Health inspection·November 7, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interviews and record reviews, the facility failed to follow their ‘Abuse and Neglect' policy and report an allegation of abuse for one (R3) out of three residents reviewed for abuse. Findings include:R1's admission Record documents in part diagnoses of bipolar disorder, major depressive disorder, and anxiety disorder.R1's Care Plan documents in part that R1 presents with a difficult or troubled past secondary to severe mental illness. R1 presents with abuse risk factors related to acting as a recipient or perpetrator of mistreatment and/or neglect, exploitation, psychiatric history, and present mental health symptoms. R1 presents with behavioral symptoms including verbal aggression, agitation, and manipulative behavior (focus initiated on 10/24/2025). R1 displays manipulative behavior which is disruptive, insensitive and/or disrespectful to staff and peers (initiated 10/17/2025). R1 has the potential to demonstrate verbally aggressive behaviors related to ineffective coping skills, mental illness, and poor impulse control (initiated 10/17/2025).R3's admission Record documents in part diagnoses of schizophrenia, delusional disorders, major depressive disorder, and anxiety disorder.On 11/05/2025 at 1:11 PM, R3 was alert and oriented to person, facility, and date. R3 stated that the former roommate (R1) was violent. R3 alleged that R1 wanted to hit R3 in the face because R1 accused R3 of turning off R1's television. R3 alleged that R1 has been threatening R3 for the past three days with R1 also requesting money from R3. R3 described a staff member that was currently working on another floor (V7 - Nurse) as a witness. During a follow-up interview with R3 on 11/06/2025 at 9:40 AM, R3 stated R1's threats started over the weekend. R3 also alleged that R1 took R3's debit card. R3 requested to get it back but R1 threatened to hit R3. R3 stated notifying staff but R1 continued to be R3's roommate until R1 was sent out to the hospital Tuesday evening.On 11/05/2025 at 1:40 PM, V7 (Nurse) stated on Monday evening (11/03/2025), a CNA (Certified Nurse Aide) notified V7 that R1 was threatening to hit R3. V7 denied witnessing or hearing the threats firsthand. V7 stated the CNA (who facility assumes is V16) mentioned R1 was upset that R3 was pressing the television volume down. V7 stated informing the social worker (V9) who then went to speak to R1 and R3. When asked if V7 reported the abuse allegation to the abuse coordinator (V1), V7 stated reporting it to V9.Attempted telephone interviews with V16 (CNA) on 11/06/2025 at 10:10 AM and 1:22 PM and again on 11/07/2025 at 9:03 AM; however, V16 did not answer or return the calls. V16 was scheduled to work 11/06/2025 afternoon/evening; but did not present to work during surveyor's allotted work time.During an interview with V9 (Social Service Director) on 11/05/2025 at 2:47 PM, V9 described R1 as attention-seeking, manipulative, and very behavioral. V9 stated on Monday evening, V9 received a text message from V10 (Restorative Nurse) that R1 was having behaviors but no mention of abuse. V9 stated [V9] was no longer in the facility at the time. V9 stated sharing an office with V10 and it was V10 who went to speak with the residents.During an interview with V10 (Restorative Nurse) on 11/05/2025 at 3:01 PM, V10 stated V7 called Monday evening to report that R1 was acting up. V7 did not mention any allegation of abuse between R1 and R3. When V10 arrived on the floor, R1 was in (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145679 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145679 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Carlton at the Lake, The 725 West Montrose Avenue Chicago, IL 60613 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)