Carlton at the Lake, the

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure to ensure a resident who was admitted with multiple wounds were obtained initial wound treatment orders for one (R3) out of three residents reviewed for wound care. Findings Include:R3's clinical record shows an initial admission on [DATE], with discharge to the hospital on 5/27/26. R3 was readmitted on [DATE] and again discharged to the hospital on 6/6/26. A review of R3's physician order sheets, Treatment Administration Records (TARs), and Medication Administration Records (MARs) from May through June 2026 revealed no wound treatment orders during either admission period. Review of R3's admission and readmission progress notes dated 5/26/26 and 6/2/26, documented by V11 (Registered Nurse/RN), reads in part: Full body assessment performed. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide effective and consistent mice control for residents in the facility. This applies to 5 residents (R14, R15, R16, R17 and R18) in the sample of 9 receiving pest control treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the Daily Nurse Staffing was visible to the public and updated daily. This failure has the potential to affect all 169 residents residing in the facility.

Inspectors wroteBased on observations, interviews and record review the facility failed to monitor the temperature in the walk-in refrigerator, failed to ensure male staff were covering facial hair, failed to discard expired food, failed to ensure the dish washer machine sanitized the dishes at the proper temperature. These failures have the potential to cause foodborne illnesses to all 172 residents receiving oral nourishment in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to monitor personal refrigerator temperature logs; and failed to ensure that a resident's personal refrigerator had a thermometer. These failures affected four residents (R22, R110, R135, and R146), out of 67 residents in the total sample.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that consent was provided for psychotropic medications prior to administration. This failure affected one resident R42 in a sample size of 67 reviewed for psychotropic medications. On 03/23/2026 at 10:40 AM, R42 was observed sitting on bed in his room, he is alert and responsive and has capped trach, states that he is not aware of the reason why when he readmitted to facility after a hospital stay, he was placed on Quetiapine, and he never consented to these medications. R42 stated he never consented for any psychotropic medication, R42 stated he is his own responsible party and that his father is only listed in case of an emergency. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure ADL's (Activities of Daily Living) was completed for 4 dependent residents (R8, R51, R95, R110) to maintain dignity and good oral and personal hygiene. This failure affected 4 residents out of a sample size of 67.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and date oxygen tubing and nebulizer equipment for three residents (R17, R48, and R167) per the facility policy. The facility also failed to ensure the nebulizer mouthpiece was contained for two residents (R167 and R48) when not in use by the residents. These failures affected three residents (R17, R48, and R167) reviewed for respiratory equipment, in a total sample of 67 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the medication carts were kept clean with no loose medication pills, failed to store medication as recommended by dispensing pharmacy and manufacturer's guidelines, failed to discard expired medication. This failure has the potential to affect all 21 residents assigned to the medication carts for 3rd floor and all 60 residents assigned to the medication carts for 5th floor.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that infection control practices were performed for two residents. This failure affected two residents R33 and R147 out of a sample size of 67. R33's face sheet dated March 25, 2026 documents in part that R33 admitted to the facility on [DATE] with diagnosis of: Hemiplegia, essential hypertension, atrial fibrillation, chronic systolic congestive heart failure, dysphagia, gastro esophageal reflux disease, constipation, tracheostomy, gastrostomy, acute respiratory failure. R33's Minimum data sheet dated February 6, 2026 documents in part that; R33 has a score of 2 which means that R33 is severely cognitively impaired; Functional abilities section dated February 6, 2026 documents in part; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer residents' prescribed medications in a timely manner according to the physician orders. These failures have the potential to affect 145 residents residing in the facility.

Inspectors wroteBased on observation, interviews and records review, the facility failed to follow its call light policy for one (R1) of four residents reviewed in a sample of seven. R1's medical diagnosis in current face sheet includes but not limited to hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting left non-dominant side, major depressive disorder, recurrent, moderate, dysphagia following cerebral infarction. MDS (Minimum Data Set) section C-Cognitive patterns dated February 16, 2026, documents R1's Brief Interview for Mental Status (BIMS) as 15/15 indicating R1 has intact cognitive abilities. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide clean and odor-free shower rooms. This applies to 1 resident (R1) in the sample of 3 reviewed for clean shower rooms.

Inspectors wroteBased on interviews and records review, the facility failed to follow their policy on following physician orders related to diabetes blood sugars and lab monitoring for one (R5) of three residents reviewed in a sample of seven. R5's current face sheet documents R5 medical diagnosis to include but not limited to metabolic encephalopathy, bipolar disorder, current episode manic without psychotic features, unspecified, difficulty in walking, not elsewhere classified, chronic embolism and thrombosis of femoral vein, bilateral, schizoaffective disorder, bipolar type, type 2 diabetes mellitus with hyperglycemia. MDS (Minimum Data Set) section C dated 01/29/2026 documents R5's Brief Interview for Mental Status (BIMS) as 3/15 indicating R5 has severe cognitive impairment. On 02/28/2026 at 1:25PM, R5 was observed lying in bed, R5 stated she had a blood draw recently and finger blood tests. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide on a consistent basis the dietary needs and food preferences of a resident. This applies to 1 resident (R2) in the sample of 3 reviewed for dietary preferences.

Inspectors wroteBased 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.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their 'Abuse and Neglect' policy and report an allegation of abuse to the Illinois Department of Public Health (IDPH) for one (R1) out of three residents reviewed for abuse.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy and procedure to ensure that abuse allegation was reported no later than two hours to the State Agency (SA) for one (R1) out of three residents reviewed for abuse. Findings Include:R1's clinical records revealed an admission date of [DATE] with included diagnoses but not limited to major depressive disorder, epilepsy, bipolar disorder, anxiety disorder, and dissociative and conversion disorder. R1's admission minimum data set (MDS) assessment dated [DATE] shows R1 is cognitively intact with BIMS (Brief interview for Mental Status) score of 15 and requires supervision with activities of daily living. On [DATE] at 9:42 AM, interviewed R1 regarding his out on pass incident on [DATE]. R1 stated, I had a pass with an escort. That day somebody signed me out. It was my cousin [V3 (R1's Cousin)]. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their policies and procedures to ensure (a) the police were contacted to assist with finding a resident who was on supervised community pass and did not return as indicated on the sign out sheet, (b) a resident was reviewed for risk for elopement concerns upon admission, and (c) a person-centered care plan was initiated timely to address community pass privilege. These failures affected one (R1) out of three residents reviewed for community pass privileges. Findings Include:R1's clinical records revealed an admission date of 7/24/25 with included diagnoses but not limited to major depressive disorder, epilepsy, bipolar disorder, anxiety disorder, and dissociative and conversion disorder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for two (R1, R2) residents out of three residents reviewed for pest control. This failure has the potential to affect all 169 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents have access to their personal clothing and belongings. This failure affects two (R1, R2) residents out of three residents reviewed for resident rights.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure and include medical diagnosis and medication regimen in providing preventive interventions to prevent falls/accidents, failed to utilize fall assessment in providing effective fall interventions in the fall care plan, and failed to identify and address the resident's hypotensive state after the fall to prevent recurrence of similar accidents. These failures affected 1 resident (R2) out of 3 residents reviewed for the right of every resident to be free from injury resulted by accident. As a result, 1 resident (R2) sustained a forehead laceration due to fall that required suturing and a laceration to the left arm that required medical attention.

Inspectors wroteBased on review of records and interviews, the facility failed to administer physician-prescribed medications to treat hypotension or low blood pressure. The failure applied to 1 (R2) of 3 residents evaluated for pharmacy services. This failure resulted in R2 experiencing low blood pressure and a fall sustaining injuries of laceration on the forehead and left arm.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders and plan of care for restorative services and failed to complete quarterly restorative assessments that detail the progress or lack of progress in the restorative services for 4 (R6, R71, R87, R159) residents out of 5 reviewed for limited range of motion and/or restorative services in the sample of 36. Findings Include: On 4/8/25 at 11:09 AM, R87 was lying in bed alert and able to verbalize needs. R87 was noted with left arm paralysis and contracture. When asked if R87 has been receiving some type of range of motion exercises for his left arm and hand in the last 30 days, R87 answered No. R87 stated that staff does not perform any exercises on his left arm/hand. Surveyor observed left hand splint was not applied on R87's left hand and was sitting on top of his bed side table. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility: 1. Failed to change and maintain proper storage of nebulizer mask when not in use for 1(R30) resident. 2. Failed to change oxygen nasal cannula tubing and humidifier bottle for 1(R50) resident. 3. Failed to maintain proper storage of nebulizer mask when not in use for 1(R145) resident. 4. Failed to follow oxygen liter flowrate as ordered for 2 (R50, and R159) residents. These failures could potentially affect 4 (R30, 50, R145, and 159) of 4 residents reviewed for respiratory care in a sample of 36. Findings Include: R30's Minimum Data Set (MDS) dated [DATE], Brief interview score (15) indicates R30 is cognitively intact. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow their policy and procedures to ensure (a) signage outside of the resident's room indicating Enhanced Barrier Precaution (EBP) was posted for 1 resident (R167); and (b) proper Personal Protective Equipment (PPE) were worn by staff when providing high contact resident care activities to 2 (R24 and R68) residents. These failures have the potential for cross contamination or transmission of infection to 11 residents assigned to V22 (Licensed Practical Nurse/LPN).

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure call light was in reach for two (R49, R118) out of eight residents reviewed for call lights in a total sample of 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 (R68) resident was free from physical restraint. This failure could potentially affect 1 (R68) of 2 residents reviewed for physical restraint in a sample of 36.

Inspectors wroteBased on observation, interviews, and record review the facility failed to a.) ensure fall preventative measure was followed for a resident (R6) at high risk for falling, and b.) prevent a second fall post-hospitalization for an initial fall which occurred at the facility for one (R32) out of eight residents reviewed for falls in a total sample of 36.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate care and services were provided to residents by not applying dressing to G-tube site and not following enteral feeding formula as ordered by physician. These failures have the potential to affect 2 (R141 and R149) of 3 residents reviewed for Tube Feeding in a sample of 36.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the appropriate side rails were used for one resident (R87) out of a total sample of 36 residents reviewed for accidents/hazards. Findings Include: On 4/8/25 at 11:09 AM, R87 was lying in bed alert and able to verbalize needs. R87 was noted with left arm paralysis and contracture. R87's bed had three half side rails up: 2 half upper rails and 1 half lower rail. On 4/9/25 at 10:26 AM, R87 was sleeping in bed and noted with three half side rails up. On 4/9/25 at 10:53 AM, interviewed V18 (Restorative Director/Licensed Practical Nurse) and stated, We have to get consent and see what the use of the side rail is for. The side rail assessment should be under restorative assessment and should be re-evaluated quarterly, annually, and as needed. The side rail consent should be signed prior to using them. [...]

Inspectors wroteBased on interview and record review facility failed to follow their policy for residents that meet the Subpart S guidelines for one resident (R138) out of three residents reviewed for specialized rehabilitation service. This failure resulted in the facility not following R138's individualized treatment plan to receive psychotherapy and did not document that R138 was not attending or had refused attend psychotherapy since October 27, 2024. Findings Include: Facility's list of residents receiving Psychotherapy services does not refelct R138s' name on it. R138's care plan reads: [...]

Inspectors wroteBased on interview and record review the facility failed to follow a physician's order for a resident (R1) in a timely manner. This failure affected one resident (R1) out of three residents reviewed for improper nursing care and resulted in R1 not receiving the medication from 10/22/24 to 10/31/24.

Inspectors wroteBased on observation, interview, and record review the facility failed to appropriately document in the eMAR (Electronic Medication Record). This failure affected one resident (R3) of three residents reviewed for improper nursing care.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures and failed to revise comprehensive care plans with preventive interventions to ensure resident safety for two of three residents (R3, R4) reviewed for injury of unknown origin.

Inspectors wroteBased upon observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that enteral feedings are administered as ordered, and failed to document enteral intake for two of three residents (R1, R4) reviewed for dehydration.

Inspectors wroteBased on observation, interview, and record review 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. This failure has the potential to affect 20 residents residing in the facility. Findings Include: On 04/13/2024 at 9:09AM, surveyor located on the second floor of the facility with V3 (Registered Nurse/RN). Surveyor observes V3 performing a medication administration pass using medication cart (identified as Team 1 medication cart). V3 states he is responsible for Team 1 medication cart. Surveyor observes inside medication cart (identified as Team 1 medication cart) a bottle of opened house stock medication labeled Docusate Sodium 100mg with an expiration date of December 2022. V3 states expired medications should not be stored in the medication carts and should be discarded. [...]

Inspectors wroteBased on interview and record review, the facility failed to convey funds to the resident's family after a resident expired. This failure affects one of three residents (R4) reviewed for resident funds in a total sample of five residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide incontinence care for one (R5) dependent resident out of three residents reviewed for ADL care.

Inspectors wroteBased on interviews and record reviews, the facility failed to a.) evaluate a high-risk resident's (R285) nutritional status within 14 days of admission; b.) implement a person-centered comprehensive care plan with nutritional interventions and goals addressing R285's nutritional risk factors; c.) follow their policy to obtain resident's weights monthly for 4 (R40, R49. R91, R106); d.) identify and address weight loss in a timely manner when significant changes occurred for 5 (R40, R49, R 91, R106, R285). These failures resulting in significant/severe weight loss for 4 (R40, R49, R106, R285) out of 4 residents reviewed for nutrition in a sample of 39.

Inspectors wroteBased on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) in alignment with facility policy for eight residents (R19, R21, R26, R27, R40, R49, R60, R136) out of 39 residents in a total sample reviewed. On 3/13/2024 at 10:43 AM, PASARR Level One presented by V1 (Administrator) was reviewed for R19. R19 PASARR Level One Screen has been completed by outside agency and is dated 3/13/2024. PASARR Level One determination for R19 was a referral for Level II onsite. Suspected or confirmed PASRR condition was noted to be (MH) Mental Health Disability. On 3/14/2024 at 9:10 AM, V1 (Administrator) presented the admission record for R19 noting an initial admission date of 8/3/2018 and a readmission date of 4/20/2020. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure low air loss mattress devices were on the correct settings for 2 dependent residents (R21, R78) who are high risk in developing pressure ulcers and for 4 (R49, R160, R168, R285) out of 6 dependent residents with current pressure ulcers in a sample of 39 residents. Findings Include: 1. On 3/12/24 at 11:34 AM, Surveyor asked V6 (Registered Nurse) to check on R168's low air loss mattress. V6 stated that it was set to 350 pounds. On 3/13/24 at 9:52 AM, V36 (Certified Nursing Assistant/CNA) and V35 (Certified Nursing Assistant) were observed providing incontinence care to R168 in bed. R168's low air loss mattress weight control knob was set to 250 pounds. [...]

Inspectors wrote3. On 03/12/24 at 12:18 PM, observed R91 lying in bed with oxygen infusing via nasal cannula. Observed oxygen concentrator set and infusing at four liters per minute. Observed nasal canula tubing wrapped in a circle laying on R91's side table uncovered, not in a storage bag. R91 did not have any Oxygen in Use signage posted outside R91's room or doorway. R91 stated I am on oxygen all the time now and it is set at 3L and I use that tubing (pointing to the tubing wrapped in a circle on side table uncovered, not in a storage bag) when I am out of bed because it is longer. I used it over the weekend. On 03/12/24 at 12:24 AM, V9 (Registered Nurse) observed R91's oxygen concentrator and stated it is set at 4 liters per minute but should be set between 2-3 liters per minute. Observed V9 adjust infusion rate down to 3 liters per minute. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly: (a) date opened multi-dose insulin for 1 resident (R13); (b) date opened multi-dose eye drops for 1 (R117) resident; (c) store / refrigerate unopen multi-dose insulin for 2 residents (R97 and R141) reviewed for medication storage and labeling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: (a.) ensure the appropriate use of personal protective equipment (PPE) worn by staff while providing high contact resident care activities; (b.) post appropriate EBP (Enhanced Barrier Precaution) sign on the door of resident on EBP; (c.) ensure PPE supplies were easily accessible for resident on EBP; (d.) clean or disinfect shared reusable equipment in between resident's use to prevent cross contamination. These failures could potentially affect 40 residents residing on the 2nd floor and 58 residents residing on the 5th floor as of census 3/12/24 reviewed for infection control.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a call light was in reach for one (R235) out of a total of 39 sampled residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to update two residents' (R115, R235) comprehensive care plan for advanced directives for two out of a total sample of 39 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drainage collection device will have a dignified intervention ensuring elimination is covered for 2 (R165 and R175) residents and catheter tubing and drainage bag were kept off the floor for 2 (R120 and R165) residents reviewed for urinary catheter care in a sample of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medication error rate of less than 5% for 2 (R156 and R175) of 7 residents in the sample reviewed for medication administration. There were 28 opportunities and 6 errors resulting to 21.43% medication error rate.

Inspectors wroteBased on interview and review of records, facility failed to follow their policy to ensure appropriate interventions are in place to prevent falls for 1 of 3 (R9) residents reviewed for accidents and hazards. This failure resulted in R9 sustaining a subdural hematoma and being hospitalized .

Inspectors wroteBased on interview and review of records, facility failed to follow their policy to ensure appropriate skin evaluation management are done in order to prevent worsening of pressure ulcers for 1 of 3 residents (R9) reviewed for pressure ulcer.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the appropriate side rails were used for 2 out of 3 residents (R1, R3), with multiple history of falls. Findings Include: 1. On 12/05/23 at 11:41 AM, R1 was eating in R1's room in bed with head of bed up to 90 degrees and all four side rails up. R1 was alert and verbally responsive but with some disorientation noted. R1 stated R1 does not know why all R1's side rails are up. R1 stated, I'd rather not have them up. I'd rather have them down. I can't really move when they are all up like this. At 11:47 AM, V6 (Agency Registered Nurse) stated that R1 is high risk for falls and can walk with assistance with a walker. V6 stated that R1 can move all R1's extremities. V6 stated that R1 has four side rails up so R1 can't get out of bed by herself due to being high risk for falling. [...]

Inspectors wroteBased on interview and record review the facility failed to perform a two person assist for repositioning in bed for a dependent resident (R5), who was assessed as a two person assist for bed mobility. This failure resulted in R5 sustaining an acute, mildly displaced proximal left humeral fracture.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to ensure that facility is free of roaches. This failure affected R6 and has the potential to affect all 181 residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a homelike environment for four residents (R1, R7, R10, and R11) reviewed for home like environment in the sample of 18 residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure one resident's (R9) call device was within reach of the resident. This failure affected one of three residents (R9) reviewed for call device.

Inspectors wroteBased on interview and record review, the facility failed to provide a dependent resident oral suctioning per the facility's procedure which affected one (R4) of four residents reviewed for improper nursing care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from Sexual Abuse for 1 (R2) of 4 residents reviewed for abuse. This failure resulted in R2 who is cognitively impaired being found in R11's room naked from the waist down, requiring hospital evaluation and R2's laboratory result from the hospital affirming male DNA (Deoxyribonucleic Acid) was found in the vaginal specimen. This was identified as an Immediate Jeopardy situation which began on 11/19/2022. On 09/28/2023 at 12:56 PM, the administrator was notified of the Immediate Jeopardy. The Immediate Jeopardy Plan was removed on 10/02/2023 at 10:23 AM. However, the deficiency remains at the second level until the facility determines the effectiveness of the implementation of the removal plan. Findings Include: [...]

Inspectors wroteBased on interview and record review the facility failed to provide one of four residents [R1] with prescribed medications. This failure resulted in [R1] being hospitalized for shortness of breath, low oxygen levels, and left lobe pneumonia.

Inspectors wroteBased on interview and record review, the facility administration failed to carry through the facility's Abuse policy regarding identification of potential abuse. As a result, the administration failed to determine abuse when a resident with a BIMS of 15 pulled the pants down of a resident with a BIMS of 00. This deficient practice created a systemic failure having the potential to affect all 179 residents in the facility. Findings Include: R2's Abuse assessment prior to 11/19/22 is not accurate. The Facility does not have an effective Abuse Policy and V1 (Administrator) failed to identify the allegation as abuse. R11 was admitted to the facility on [DATE] with diagnosis not limited to Essential (Primary) Hypertension, Anemia, Presence of Right Artificial Shoulder Joint, Localized Edema, Chronic Postprocedural Pain, Major Depressive Disorder and Cardiomyopathy. [...]