Carlton at the Lake, the
725 West Montrose Avenue · Chicago, IL · 60613 · 7739291700
244 certified beds For profit - Limited Liability company Chain: Legacy Healthcare
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- 5 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
Medicare/Medicaid payments were denied
CMS refused payment for new admissions for a period — one of its strongest enforcement tools.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 2 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.15 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.74 | 0.55–0.75 |
| Weekend hours / resident-day | 3.01 | ≈ weekday level |
| Nursing turnover / year | 36% | median 45% |
| Fines (3-yr window) | 4 · $241,131 |
Inspection citations (61 in the current record)
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Potential for harm · D March 5, 2026 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected March 6, 2026 · Resident Rights
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Potential for harm · D March 5, 2026 · found via complaint
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 March 6, 2026 · Resident Rights
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Potential for harm · D March 5, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 6, 2026 · Quality of Life and Care
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Potential for harm · E March 5, 2026 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected March 6, 2026 · Pharmacy Service
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Potential for harm · D March 5, 2026 · found via complaint
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected March 6, 2026 · Nutrition and Dietary
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Potential for harm · F November 21, 2025 · found via complaint
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected November 22, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 21, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected November 22, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 7, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected November 8, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D September 8, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected September 9, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D September 8, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected September 9, 2025 · Quality of Life and Care
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Potential for harm · D August 25, 2025 · found via complaint
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected August 26, 2025 · Resident Rights
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Potential for harm · F August 25, 2025 · found via complaint
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected August 26, 2025 · Environmental
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Actual harm · G May 2, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected May 3, 2025 · Quality of Life and Care
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Potential for harm · D May 2, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected May 3, 2025 · Pharmacy Service
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Potential for harm · D April 11, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected April 12, 2025 · Resident Rights
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Potential for harm · D April 11, 2025
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected April 12, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E April 11, 2025
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 April 12, 2025 · Quality of Life and Care
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Potential for harm · D April 11, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected April 12, 2025 · Quality of Life and Care
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Potential for harm · D April 11, 2025
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 April 12, 2025 · Quality of Life and Care
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Potential for harm · E April 11, 2025
Provide safe and appropriate respiratory care for a resident when needed.
Corrected April 12, 2025 · Quality of Life and Care
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Potential for harm · D April 11, 2025
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 April 12, 2025 · Quality of Life and Care
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Potential for harm · D April 11, 2025
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected April 12, 2025 · Quality of Life and Care
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Potential for harm · E April 11, 2025
Provide and implement an infection prevention and control program.
Corrected April 12, 2025 · Infection Control
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Potential for harm · D November 7, 2024 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected November 8, 2024 · Quality of Life and Care
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Potential for harm · D November 7, 2024 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected November 8, 2024 · Resident Assessment and Care Planning
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 15, 2024 | Fine | $16,822 |
| January 19, 2024 | Fine | $16,052 |
| November 2, 2023 | Fine | $11,180 |
| November 2, 2023 | Payment Denial | 25 days |
| October 4, 2023 | Fine | $197,077 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 145679 · certified since June 13, 1990. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.