Map showing the location of CARLTON AT THE LAKE, THE in CHICAGO, Illinois
725 WEST MONTROSE AVENUE, CHICAGO, IL, 60613

Overall Score

CMS Five-Star Quality Rating
2/5Below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • IllinoisAbove only 37% of peers665 rated homes · average 2.5★
  • Cook CountyAbove only 33% of peers201 rated homes · average 2.6★
  • United StatesAbove only 20% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.7 vs IL avg
  • StaffingCan add or remove a star2★−0.1 vs IL avg
  • Quality measuresCan add or remove a star3★+0.1 vs IL avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersIL avg2.7★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 45% of peersIL avg2.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 39% of peersIL avg2.9★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.28hrsAbove only 45% of peersIL avg3.49Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.76hrsAbove 65% of peersIL avg0.73Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better36%Above 75% of peersIL avg46%RN turnover31%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$241,131Above only 12% of peersIL avg$95,677Fines · denials4 · 1
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
60citations
17inspection dates
6actual harm (G–I)
1immediate jeopardy (J–L)
Nov 21, 2025most recent

Citations by monthFeb 2023 – Nov 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Nov 21, 20252 citationsCycle 1worst F · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 22, 2025
  2. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationF · widespreadCorrected Nov 22, 2025
Nov 7, 20251 citationCycle 1worst D · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Nov 8, 2025
Sep 8, 20252 citationsCycle 1worst D · no actual harm
  1. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 9, 2025
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Sep 9, 2025
Aug 25, 20252 citationsCycle 1worst F · no actual harm
  1. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalF · widespreadCorrected Aug 26, 2025
  2. F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsD · isolatedCorrected Aug 26, 2025
May 2, 20252 citationsCycle 1worst G · actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected May 3, 2025
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected May 3, 2025
Apr 11, 20259 citationsCycle 1worst E · no actual harm
  1. F693Ensure 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.Quality of Life and CareD · isolatedCorrected Apr 12, 2025
  2. F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Apr 12, 2025
  3. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Apr 12, 2025
  4. F700Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.Quality of Life and CareD · isolatedCorrected Apr 12, 2025
  5. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Apr 12, 2025
  6. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Apr 12, 2025
  7. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Apr 12, 2025
  8. F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 12, 2025
  9. F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareE · patternCorrected Apr 12, 2025
Nov 7, 20242 citationsCycle 2worst D · no actual harm
  1. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Nov 8, 2024
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Nov 8, 2024
Aug 5, 20242 citationsCycle 2worst D · no actual harm
  1. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Aug 6, 2024
  2. F693Ensure 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.Quality of Life and CareD · isolatedCorrected Aug 6, 2024
Apr 15, 20243 citationsCycle 2worst E · no actual harm
  1. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Apr 16, 2024
  2. F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceE · patternCorrected Apr 16, 2024
  3. F569Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.Resident RightsD · isolatedCorrected Apr 16, 2024
Mar 15, 202410 citationsCycle 2worst G · actual harm$16,822
  1. F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceE · patternCorrected Mar 16, 2024
  2. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Mar 16, 2024
  3. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningE · patternCorrected Mar 16, 2024
  4. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Mar 16, 2024
  5. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareE · patternCorrected Mar 16, 2024
  6. F690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and CareD · isolatedCorrected Mar 16, 2024
  7. F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareG · isolatedCorrected Mar 16, 2024
  8. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareE · patternCorrected Mar 16, 2024
  9. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Mar 16, 2024
  10. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Mar 16, 2024
Jan 19, 20242 citationsCycle 3worst G · actual harm$16,052
  1. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Feb 3, 2024
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Feb 3, 2024
Dec 8, 20231 citationCycle 3worst D · no actual harm
  1. F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 20, 2023
Nov 2, 20235 citationsCycle 3worst G · actual harm$11,180, payment denial
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Nov 3, 2023
  2. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Nov 3, 2023
  3. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsE · patternCorrected Nov 3, 2023
  4. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Nov 3, 2023
  5. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalF · widespreadCorrected Nov 3, 2023
Oct 4, 20233 citationsCycle 3worst J · immediate jeopardy$197,077
  1. F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationJ · isolatedCorrected Oct 17, 2023
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareG · isolatedCorrected Oct 17, 2023
  3. F607Develop and implement policies and procedures to prevent abuse, neglect, and theft.Freedom from Abuse, Neglect, and ExploitationF · widespreadCorrected Oct 17, 2023
Jul 1, 20232 citationsCycle 3worst E · no actual harm
  1. F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareE · patternCorrected Jul 14, 2023
  2. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Jul 14, 2023
May 8, 20234 citationsCycle 3worst G · actual harm
  1. F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected May 9, 2023
  2. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected May 9, 2023
  3. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 9, 2023
  4. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareG · isolatedCorrected May 9, 2023
Feb 3, 20238 citationsCycle 3worst F · no actual harm
  1. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Feb 4, 2023
  2. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlE · patternCorrected Feb 4, 2023
  3. F888Ensure staff are vaccinated for COVID-19Infection ControlE · patternCorrected Feb 4, 2023
  4. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Feb 4, 2023
  5. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Feb 4, 2023
  6. F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesD · isolatedCorrected Feb 4, 2023
  7. F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceE · patternCorrected Feb 4, 2023
  8. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Feb 4, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.28hrsAbove only 45% of peers−0.21 vs IL avg
  • Registered nursesRN hours only0.76hrsAbove 65% of peers+0.03 vs IL avg
  • Licensed practical nursesLPN hours0.71hrs
  • Nurse aidesCNA hours1.81hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.11hrs
  • Illinois average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better36%Above 75% of peersIL avg 46%
  • RN turnoverRegistered nurses only31%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy244 certified beds · ~168 residents a day69%Above only 35% of peersIL avg 74%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $241,131In fines
  • 4Fines
  • 1Payment denial
  • $95,677IL avg in fines
Above only 12% of peersFewer fines than 12% of rated homes in Illinois

Actions on record

  1. Mar 15, 2024Civil money penalty$16,822
  2. Jan 19, 2024Civil money penalty$16,052
  3. Nov 2, 2023Civil money penalty$11,180
  4. Nov 2, 2023Denial of payment for new admissionsfrom Nov 25, 2023
  5. Oct 4, 2023Civil money penalty$197,077

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Legacy Healthcare90 facilities in the chain3.0★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Doros Generation Trust U/A/D 1/3/12
  • Gpn Fam Tr Ua 04282008
Corporate officers
  • Menachem Shabat
Managing employees
  • Joanne Ventrella
5% Or Greater Security Interest
  • Carlton Associates Limited Partnership

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 145679 · 725 WEST MONTROSE AVENUE, CHICAGO, IL, 60613.
  • Percentiles compare this facility with every rated nursing home in Illinois and Cook County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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