Carlton At The Lake, The

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

her about the sexual assault allegation. On [DATE REDACTED] at 2:02 PM, V1 (Administrator) stated that she is the abuse coordinator and the facility's abuse policy is to report any abuse allegation to IDPH (Illinois Department of Public Health) no later than 2 hours. V1 stated that V11 reported to her that Resident R1 had texted V11 that he was sexually assaulted in the community. V1 stated that V11 called her over the weekend on a Saturday ([DATE REDACTED]), but V1 does not remember the exact time. V1 stated she did not do the initial reporting to IDPH within two hours and did it the next day because there were conflicting stories. V1 stated that Resident R1 refused to tell V23 (Registered Nurse/Nursing Supervisor) anything when Resident R1 came back in the facility. V1 stated Resident R1 did not disclose the sexual assault to the hospital. V1 stated the next day ([DATE REDACTED]), V16 questioned Resident R1 specifically. Resident R1 did tell V16 that he was sexually assaulted and that's when V1 did the initial report to IDPH. The facility's Abuse Report Initial Form for Resident R1's sexual allegation shows date and time the report was sent to IDPH: [DATE REDACTED] at 4:00 PM. Date and time the alleged incident occurred: [DATE REDACTED] at 7:30 PM. Allegation details documents in part: [Resident R1] stated that when he went out on independent pass yesterday with his cousin [V3] he was drugged and sexually assaulted in the community on the south side of Chicago

on the street at a bus stop by 2 individuals unknown to him [Resident R1]. A nursing assessment was done with no new injury noted, no swelling, bruising noted. [Resident R1] complains of pain on bilateral upper extremities and dorsal aspect of the toes of both feet. The police were called, an officer came to interview [Resident R1] and a police report was filed with report number JJ396568. [Resident R1] is being sent to the ER [Emergency Room] for evaluation. A final report will be sent to the state within 5 working days.The facility's Abuse and Neglect policy dated [DATE REDACTED] documents in part: All allegations of abuse will be reported to IDPH immediately not exceeding 2 hours after the initial allegation is received.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Carlton at the Lake, The

725 West Montrose Avenue Chicago, IL 60613

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

8:00 AM, I started calling his [Resident R1] cell phone multiple times. [Resident R1] did not answer. I also tried calling [V3] he was the one signed him [Resident R1] out but it was not connecting. I called [V3] multiple times. I informed [V2 (Director of Nursing)] and [V11] that [Resident R1] has not returned. I also contacted his [Resident R1] other responsible party

they said that [Resident R1] did not contact them. V23 stated that Resident R1 returned in the facility on 8/30/25 at around 7:30 PM.On 9/7/25 at 3:04 PM, a phone interview was conducted with V25 (Receptionist) and stated that

she worked on 8/29/25 PM shift. V25 stated, [Resident R1] told me that he was going to head out. [Resident R1] was waiting in

the lobby area. [Resident R1's] cousin [V3] came with another friend. They left the building around 4:30 PM. [V3] signed [Resident R1] out. [V3] put his information on the sign out sheet. All three of them left the facility together at around 4:30 PM. When [Resident R1] did not return at 8:00 PM, I called [Resident R1] three times, and I called [V3] three times. [V3's] number went straight to voicemail. [Resident R1] did not answer.On 9/7/25 at 2:45 PM, V1 (Administrator) stated that the facility calls the police if a resident does not return the facility from out on pass for more than 24 hours. V1 stated that Resident R1 went out on pass with a family member on 8/29/25, did not return by 8:00 PM, but called at around 4:00 PM the next day informing the facility that he will be returning.

V1 stated that all residents are allowed to go out on pass with escort or with family members. V1 stated that Resident R1 is not allowed to go on independent pass because of Resident R1's history of substance abuse and suicidal ideation.On 9/7/25 at 2:26 PM, V24 (Clinical Care Coordinator) stated that the out on pass privileges care plan is initiated after the order is obtained and the resident and the family have been informed that there's

an order. V24 stated that the purpose of the comprehensive care plan is for the interdisciplinary team to be able to identify the active and potential problems and able to specify interventions to minimize or prevent or address the problems. V24 stated that if Resident R1's out on pass privilege was ordered on 8/26/25 the comprehensive care plan should have been initiated between 8/26/25 to 8/29/25. V24 stated if it was initiated on 9/3/25, the care plan is late. The facility's Elopement policy dated 7/26/24 documents in part: It is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. All residents will be assessed for behaviors or conditions that put them at risk for wandering/elopement. All residents so identified will have these issues addressed in their individual plan of care. All residents shall be reviewed for safety awareness impairment and elopement/wandering concerns upon admission, readmission, quarterly, significant change in condition and as needed. If the case is that of

a resident who went OOP [Out On Pass] and did not come back on the day and time indicated the resident is supposed to come back, the facility will wait for 2 more hours to allow time for resident to return (as in many situations, the delay in the resident's return is a result of traffic, [NAME] pick up, etc). One the 2 hour grace period has elapsed, the facility will contact the police to assist with finding the resident. The facility will also call possible places like hospital ERs, shelters, family and friend's houses, etc where the resident be at.The facility's Care Plan policy dated 6/30/25 documents in part: After the comprehensive assessment (state/federal-required MDS) is completed, the facility will put in place person-centered care plans outlining care for the resident within 7 days.

Event ID:

Facility ID:

If continuation sheet