F · Potential for more than minimal harm
2023-11-02
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-11-03
E · Potential for more than minimal harm
2023-11-02
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-11-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-03
D · Potential for more than minimal harm
2023-11-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-03
J · Immediate jeopardy
2023-10-04
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-17
G · Actual harm
2023-10-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-10-17
F · Potential for more than minimal harm
2023-10-04
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-10-17
E · Potential for more than minimal harm
2023-07-01
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-07-01
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-07-14
G · Actual harm
2023-05-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-05-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-05-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-05-09
D · Potential for more than minimal harm
2023-05-08
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-05-09
F · Potential for more than minimal harm
2023-02-03
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-04
E · Potential for more than minimal harm
2023-02-03
F761 · Pharmacy Service Deficiencies
Health
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 2023-02-04
E · Potential for more than minimal harm
2023-02-03
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-02-04
E · Potential for more than minimal harm
2023-02-03
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2023-02-04
D · Potential for more than minimal harm
2023-02-03
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-04
D · Potential for more than minimal harm
2023-02-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-04
D · Potential for more than minimal harm
2023-02-03
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-02-04
D · Potential for more than minimal harm
2023-02-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-04
Penalties and ownership
What sits behind the stars
$16,822
2024-03-15
Fine
Fine · fine $16,822
Fine
$16,052
2024-01-19
Fine
Fine · fine $16,052
Fine
$11,180
2023-11-02
Fine
Fine · fine $11,180
Fine
$0
2023-11-02
Payment Denial
Payment Denial · denial start 2023-11-25 · 25 days
25 day denial
$197,077
2023-10-04
Fine
Fine · fine $197,077
Fine
Ownership
Chaim Rajchenbach Descendants Tr Ua 04282008
5% Or Greater Direct Ownership Interest · Organization
Doros Generation Trust U/A/D 1/3/12
5% Or Greater Direct Ownership Interest · Organization
Carlton Associates Limited Partnership
5% Or Greater Security Interest · Organization
Shabat, Menachem
Corporate Officer · Individual
Ventrella, Joanne
W-2 Managing Employee · Individual
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