
Report
TheVardellReport
Carlton at the Lake, the
Skilled nursing facility and nursing facility
725 West Montrose Avenue
Chicago, IL 60613

TheVardellReport
Skilled nursing facility and nursing facility
725 West Montrose Avenue
Chicago, IL 60613
Life by Vardell Presents
The deeper story, beautifully organized. Available records, historical context, and questions worth asking.
This report is free. Vardell does not certify, grade or endorse; it shows what the record documents.
The Essentials
Across 18 inspections from October 2023 to July 2026, state surveyors documented 61 findings at Carlton at the Lake, the; 61 have a recorded correction; CMS lists 5 enforcement actions in the window.
* Partial year, through October 1, 2026.
| Year | Inspections | Findings | Of which, actual harm (level G or above) |
|---|---|---|---|
| 2023 | 3 | 9 | 3 |
| 2024 | 5 | 19 | 2 |
| 2025 | 6 | 18 | 1 |
| 2026 | 4 | 15 | 0 |
Chronology
Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
8 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
5 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
9 findings
Enforcement Action
Civil money penalty, $12,425 imposed August 25, 2025. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of April 11, 2025, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
3 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
10 findings
Enforcement Action
Civil money penalty, $16,822 imposed March 15, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of March 15, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
2 findings
Enforcement Action
Civil money penalty, $16,052 imposed January 19, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the complaint investigation of January 19, 2024, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
1 finding
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
5 findings
Enforcement Action
Civil money penalty, $11,180 imposed November 2, 2023. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the complaint investigation of November 2, 2023, the nearest before the penalty date.
Enforcement Action
Denial of payment imposed November 2, 2023. Status: Closed, December 20, 2023. CMS does not tie a penalty to a survey; listed with the complaint investigation of November 2, 2023, the nearest before the penalty date.
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
3 findings
Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)
Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.
Context
A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.
Inspectors cited F684 in October 2023, November 2023, November 2024, March 2026 and July 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F689 in November 2023, January 2024, April 2025, May 2025 and September 2025. This citation covers whether residents are protected from accident hazards and supervised closely enough to prevent accidents, including falls. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F558 in November 2023, March 2024, April 2025 and March 2026. This citation covers whether the home reasonably accommodates each resident’s needs and preferences. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F609 in September 2025, November 2025 and November 2025. This citation covers whether suspected abuse, neglect or theft is reported to the authorities on time, with the results of the home’s investigation. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F695 in March 2024, April 2025 and March 2026. This citation covers oxygen, breathing treatments and other respiratory care. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F761 in March 2024, April 2024 and March 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F880 in March 2024, April 2025 and March 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F925 in November 2023, August 2025 and May 2026. The agency describes it this way: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F584 in November 2023 and March 2026. This citation covers whether rooms and shared spaces are kept safe, clean, comfortable and homelike. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F604 in December 2023 and April 2025. The agency describes it this way: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F607 in October 2023 and November 2025. The agency describes it this way: Develop and implement policies and procedures to prevent abuse, neglect, and theft. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F657 in March 2024 and August 2024. This citation covers whether care plans are written on time and revised by a team that includes the resident’s caregivers. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F677 in April 2024 and March 2026. This citation covers help with bathing, dressing, eating and toileting for residents who cannot manage alone. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F686 in January 2024 and March 2024. This citation covers how the home prevents and treats pressure injuries (bedsores). None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F693 in August 2024 and April 2025. The agency describes it this way: 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. None rose above level D (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
Inspectors cited F755 in May 2025 and March 2026. This citation covers pharmacy services and the licensed pharmacist who oversees them. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.
For Your Next Visit
Bring these to the tour. Each one comes from something in the record; the reason is under the question.
How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?
Quality of Care: cited in five inspections, most seriously at level G.
What changed in fall prevention and supervision after the last citation, and how do you check that it is still working?
Accident Hazards and Supervision: cited in five inspections, most seriously at level G.
How do you adjust rooms, schedules and routines to a resident’s needs and preferences?
Needs and Preferences: cited in four inspections, most seriously at level D.
How are staff trained to report suspected abuse or neglect, and who reports it to the state?
Reporting Suspected Abuse: cited in three inspections, most seriously at level D.
Who manages oxygen and breathing treatments on each shift, and how is the equipment checked?
Respiratory Care: cited in three inspections, most seriously at level E.
How are medications stored and secured, and who checks the medication carts?
Medication Labeling and Storage: cited in three inspections, most seriously at level E.
Who leads infection control here, and how often are hand-hygiene and isolation practices audited?
Infection Control: cited in three inspections, most seriously at level E.
What changed after F925 was cited, and how do you check it now?
Citation F925: cited in three inspections, most seriously at level F.
What was done about the cleanliness citation, and how are rooms and shared spaces checked now?
A Clean, Homelike Setting: cited in two inspections, most seriously at level E.
What changed after F604 was cited, and how do you check it now?
Citation F604: cited in two inspections, most seriously at level D.
What changed after F607 was cited, and how do you check it now?
Citation F607: cited in two inspections, most seriously at level F.
How often are care plans revised, and who takes part in the review?
Care Plan Timing and Review: cited in two inspections, most seriously at level D.
How long do residents usually wait for help with bathing, dressing or the bathroom, and how is that tracked?
Help With Daily Living: cited in two inspections, most seriously at level D.
How often are residents checked for pressure injuries and repositioned, and who is responsible for it?
Pressure Injury Care: cited in two inspections, most seriously at level E.
What changed after F693 was cited, and how do you check it now?
Citation F693: cited in two inspections, most seriously at level D.
How often does the consultant pharmacist review each resident’s medications?
Pharmacy Services: cited in two inspections, most seriously at level E.
How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?
No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.
What led to the 2025 fine, and has it been paid?
A $12,425 civil money penalty was imposed August 25, 2025. CMS publishes the fine, not whether it has been paid. The record holds five enforcement actions in the window.
The Evidence
Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Illinois state survey agency.
Illinois state survey agency
Inspection Oct 4, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Nov 2, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Dec 8, 2023 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Jan 19, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Mar 15, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Apr 15, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Aug 5, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Nov 7, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Apr 11, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection May 2, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Aug 25, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Sep 8, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Nov 7, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Nov 21, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Mar 5, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Mar 26, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection May 28, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Illinois state survey agency
Inspection Jul 10, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Centers for Medicare & Medicaid Services · 145679
Published Oct 1, 2026 · Retrieved Nov 1, 2026
Record windowOctober 4, 2023 – October 1, 2026
Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.
Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.