Inspection·November 3, 2023

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of records, the facility failed to protect a resident's right (R15) to be free from physical abuse and failed to address continuing abusive behaviors of a resident (R4). These failures affected 2 residents (R4 and R15) out of 5 residents (R4, R9, R10, R11, and R15) reviewed for abuse. These failures resulted to R4 requiring hospitalization for psychiatric evaluation and R15 being transferred to local hospital after sustaining skin tear on left eyebrow. Findings include: R4 is [AGE] years old, initially admitted on [DATE]. R4 has diagnoses of seizure, and schizoaffective disorder bipolar type. R4's minimum data set assessment dated [DATE] shows R4 scored 15 indicating that R4's cognition is intact. On 10/31/2023 at 11:38 AM, R4 was seen sitting in his wheelchair talking to himself. R4 agreed to talk in his room and was able to answer questions within topic. R4 stated that he sometimes has disagreements with other residents but cannot remember who those other residents were. R4 was noticed to get easily agitated during conversation. R4 insisted R4 be wheeled down to the first floor. V5 (Licensed Practical Nurse) stated that R4 had verbal altercation with R15 about an ice cream. V5 said that R4 said to R15, I want your ice cream. R15 was seen alert, answered only with a few words and unable to elaborate what happened. At 12:23 PM, V3 (Social Service Director) stated that he was not familiar with R4 and was not aware of any incident that happened. On 11/1/2023 at 10:17 AM, V6 (Assistant Social Service Director) stated that it was V7 (Certified Nursing Assistant) who informed him about the incident between R4 and R15. V7 told him that R15 had a laceration on his left eye. When I spoke to R15 he pointed to R4, and said ice cream, ice cream. I (V6) right away informed V3 about the situation. R4 has history of multiple behavioral problems including physical and verbal aggression. V3 (Social Service Director): Notes dated 2/3/2023, documents that R4 was verbally and physically aggressive towards staff with delusional and paranoid behavior. Notes dated 5/2/2023, documents that R4 was verbally and physically aggressive hitting staff. Notes dated 6/14/2023, by V15 (Psychiatry/Nurse Practitioner) documents that R4 present history was outburst. R4 has loud, and aggressive thought process, delusional, anxious, and blunted. Notes dated 3/28/2023, by V15 (Psychiatrist/Nurse Practitioner) documents that R15 Spanish speaking and poor historian. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 145507 Printed: 05/15/2026 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 145507 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/03/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Clark Manor 7433 North Clark Street Chicago, IL 60626 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)