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.
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)
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
Potential for harm · D April 11, 2025
Reasonably accommodate the needs and preferences of each resident.
Corrected April 12, 2025 · Resident Rights
-
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
-
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
-
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
-
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
-
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
-
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
-
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
-
Potential for harm · E April 11, 2025
Provide and implement an infection prevention and control program.
Corrected April 12, 2025 · Infection Control
-
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
-
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
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
Sign in to share your family's experience — reviews are moderated and never affect the Safety Score.
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.