Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Carlton At The Lake, The during CMS and state inspections, most recent first.
The facility failed to provide effective and consistent mice control for multiple residents. A resident reported seeing mice daily in a shared room, including under beds and moving between roommates’ belongings, and staff confirmed sightings were entered in the pest log. However, surveyors found no glue boards or RDUs in one room that was documented as treated, and only one RDU with no glue traps in another room, while vendor service records did not match the facility’s documentation. The facility did not follow its pest control policy requiring an effective pest control process.
Surveyors found that multiple nurses on several floors did not complete their morning medication passes within the facility’s required one-hour before/after window, resulting in numerous medications showing as late on the eMAR. RNs and LPNs reported starting medication administration early in their shifts but still had outstanding medications several hours later, and some acknowledged giving medications without promptly documenting them. Audit reports confirmed that multiple residents across several floors received medications late, and facility policy requires that medications be administered on time and signed on the MAR immediately after administration.
A resident with intact cognition but significant left-sided weakness and multiple care needs was observed seated in a mechanical chair while the call light was placed on the bed out of reach. The resident reported being unable to reach the call light due to weakness from a prior stroke and stated they sometimes had to shout for help or rely on a cell phone because the call light was not always accessible. A CNA and an RN both acknowledged that the resident could not reach the call light as placed and that call lights should be within residents’ reach so they can obtain assistance, and the DON confirmed that facility policy requires call lights to be placed within reach of residents able to use them at all times.
A resident with intact cognition and multiple medical conditions reported that the facility’s showers were dirty and contained soiled incontinence briefs. Surveyors later observed strong, pervasive feces and urine odors in shower rooms on multiple floors, with one shower room’s odor so strong it could not be entered and a yellowish-brown substance resembling mixed feces and urine smeared on a shower entry wall. The Environmental Services Director acknowledged the odors and substance, and the Assistant Administrator confirmed that showers are expected to be clean and odor-free, despite a policy requiring regular cleaning and disinfection of public and high-touch areas.
A resident with type 2 DM, severe cognitive impairment, and multiple comorbidities did not receive care in accordance with physician orders and facility policy. An A1c lab ordered with instructions to re-attempt using a different technician after an initial refusal was only documented as refused once, with no record of a subsequent attempt. Blood glucose monitoring parameters for when to notify the provider were not documented, and an RN reported not knowing these parameters and being unable to locate documented blood glucose values. Blood glucose checks were recorded with times that did not match the ordered administration times, despite policy requiring that all treatments and the MAR accurately reflect physician orders.
A resident with multiple medical conditions and intact cognition repeatedly did not receive requested scrambled eggs at breakfast or expected double portions, despite dietary notes documenting these preferences. CNAs and LPNs reported that the resident’s meals were often incorrect and required frequent calls to the kitchen for corrections. Review of records showed only a regular diet order without double portions and no documented Food Preference Interview, indicating that the resident’s stated dietary preferences were not consistently incorporated into formal diet orders.
Failure to verify contracted security staff background checks, licenses, and abuse/neglect training. The facility allowed contracted security personnel to begin work without first verifying background checks or obtaining copies of their licenses/registration cards, and one security worker stated he only received training through the vendor, not facility-specific abuse and neglect training. The HR Director stated the facility had not run or verified the checks because the workers were from a third-party vendor, and the required orientation documentation was incomplete for one of the two contracted security staff members.
Failure to report alleged abuse to IDPH: A resident with anxiety disorder alleged that security staff intimidated them and held a gun in front of them, prompting the resident to call police. The AA/Abuse Coordinator knew about the allegation but did not report it to IDPH as required by the facility’s Abuse and Neglect policy, while other staff stated the resident had been recording staff and became upset after being told not to.
A resident with psychiatric disorders reported ongoing threats, theft, and intimidation by their roommate, including threats of physical harm and taking of a debit card. Despite these allegations being communicated to several staff members, the incident was not reported to the abuse coordinator or administration as required by facility policy, resulting in a failure to follow mandated abuse reporting procedures.
A resident with multiple psychiatric and neurological diagnoses reported a sexual assault to the ADON after returning from a community pass. Although the facility's policy required reporting abuse allegations to the state agency within two hours, the Administrator delayed notification until the next day due to conflicting accounts and lack of initial disclosure to hospital staff. The delay in reporting exceeded the facility's stated policy and regulatory requirements.
A resident with multiple psychiatric and neurological diagnoses was allowed to leave the facility on a supervised community pass but did not return as scheduled. Staff did not contact police after the required grace period, failed to complete an elopement risk assessment upon admission, and delayed initiating a care plan for community pass privileges, all in violation of facility policy.
Two residents experienced ongoing bed bug infestations after being relocated due to an initial finding of bed bugs in their shared room. Despite treatment by a pest control company and laundering of belongings, bed bugs were observed again during a survey, and there was no documentation of follow-up inspections or checks of the new rooms as required by facility policy.
A resident with a history of hypotension and mobility issues experienced a fall resulting in injuries after the facility failed to incorporate the resident's medical diagnosis and medication regimen into the fall prevention care plan. The care plan did not address the need for Midodrine when blood pressure was low, and fall risk assessments were not consistently performed or used to guide interventions. Staff interviews revealed confusion over responsibilities and a lack of coordination in updating care plans and assessments.
A resident with a history of hypotension and mobility issues was not given physician-ordered Midodrine when their systolic blood pressure fell below the prescribed threshold. The medication was not documented as administered on the MAR, and the DON confirmed it was not given. This omission led to the resident experiencing low blood pressure and a fall, resulting in lacerations.
A resident with multiple health conditions, including diabetes mellitus, did not receive prescribed Lantus insulin for ten days due to a delay in following a physician's order. The resident's cognitive impairment and high fasting blood sugars necessitated the medication, but the order was not entered until several days after the clinic visit. The facility's policy requires timely execution of physician orders, which was not followed in this instance.
A facility failed to document medication administration for a resident with multiple health conditions, including diabetes and impaired cognition. The resident's MAR lacked a nurse's signature for a scheduled dose of Trulicity, indicating the medication may not have been administered. The ADON confirmed that missing initials suggest non-administration, and the facility's policy requires documentation after medication is given.
The facility failed to revise care plans with preventive interventions for two residents, resulting in injuries of unknown origin. A resident with dementia sustained a hand fracture, believed to be from bumping a bedside table, but the care plan lacked preventive measures. Another resident with hemiplegia was found with a leg fracture, suspected from bumping a bed rail, yet the care plan did not include interventions to prevent further harm.
The facility failed to follow procedures for administering and documenting enteral feedings for two residents, leading to discrepancies in feeding schedules and intake monitoring. One resident's feeding bottle was found full despite orders for continuous infusion, and another's bottle was not replaced as per schedule. The LPN admitted to not clearing the pump, and the facility did not document enteral intake, contributing to the deficiencies.
The facility failed to remove and discard expired medications in one of two medication carts reviewed. A surveyor found an opened bottle of Docusate Sodium 100mg with an expiration date of December 2022 in the Team 1 medication cart. The RN responsible for the cart admitted that expired medications should not be stored and should be discarded. This oversight has the potential to affect 20 residents whose medications are stored in the Team 1 medication cart on the second floor.
The facility failed to convey funds to a resident's family after the resident's death. The Business Office Manager was unaware of the facility's policies, leading to delays and miscommunication. The Administrator acknowledged that the funds should go to the individual overseeing the resident's estate, as per the facility's policy.
A facility failed to provide timely incontinence care for a dependent resident who reported being left in soiled briefs for extended periods. Despite the care plan and facility policies requiring checks every two hours, the resident was found soiled and had not been changed since the start of the CNA's shift.
Inconsistent Pest Control Treatment for Resident Rooms
Penalty
Summary
The facility failed to provide effective and consistent mice control for residents in the building, affecting five residents in the sample who were receiving pest control treatment. A housekeeper stated that a resident reported a mouse sighting, and the sighting was entered in the facility’s Pest Control Sighting Log. One resident stated that mice of different colors were seen every day in the room, including under the beds at night, and described mice moving from one roommate’s trash can near the window to another roommate’s laundry bin and nightstand area by the door. The three residents in that room were identified as roommates. The Maintenance Director stated that flat glue boards were placed under vents and behind doors in rooms where mice were reported, and that RDUs were sometimes placed in residents’ rooms. However, when surveyors and the Maintenance Director inspected the room, there were no RDUs, flat glue boards, or other pest control treatment present, despite the room being listed in the Pest Control Sighting Log as treated for mice. The pest control service inspection report showed the vendor visited the room but did not service it, even though the log indicated treatment. In another room occupied by two residents, there was only one RDU and no glue traps, and the service inspection report again showed the vendor visited but did not perform the treatment that was documented in the facility log. The facility failed to follow its Pest Control policy dated 7/3/2025, which states it is the facility’s policy to ensure an effective pest control process in the building.
Untimely Medication Administration and Delayed eMAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to administer prescribed medications in a timely manner according to physician orders and to document administration promptly on the electronic medication administration record (eMAR). On the date of survey, multiple nurses on different floors reported starting their shifts around 7:00–7:30 AM and beginning medication passes between 7:30–8:00 AM, yet by approximately 10:11–10:39 AM several had not completed their medication passes. When the surveyor reviewed the eMARs with these nurses, multiple residents’ medication entries appeared in red, which the nurses stated indicated that the medications were late. Some nurses also stated that they had administered certain medications but had not yet documented them on the eMAR. One nurse assigned to the third floor stated she had completed her medication pass and acknowledged that medications not given on time are considered medication errors and that all medications should be given on time according to physician orders. The Director of Nursing stated that the facility’s time frame for medication administration is one hour before and one hour after the scheduled time. Facility medication administration audit reports for the same date documented that multiple residents on the second, third, fourth, and fifth floors received their medications late. The facility census documented 34 residents on the second floor, 57 on the fourth floor, and 54 on the fifth floor, indicating that the issue had the potential to affect 145 residents. Facility policy titled “Medication Pass,” dated 07/02/2025, states in part that after medication is administered to each resident, staff must sign the MAR to indicate it was given. The observations, staff interviews, and audit reports collectively show that medications were not consistently administered within the prescribed time frame and were not consistently documented immediately after administration, resulting in untimely medication administration for multiple residents.
Failure to Keep Call Light Within Reach of Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its call light policy by not ensuring a cognitively intact resident with left-sided weakness could access the call light. The resident had diagnoses including hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, major depressive disorder, and dysphagia following cerebral infarction. An MDS dated February 16, 2026 documented a BIMS score of 15/15, indicating intact cognition, and Section GG showed the resident required varying levels of assistance with eating, oral hygiene, personal hygiene, toileting, dressing, footwear, and bathing. On observation at 12:26 PM, the resident was seated in a mechanical chair on the right side of the bed, while the call light was placed on the bed out of the resident’s reach. The resident stated they could not reach the call light due to left-sided weakness from a stroke, demonstrated an inability to reach it with the left hand, and reported needing to shout for help and keeping a cell phone nearby because the call light was sometimes placed too far away. At 12:49 PM, a CNA and the surveyor again observed the call light on the bed out of the resident’s reach. The CNA confirmed the resident had left-sided weakness and could not stretch far enough to reach the call light where it was placed, and stated the call light needed to be closer so the resident could call staff when help was needed, otherwise the resident’s needs would not be met and the resident could fall or choke. At 1:00 PM, an RN stated that call lights should be within residents’ reach so they can access staff for help and that if not accessible, a resident might fall out of bed trying to get help or be in an emergency and unable to reach staff. At 3:45 PM, the DON stated call lights should be placed close enough for residents to reach to call for assistance and that if the call light is far from a resident, the resident will not be able to call for assistance. The facility’s call light policy dated June 30, 2025 documented that call lights must be placed within reach of residents who are able to use them at all times, which was not followed in this case.
Failure to Maintain Clean and Odor-Free Shower Rooms
Penalty
Summary
The facility failed to maintain clean, odor-free shower rooms, resulting in a deficient environment for residents. One cognitively intact resident with multiple medical conditions, including hemiplegia, major depressive disorder, dysphagia, severe protein-calorie malnutrition, and hypertension, reported that the showers were dirty and contained soiled incontinence briefs, particularly on the floor where the resident previously lived. The resident’s BIMS score of 15 indicated little to no cognitive impairment, supporting the reliability of the report about the condition of the showers. On the day of surveyor observations, multiple shower rooms on several floors had strong, pervasive feces and urine odors. On the 4th floor, both shower rooms had such strong odors that one shower room in the East wing could not be entered by the surveyor. Similar strong odors were present in the 2nd floor shower rooms. On the 5th floor, in addition to strong feces and urine odors, there was a yellowish-brown substance approximately 7 by 10 inches smeared on the entry wall of a shower, appearing like mixed feces and urine. The Environmental Services Director acknowledged the substance and agreed the odors were unpleasantly strong and unacceptable. The Assistant Administrator stated that showers are expected to look and smell clean and free of debris, and the facility’s Public Areas Daily Cleaning Workflow policy states that public areas and high-touch areas are to be regularly cleaned, disinfected, and well-maintained to promote a hygienic environment.
Failure to Follow Physician Orders for Diabetic Monitoring and A1c Lab
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and its own policy regarding diabetes management and lab monitoring for one resident. The resident had multiple diagnoses including type 2 diabetes mellitus with hyperglycemia, metabolic encephalopathy, bipolar disorder, schizoaffective disorder, chronic embolism and thrombosis of the femoral vein, and difficulty in walking, and was documented as having severe cognitive impairment with a BIMS score of 3/15. A physician order dated 2/19/2026 directed that an A1c lab be completed on 2/20/2026, with instructions that if the resident refused, a different technician should attempt the draw in the morning. Progress notes show the resident refused the A1c at 1:02 AM on 2/20/2026, but there is no documentation that the A1c was offered again by a different technician as ordered. The DON stated that if it is not documented, it is not done. The facility also failed to document blood glucose monitoring parameters for when to notify the physician, despite the DON stating that the physician gives such parameters and that nurses should carry out orders as written. The RN caring for the resident reported that the resident is diabetic and that blood sugars are taken two times a shift, but she could not locate the blood glucose levels she documented and did not know the parameters for when to notify the physician. Blood glucose records from 2/20/2026 to 2/27/2026 show levels ranging from 122 mg/dL to 230 mg/dL, and on 2/28/2026, blood glucose checks ordered for 8:00 AM and 11:00 AM were documented as taken at 2:03 PM, which did not align with the physician’s ordered times. These actions and omissions conflict with the facility’s policy requiring that all treatments and plans of care be in accordance with physician orders and that orders in the POS be accurately reflected in the MAR.
Failure to Consistently Honor Resident Dietary Preferences and Portions
Penalty
Summary
The facility failed to consistently honor a resident’s documented dietary preferences and needs, specifically regarding double portions and scrambled eggs at breakfast. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction, muscle wasting and atrophy, dysphagia (oropharyngeal phase), benign prostatic hyperplasia, hypertension, and depression, and was documented as cognitively intact with a BIMS score of 14. The resident reported ongoing complaints about receiving the wrong food orders. The dietician stated that on one occasion the resident did not receive scrambled eggs with breakfast because the meal ticket had not been updated after the resident requested scrambled eggs every breakfast the previous day. The dietician also noted that the scrambled eggs were a preference and that the resident was to receive double portions with meals. Multiple CNAs and LPNs reported that the resident’s food orders were frequently incorrect, including not receiving scrambled eggs with breakfast and not receiving double portions as expected, requiring calls to the kitchen for corrections. One CNA reported that the resident complained that morning about not getting double the portion of eggs. Nursing staff confirmed that the resident was prescribed double portion meals and often complained about not receiving them, and one LPN stated that most of the time the resident’s meals were wrong. Review of the resident’s diet order showed only a regular diet with no specification for double portions, and although the dietician’s notes documented the preference for scrambled eggs at breakfast, there was no corresponding diet order for double portions or documentation of the required Food Preference Interview in the electronic medical record.
Failure to Verify Contracted Security Background Checks, Licenses, and Abuse/Neglect Training
Penalty
Summary
The facility failed to follow its Abuse and Neglect policy by not verifying background checks for contracted security staff, not obtaining copies of their professional licenses or registration cards, and not providing facility-specific training on abuse and neglect. On 11/14/2025, the Assistant Administrator stated the contracted security staff had started working at the facility a couple of weeks earlier, and a contracted security staff member stated he began work on 11/12/2025 and had only received training through the contracted employer, not facility-specific abuse and neglect training. During the survey, the facility was asked for the contracted security staff's background checks, licenses or certificates, and training records. On 11/18/2025, the Human Resources Director stated background checks had not been run on the contracted security staff because they were from a third-party vendor and that their background checks and licenses had not been verified. The facility later obtained IDFPR lookup details for the two contracted security staff members and provided copies of their Permanent Employee Registration Cards on 11/19/2025. The facility also provided a Security Orientation Checklist for one contracted security staff member, signed after the survey had begun, but did not provide a checklist for the other contracted security staff member. The facility's policy required background checks for contractors, copies of professional licenses for licensed staff, and training on abuse prohibition, neglect, exploitation, misappropriation of property, and related topics.
Failure to Report Alleged Abuse to IDPH
Penalty
Summary
The facility failed to follow its Abuse and Neglect policy by not reporting an allegation of abuse to the Illinois Department of Public Health within the required timeframe. A resident with a documented diagnosis of anxiety disorder stated during interviews that facility security was antagonizing and intimidating them, including curling lips, “mean mugging,” and placing a hand on a gun in front of the resident to intimidate them. The resident also stated they had to call police because the security staff member threatened them and held a gun, and identified a receptionist and Human Resources staff member as present during the incident. The Assistant Administrator/Abuse Coordinator stated they was aware the resident called police because of the allegation that security was threatening them, but the incident was not reported to IDPH and there was no open reportable related to it. Security staff denied pointing a gun or intimidating the resident and stated the resident was recording staff without consent and became upset when reminded of facility policy. The receptionist and Human Resources staff member both stated the resident called police after being told they could not record staff and after pointing to the no-gun sign at the front desk.
Failure to Report Alleged Abuse and Threats Between Roommates
Penalty
Summary
The facility failed to follow its 'Abuse and Neglect' policy by not reporting an allegation of abuse involving a resident with schizophrenia, delusional disorders, major depressive disorder, and anxiety disorder. This resident alleged that their roommate, who also had significant psychiatric diagnoses and behavioral issues, had threatened to hit them, requested money, and took their debit card. The resident reported these threats and theft to staff, stating that the threats had persisted for several days. Despite these allegations, the staff did not report the incident to the abuse coordinator or the appropriate authorities as required by facility policy. Multiple staff members were aware of the situation, with some reporting the behavior to other staff but not escalating it to the designated abuse coordinator or administrator. Interviews revealed confusion and lack of communication among staff regarding the reporting process. The nurse who was informed of the threats relayed the information to the social worker, who in turn did not report it to the abuse coordinator. The social worker and restorative nurse both stated they were not made aware of any abuse allegations, and the director of nursing and assistant administrator confirmed they were not informed until the surveyor brought it to their attention. The facility's policy clearly states that all allegations or suspicions of abuse must be reported immediately to the administrator or their designee, which did not occur in this case.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to follow its abuse policy and procedure by not reporting an allegation of sexual abuse to the State Agency within the required two-hour timeframe. A resident with diagnoses including major depressive disorder, epilepsy, bipolar disorder, anxiety disorder, and dissociative and conversion disorder, who was cognitively intact, reported being sexually assaulted while out on pass with a family member. The resident communicated the assault to the Assistant Director of Nursing via text message, who then informed the Administrator. Despite the facility's policy requiring immediate reporting of abuse allegations to the Illinois Department of Public Health (IDPH) within two hours, the Administrator delayed the report until the following day, citing conflicting stories and lack of disclosure to hospital staff upon the resident's return. The initial report to IDPH was made more than 20 hours after the resident returned to the facility and disclosed the assault. Documentation shows that the resident described the assault, underwent a nursing assessment, and a police report was eventually filed. The facility's own policy clearly states that all allegations of abuse must be reported to IDPH immediately, not exceeding two hours after the initial allegation is received, but this protocol was not followed in this case.
Failure to Follow Elopement Policy and Timely Care Planning for Community Pass Privileges
Penalty
Summary
The facility failed to follow its policies and procedures to ensure the safety and supervision of a resident who was on a supervised community pass. Specifically, the facility did not contact the police to assist in locating the resident when he did not return at the indicated time, as required by their elopement policy. Staff attempted to reach the resident and his family by phone but did not escalate the situation to law enforcement after the two-hour grace period had elapsed. Multiple staff members were unclear about the policy for contacting the police, and communication was limited to internal notifications and calls to emergency contacts. Additionally, the facility did not complete a risk for elopement assessment for the resident upon admission, as mandated by their own elopement policy. The assessment was only completed several days after admission, leaving a gap in identifying and addressing potential elopement risks. The resident had a history of major depressive disorder, epilepsy, bipolar disorder, anxiety disorder, and dissociative and conversion disorder, and was considered cognitively intact but required supervision with activities of daily living. Furthermore, the facility did not initiate a person-centered care plan to address the resident's community pass privilege in a timely manner. Although a physician's order for outside pass privileges was obtained, the corresponding care plan was not started until several days later, beyond the expected timeframe. This delay in care planning meant that the interdisciplinary team did not have timely guidance to address the resident's needs and potential risks associated with community outings.
Failure to Maintain Effective Pest Control Program for Bed Bugs
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of bed bugs in the rooms of two residents. Approximately three weeks prior to the survey, bed bugs were found in the room shared by these residents, prompting their temporary relocation. One resident reported the discovery of bed bugs, while the other was unaware of the reason for the move. During the survey, a bed bug was observed crawling on one resident's bed, and multiple dried blood spots were noted on the bed sheets. Upon further inspection, multiple bed bugs were found under the mattress. The maintenance staff confirmed the presence of bed bugs and acknowledged that the pest control company had previously treated the room with chemicals, and that belongings were bagged and laundered. However, there was no documentation of follow-up inspections or confirmation that the new rooms to which the residents were moved were inspected for bed bugs. Record review showed that the facility's pest control service had documented the initial bed bug finding and treatment, but there was no evidence of subsequent inspections or monitoring to ensure eradication. The facility's own policies require inspection of the affected room, adjacent rooms, and the new room to which residents are relocated, as well as the use of non-chemical control measures when practical. These steps were not documented as completed. The lack of follow-up and failure to inspect new rooms upon relocation contributed to the ongoing presence of bed bugs, affecting the residents involved and potentially the entire facility population.
Failure to Address Hypotension and Medication Needs in Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident's medical diagnosis and medication regimen were incorporated into preventive interventions to avoid falls and accidents. Specifically, the care plan and fall interventions did not address the resident's diagnosis of hypotension or the prescribed medication, Midodrine, which was to be administered when the resident's systolic blood pressure dropped below 95 mm/Hg. Documentation showed that there were days when the resident's blood pressure was below this threshold, but the medication was not administered as ordered. The care plan prior to the fall only included teaching on positioning and instructions for assistance, with no reference to the resident's hypotension or related interventions. The resident, who had a history of hypotension, abnormal gait, lack of coordination, and muscle wasting, experienced a fall resulting in a forehead laceration requiring sutures and a laceration to the left arm. At the time of the fall, the resident's blood pressure was recorded at 85/63 mm/Hg, which was significantly lower than their baseline. The fall occurred when the resident attempted to pick something up from the floor after getting up from bed. Staff interviews revealed that the fall care plan and assessments did not consistently consider the resident's medical conditions or medication regimen, and there was confusion among staff regarding responsibility for fall assessments and care plan updates. Further, the facility's policy required fall risk assessments upon admission, readmission, quarterly, significant change, and annually, with interventions to be reevaluated and revised as necessary. However, the Falls Coordinator stated that quarterly assessments were not performed and that interventions were only added after a fall occurred. There was also a lack of communication and coordination between the restorative nurses and the Falls Coordinator regarding fall assessments and care planning. The failure to address the resident's hypotensive state and medication needs in the care plan and to utilize fall assessments contributed to the resident's fall and subsequent injuries.
Failure to Administer Prescribed Medication for Hypotension Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to administer a physician-prescribed medication, Midodrine 10 mg, to a resident with a diagnosis of hypotension and other mobility-related conditions. The resident was prescribed Midodrine to be given when systolic blood pressure dropped below 95 mm/Hg. Review of the resident's blood pressure logs showed multiple instances of systolic blood pressure below this threshold, but the medication administration record (MAR) did not document that Midodrine was given on those occasions. The Director of Nursing confirmed that if the medication was not documented as administered on the MAR, it was not given, and stated that the expectation is to follow the physician's order for as-needed medication. As a result of this failure, the resident experienced an episode of hypotension with a blood pressure reading of 85/63 mm/Hg and subsequently fell, sustaining lacerations to the forehead and left arm. The facility's medication pass policy requires adherence to physician orders and proper documentation on the MAR after medication administration. The failure to administer the prescribed medication as ordered directly contributed to the resident's hypotensive episode and fall.
Failure to Administer Insulin in a Timely Manner
Penalty
Summary
The facility failed to follow a physician's order for a resident in a timely manner, resulting in the resident not receiving prescribed medication for a period of ten days. The resident, who has a severely impaired cognitive status as indicated by a BIMS score of 03, was diagnosed with multiple conditions including diabetes mellitus, vitamin D deficiency, and other metabolic disorders. On 10/22/2024, a clinic record indicated the need to restart Lantus insulin due to high fasting blood sugars. However, the order for Lantus was not entered until 11/01/2024, and the medication was not administered until after this date. The Assistant Director of Nursing (ADON) stated that the nurse responsible for receiving the resident from a hospital or clinic appointment should review any new medication orders before the end of their shift and verify them with the resident's physician or nurse practitioner. The delay of eight to nine days in contacting the physician to verify the medication order was deemed unacceptable. The facility's policy on physician orders requires that they be carried out within a reasonable time, which was not adhered to in this case.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to appropriately document in the Electronic Medication Record (eMAR) for a resident, identified as R3, who was reviewed for improper nursing care. R3's medical history includes multiple diagnoses such as heart failure, type 2 diabetes mellitus with hyperglycemia, and schizoaffective disorder, among others. The resident's Brief Interview for Mental Status (BIMS) score indicated severely impaired cognition. During a review of R3's Medication Administration Record (MAR) and Physician Order Statement (POS), it was found that there was a missing nurse's signature for a scheduled dose of Trulicity, a medication for diabetes, on a specific date in October 2024. The Assistant Director of Nursing (ADON) confirmed that the assigned nurse is responsible for administering medications and documenting them in the MAR. The ADON stated that missing initials on the MAR suggest the medication was not administered, and there are codes available to indicate reasons for non-administration. The facility's policy requires nurses to sign the MAR after administering medication, and the job descriptions for Registered Nurses (RN) and Licensed Practical Nurses (LPN) emphasize the importance of completing medical records in accordance with nursing policies. The failure to document the administration of medication as per the facility's policy led to the identified deficiency.
Failure to Revise Care Plans with Preventive Interventions
Penalty
Summary
The facility failed to revise comprehensive care plans with preventive interventions for two residents, leading to injuries of unknown origin. Resident R3, diagnosed with dementia, sustained a non-displaced fracture of the right-hand proximal third phalanx, believed to be caused by bumping his hand on a bedside table. Despite the incident, R3's care plan only included monitoring and follow-up actions without preventive measures to avoid further injury. The Care Plan Coordinator acknowledged the absence of preventive interventions, such as assisting the resident or repositioning the bedside table, which were not included in R3's care plan. Similarly, Resident R4, who has hemiplegia/hemiparesis affecting the right side and is non-verbal, was found with a tibial fibula fracture on the right leg. The injury was suspected to have occurred when R4 attempted to move his paralyzed leg using his left leg, causing it to bump against the lower side rail of the bed. R4's care plan lacked interventions to prevent further harm, such as padding the lower side rails, despite the presence of padded upper side rails. The facility's care plan policy mandates the development of person-centered plans within seven days of assessment, but the plans for R3 and R4 did not include necessary preventive measures.
Failure to Administer and Document Enteral Feedings Properly
Penalty
Summary
The facility failed to adhere to its policy procedures regarding the administration and documentation of enteral feedings, leading to deficiencies in the care of two residents. Resident 1, who has anoxic brain damage, tracheostomy status, gastrostomy status, and is dependent on a ventilator, was observed with discrepancies in the administration of their enteral feeding. Despite orders for Jevity 1.5 to be infused at 60ml/hr and a 250ml water flush every 6 hours, the feeding bottle was found full, and the pump indicated an incorrect infused amount. The Licensed Practical Nurse (LPN) admitted to not clearing the pump, which is necessary for accurate monitoring of intake, and there was a lack of documentation on the resident's enteral intake. Similarly, Resident 4, who also has gastrostomy status and is ventilator-dependent, was found with an enteral feeding bottle that should have been empty based on the prescribed infusion rate. The LPN confirmed that the bottle had been hanging since the morning, indicating a failure to follow the prescribed feeding schedule. The Assistant Director of Nursing acknowledged that the facility does not document enteral intake, despite the policy requiring nurses to follow orders for feeding type, rate, and duration. This lack of documentation and adherence to feeding schedules contributed to the identified deficiencies.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to remove and discard expired medications that had been open in one of two medication carts reviewed for medication labeling and storage. During an observation on the second floor, a surveyor found an opened bottle of Docusate Sodium 100mg with an expiration date of December 2022 in the Team 1 medication cart. The Registered Nurse responsible for the cart admitted that expired medications should not be stored and should be discarded. The nurse also mentioned that the night shift usually checks for expired medications, but he last checked the cart two to three weeks ago. This oversight has the potential to affect 20 residents whose medications are stored in the Team 1 medication cart on the second floor. A resident reported that a female nurse informed her she was receiving expired medications, although the resident could not identify or describe the nurse. The resident's Minimum Data Set indicated she was cognitively intact. Her physician order sheet included an order for Docusate Sodium 100mg to be taken as needed for constipation. The facility's policy on medication storage, labeling, and disposal states that house stock medications should be labeled with the name, strength, instructions, and expiration date, and should be discarded based on the manufacturer's expiration guidelines.
Failure to Convey Resident Funds After Death
Penalty
Summary
The facility failed to convey funds to a resident's family after the resident's death. The family member of the deceased resident (R4) reported that the Business Office Manager (V6) explained the trust funds would be used for funeral expenses and any remaining balance would be sent back to the state. Despite the family providing a small estate affidavit and invoices for the funeral expenses, V6 insisted that the funds should go to the funeral home directly. The family member expressed frustration and confusion over the process, as the Administrator acknowledged that the funds should go to the individual overseeing the resident's estate, according to the facility's policy. The review of R4's trust fund showed a balance of $7980.88. The facility's policy states that upon a resident's death, the facility must convey the resident's funds and a final accounting of those funds within 30 days to the individual or probate jurisdiction administering the resident's estate. The Business Office Manager admitted to not being aware of the facility's policies concerning the trust fund, leading to a delay and miscommunication in handling the deceased resident's funds. This deficiency affected one of three residents reviewed for resident funds in a total sample of five residents.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a dependent resident, identified as R5, who reported that no one had come to her room to change her incontinence briefs on the morning of 04/13/2024. R5 stated that she was currently soiled and often had to remain in soiled briefs for extended periods, indicating this was an ongoing issue. A Certified Nursing Assistant (CNA), identified as V4, confirmed that she had not yet changed R5's incontinence briefs since starting her shift at 7 AM and was observed checking and finding R5's briefs soiled with urine at 9:38 AM. V4 then proceeded to change the briefs. R5's medical records indicate she is cognitively intact with a BIMS score of 14/15 and is always incontinent of bowel and bladder, requiring complete assistance with ADL care. R5's care plan includes specific instructions for incontinence care, such as checking for incontinence at least every two hours and ensuring soiled areas are washed, rinsed, and dried. The facility's policies on incontinence and perineal care, as well as ADL care, also mandate regular checks and appropriate care based on comprehensive assessments and care plans. Despite these guidelines, the facility did not adhere to the required care protocols, resulting in R5 remaining in soiled briefs for an extended period on the day of the observation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,544 citations issued within 25 miles in the last 12 months — including the 27 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alden Lakeland Rehab & Hcc | 0.5 mi | ★★★★★ | 17 | 2 |
| Mado Healthcare - Uptown | 0.7 mi | ★★★★★ | 1 | 0 |
| Complete Care At Margate Park | 0.8 mi | ★★★★★ | 27 | 0 |
| Selfhelp Home Of Chicago | 0.8 mi | ★★★★★ | 0 | 0 |
| Complete Care At Sheriden Commons | 0.9 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Carlton At The Lake, The.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.