Inspection·November 21, 2025

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm Based on interviews and record reviews, the facility failed to follow their Abuse and Neglect policy by failing to verify background checks of contracted staff, failing to obtain a copy of their professional licenses, and failing to train contracted staff on issues related to abuse and neglect. These failures have the potential to affect all 174 residents residing in the facility. Findings include: On 11/14/2025 at approximately 10:16 AM, V2 (Assistant Administrator) stated contracted security staff started working at the facility a couple of weeks ago. On 11/14/2025 at approximately 11:10 AM, V9 (Contracted Security) stated started work for facility on Wednesday (11/12/2025). V9 stated received training through contracted employer. Did not receive facility specific training on abuse and neglect. On 11/14/2025 at approximately 2:30 PM, requested contracted security staff's background checks, copies of the licenses or certificates, and training from V2, V3 (Director of Nursing), and V11 (Nurse Consultant).On 11/18/2025 at approximately 9:23 AM, V2 stated contracted security company did not provide background checks and copies of licenses or certificates yet. V2 stated [V2] was having a difficult time getting the information from the contracted security company. V2 stated they should be in the IDFPR (Illinois Department of Financial and Professional Regulation) portal. On 11/18/2025 at approximately 9:47 AM, V12 (Human Resources Director) stated did not run the background checks on V9 or V13 (evening Contracted Security) because they are from a third-party vendor (contracted). V12 stated did not verify the contracted security staff's background checks or licenses. V12 stated will verify and pull their licenses through IDFPR now. At approximately 10:08 AM, V12 returned with copies of V9 and V13's IDFPR ‘Lookup Detail View.' Time stamps were 11/18/2025 10:00 AM on V9's sheet and 11/18/2025 10:06 AM on V13's sheet. Facility's contract with the security company documents in part that it started on 11/03/2025. It also documents in part that the facility can request background checks from the contracted company at any time.Facility did not provide copy of V9 and V13's Permanent Employee Registration Cards until 11/19/2025 at 1:54 PM. Facility provided a copy of V9's ‘Security Orientation Checklist' on 11/19/2025 at 5:02 PM. V9 signed it on 11/17/2025 (after start of survey). Facility did not provide a ‘Security Orientation Checklist' for V13. Facility's Abuse and Neglect policy (last revised 6/26/2025) documents in part: The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. These guidelines include compliance with the seven (7) federal components of prevention and investigation. Screen potential employees for a history of abuse, neglect, exploitation, misappropriation of property, or mistreating residents. Similarly, prior to placement in the facility, the facility will require background check of prospective consultants, contractors, volunteers, caregivers working in behalf of the facility, and students in its nurse aide training program and students from affiliated academic institutions, including therapy, social, and activity programs to care for residents to be done either the facility itself, the third-party agency, or academic institution. For licensed staff, obtain a copy of professional licenses. Train employees, through orientation and on-going sessions on issues Residents Affected - Many (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 3 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 11/21/2025 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)