Inspection·May 17, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident should not have to sit and watch another resident eating food when they do not have anything to eat. V23 stated there should be a seating chart for the dining rooms so that all the residents sitting at the same table get served their meals at the same time. V23 stated currently there is no seating chart for the dining rooms. On 05/16/24 at 8:21 AM, V34 (Registered Dietitian) stated residents sitting at the same table should receive their meals at that same time. V34 stated it is a dignity issue because everyone should not be watching one person eating their food. R31's diagnoses which includes but not limited to Parkinson's Disease without Dyskinesia, and Schizoaffective Disorder Bipolar Type. R31's Physician Orders dated 05/15/24 documents in part General diet regular texture, thin liquids consistency ordered 05/13/20. R31's MDS (Minimum Data Set) from 02/22/24 BIMS (Brief Interview for Mental Status) was 15 out of 15 indicating intact cognition. R36's diagnoses which includes but not limited to Polyosteoarthritis, Mild Dementia without Behavioral Disturbance, Chronic Peptic Ulcer, Chronic Obstructive Pulmonary Disease, and Paranoid Schizophrenia R36's Physician Orders dated 05/15/24 documents in part No restriction (Regular) diet regular texture, thin liquids consistency ordered 02/07/24. R36's MDS (Minimum Data Set) from 05/03/24 BIMS (Brief Interview for Mental Status) was 10 out of 15 indicating moderately impaired cognition. R40's diagnoses which includes but not limited to Polyosteoarthritis, Epileptic Seizures, Schizoaffective Disorder, Bipolar Type, Sensorineural Hearing Loss, Unspecified Dementia without Behavioral Disturbance, Chronic Obstructive Pulmonary Disease, and Gastroesophageal Reflux Disease without Esophagitis. R40's Physician Orders dated 05/15/24 documents in part NAS (No Added Salt) diet regular texture, thin liquids consistency ordered 03/22/22. R40's MDS (Minimum Data Set) from 03/12/24 BIMS (Brief Interview for Mental Status) was 05 out of 15 indicating severely impaired cognition. R129's diagnoses which includes but not limited to Major Depressive Disorder, History of Falling, Anxiety Disorder, Gastroesophageal Reflux Disease, and Unspecified Dementia. R129's Physician Orders dated 05/15/24 documents in part General diet regular texture, thin liquids consistency ordered 07/10/21. R129's MDS (Minimum Data Set) from 03/12/24 BIMS (Brief Interview for Mental Status) was 10 out of 15 indicating moderately impaired cognition. R139's diagnoses which includes but not limited to Asthma, Schizoaffective Disorder, Dementia, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 2 of 21 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 05/17/2024 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)

F 0550 Level of Harm - Minimal harm or potential for actual harm Restlessness and Agitation, Gastroesophageal Reflux Disease without Esophagitis, Paranoid Schizophrenia, Type 2 Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease. R139's Physician Orders dated 05/15/24 documents in part CCHO (Consistent Carbohydrates) diet regular texture, thin liquids consistency large portions to current diet ordered 12/22/22. Residents Affected - Some R139's MDS (Minimum Data Set) from 04/02/24 BIMS (Brief Interview for Mental Status) was 07 out of 15 indicating severely impaired cognition. R205's diagnoses which includes but not limited to Arthritis, Bipolar Disorder, Mild Cognitive Impairment, Chronic Diastolic (Congestive) Heart Failure, Dementia, and Peripheral Vascular Disease. R205's Physician Orders dated 05/15/24 documents in part Regular diet regular texture, thin liquids consistency ordered 03/31/23. R205's MDS (Minimum Data Set) from 04/03/24 BIMS (Brief Interview for Mental Status) was 04 out of 15 indicating severely impaired cognition. On 05/15/24 at 2:01 PM, V2 (Assistant Director) showed surveyor document titled, HCCI Health Care Council of Illinois, Resident admission Packet and stated every resident receives this packet upon admission to the facility. Facility provided document titled, HCCI Health Care Council of Illinois, Resident admission Packet dated July 2023, which documents in part no resident shall be deprived of any rights, benefits, or privileges guaranteed by law, the Constitution of the State of Illinois, or the Constitution of the United States solely on account of his or her status as a resident of the Community and a facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, and the facility must protect and promote the rights of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 3 of 21 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 05/17/2024 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)

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one (R221) resident had access to call light of six residents reviewed for call lights in a sample of 35 reviewed. Residents Affected - Few Findings include: Minimum Data Set, 2/21/2024, Brief Interview for Mental Status score indicates R221 has moderate cognitive impairment; does not have behavioral concerns with inattention, disorganized thinking, altered level of consciousness. Nursing-Admission/readmission UDA, 2/14/2024, call light evaluation indicates R221 is cognitively able to use the call light and is able to call for assistance by pulling the call light string with the use of the right and left finger(s), hand or arm. On 5/14/24 at 12:29 PM, observed R221 lying in bed watching television. The call light was observed clipped to the upper right corner of R221's pillow that was behind R221's head. No part of the string draped to the front of the pillow. R221's call light system consists of a string that reaches from a toggle switch located on the wall behind and to the right of R221's bed. The other end of the string has a clip. R221 was observed with limited mobility in all four extremities. R221 stated R221 requires assistance to get up. Writer asked R221 where R221's call light is. R221 responded Not sure where the call light is. Writer informed R221 that the call light was clipped to the pillow behind R221. Writer asked R221 to pull the call light. R221 raised the right arm, bent at the elbow, and swung it back toward the pillow. R221 said I can't reach the call light. On 5/14/24 at 12:40 PM, observed R221's call light with V22 (Licensed Practical Nurse). V22 moved/clipped the call light down toward the center of the pillow to the right side. R221 attempted to reach for the call light but could not reach it. V22 stated, usually restorative assesses the call light placement so the resident can pull it. V22 had V47 (Restorative Aide) come into R221's room to add string to R221's call light to make it longer. V47 added string to lengthen R221's call light and clipped it to the pad that R221 was lying on close to R221's right hand. R221 was shown where the call light was placed and asked to pull the call light. R221 grabbed and pulled the string and was able to activate the call light. R221 stated That's better. I can pull it. V22 stated, restorative rounds in the mornings to see if residents can pull the call light. The CNA's (Certified Nursing Assistants) put the call lights in place after cleaning the resident. R221 could not use the call light where it was originally placed on the pillow. R221 would not have been able to call for help. The purpose of the call light is for emergencies, call for help, to get staff attention. Writer asked R221 what was the purpose of the call light? R221 responded To call for help if I'm having trouble. R221 stated R221 has a sense of completeness now that R221 can find the call light. On 5/14/24 at 12:55 PM, V8 (Certified Nursing Assistant) stated V8 clipped the call light to the center of R221's pillow. On 5/14/24 at 1:09 PM, writer asked V47 (Restorative Aide) what did V47 just do to R221's call light? V47 stated V47 added a longer string to R221's call light because V47 was told it was too short. V47 stated the call light was clipped to the upper right corner of R221's pillow when V47 assessed R221 this morning. V47 stated R221 was centered in the bed and able to reach it. I asked R221 if R221 could reach it. I was not able to test R221's reach because R221 was receiving care from the CNA. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 4 of 21 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 05/17/2024 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)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V47 stated the purpose of the call light is for emergency if the resident needs help. V47 stated we do a call light assessment on admission. V47 stated we assess/round every morning. V47 stated we are checking to see if the call light is reachable. V47 stated staff is not in the resident's room [ROOM NUMBER]/7. If R221 is unable to reach the light, then R221 cannot call for help. On 5/14/24 at 3:20 PM, V3 (Director of Nursing) stated the call light is for if the resident needs help. All residents should have a call light and it should be reachable. If the call light is not reachable the resident cannot call for assistance. Facility Call Light Policy, 7/27/23, documents in part: Be sure call lights are placed within reach of residents who are able to use it at all times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 5 of 21 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 05/17/2024 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)

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and records review, the facility failed to protect one (R101) resident's personal and confidential information of 6 residents reviewed for patient information protection in a sample of 35. Residents Affected - Few Findings include: On 5/14/2024 at 10:02am during inspection of the medication cart on the 5th floor with V28 (Licensed Practical Nurse-LPN), V28 was observed going to the medication room and leaving her computer on, with the computer screen displaying R101's picture, medical and personal information. The computer screen was observed facing the main hallway of the unit, and it was visible to staff members and residents passing by. V28 stated she should have closed or made sure the contents of the screen were hidden and not visible to anyone (public) because that's a HIPAA (Health Insurance Portability and Accountability Act) violation. V28 stated she should have closed the computer, but since she was not going far, she didn't think she needed to close the computer. On 5/14/2024 at 12:44pm, V4 (Assistant Director of Nursing-ADON) stated computer screen needs to be closed for privacy of the residents because their pictures and medications are showing and other people might look and see what medications the resident is taking, and that's a violation of their privacy. On 05/16/2024 at 12:26 V1 (Administrator) and V2 (Assistant Administrator) stated they educate their staff on privacy, such as covering the date of birth , diagnosis, full names, not to be provided to anyone not providing care to the residents. V2 stated if the nurse is stepping away from her computer even for a short time, the nurse needs to minimize, close the screen to make sure the resident information is not visible to anyone passing by staff or residents. If the computer screen is left visible to other people not taking care of the resident, because that's a HIPPA violation and other people can get hold of resident's information which is sensitive confidential personal information for the resident. Facility Policy titled Statement of Resident Rights Cont. Documents: -(h) Privacy and Confidentiality. The Resident has a right to personal privacy and confidentiality of his or her personal and medical records. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 6 of 21 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 05/17/2024 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)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to initiate a new Level I screen for a resident with a known mental illness for one (R223) resident reviewed for Pre-admission Screening and Record Review (PASARR) in a sample of 35. Residents Affected - Few Findings include: R223's Face sheet documents that R223 was admitted to the facility on [DATE] with diagnoses not limited to: Schizoaffective Disorder Bipolar Type. R223's Level II PASARR outcome letter documents that R223 has a short-term approval without special services dated [DATE] with an expiration date of [DATE]. R223's Level II PASARR outcome letter documents in part, This determination allows you a limited number of days in a Medicaid-certified nursing facility. The short-term approval will end on the Date Short Term Approval Ends listed on the Notice of PASRR Level II Outcome that came with this letter. If you or your care provider thinks you need to stay after that date, a nursing facility staff member must submit a new Level I screen. The new Level I screen must be submitted no later than 10 days before the Date Short Term Approval Ends. On [DATE] at 2:08PM, V19 (Social Services Director) stated he has been working at the facility for five years. V19 states a PASARR/Preadmission Screening and Resident Review is a screening that needs to be done prior to a resident being admitted to the facility. V19 states he is unaware of what the PASARR screenings are indicative of. V19 states the facility checks to see if a resident has a PASARR screening upon admission. V19 states the PASARR indicates the determination of needs/DON score for the individual resident. V19 states based on the DON score, it is determined if a resident is appropriate for the nursing home setting or not. V19 states he is unaware of the DON score ranges or what the different DON score ranges are indicative of. V19 states a PASARR Level II is needed for a resident if it is determined that the resident has an SMI/severe mental illness. V19 states the determination for a Level II PASARR screening is based off of the results of the Level I PASARR screening. V19 states he reviews the PASARR screenings at least once a month and also reviews the PASARR screenings for expirations. V119 states the last time he checked the PASARR screenings was on [DATE]. V19 states he is the person responsible for submitting resident PASSAR screenings. V19 states when a resident's PASARR screening expires, he should submit another one as soon as he can. V19 states he is not sure if there is a time frame for submitting a new PASSAR screening once it expires. On [DATE] at 3:52PM, V19 states R223's PASSAR screening expired on [DATE]. V19 states once a resident's PASARR screening expires, a new Level I PASARR screening has to be submitted before a resident can receive a Level II PASARR screening. V19 states he was just made aware of this information and submitted a new PASARR screening for R223 today on [DATE]. Facility policy dated [DATE] titled PASSAR Screening of Residents with Mental Disorder of Intellectual Disability documents in part, Policy: It is the facility's policy to ensure that residents with Mental Disorder and those with Intellectual Disorder will receive PASSAR Screening within the timeframe allowed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 7 of 21 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 05/17/2024 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide necessary services that are consistent with professional standards to prevent the development and worsening of pressure ulcers. The facility failed to a. follow the provider order in the prevention of pressure injury for one resident (R44), b. follow policy and manufacturer directions when adding multiple layers on low air loss mattresses for two residents (R212) and (R91) and c. provide adequate supervision for low air loss devices to prevent accidents for one resident (R158) out of a total sample of thirty-five residents. Residents Affected - Some Finding include: On 05/14/24 10:00AM R91 observed in bed with a drive low air loss mattress head of bed elevated. R91 observed laying on one fitted sheet, two incontinent cloth pads and a folded flat sheet used for a draw sheet along with adult brief. On 05/16/24 11:00AM PM surveyor accompanied with V27 and V10 observed R158 lying in bed on air mattress g-tube infusing rate of 60ml/hr. Observed V27 and V10 reposition and do skin check. Observed R158 with redness to sacral area. R158 on low air loss mattress Drive manufacturer. Low air loss mattress noted unplugged. On 05/15/24 9:50AM surveyor observed R212 in bed with g-tube feeding infusing. R212 with foley catheter. Surveyor observed R212 on low air loss mattress with one fitted sheet, flat sheet double folded, one cloth pad and incontinence brief. On 05/14/2024 at 12:38PM V9 states, residents that have air mattresses should have two layers and diaper. If multiple layers are on the air mattress can possibly cause bed sores or make the wounds worse. On 5/14/2024 at 9:50AM V10 states, residents with air mattress should only have one layer on the mattress multiple layers can cause wounds to get worst. On 5/15/2024 at 2:00PM V27 (Wound care nurse) stated, I've been here for 9 years. Residents with air mattresses should only have flat sheet and pad on each. Resident with wounds should only have two layers. Individuals that don't have wounds and is on the air mattress for prevention can have fitted sheet and a pad. If multiple layers are on the air mattress it can cause additional skin breakdown. All staff should make sure air mattresses are working properly and making sure mattress are plugged. If mattress malfunction staff should report immediately. R91 record reviewed physician orders dated 5/9/2024 document SITE: Right ischial tuberosity- Cleanse with normal saline. apply Collagen and calcium alginate to base of the wound, secure with Bordered gauze. physician order dated 11/08/2023. Reviewed R91 current wound assessment dated [DATE],4/30/2024,5/7/2024,5/14/24 showed wound had increase from 5/7/2024 to next assessment date 5/14/2024. Foley catheters care every shift for pressure injury. Physician order dated 11/08/2023 low air loss mattress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 8 of 21 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 05/17/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm On 5/16/2024 2:30PM Review of R91 care plan dated 4/17/2024 includes the following focus areas: R91 has pressure injuries to the following sites: left buttocks- stage 3-resolved 12/2/2023 right ischium- stage 3 R91 pressure injuries will show signs of healing and remain free from infection by/through the next review date. Residents Affected - Some R91 requires low air loss mattress bed and gel cushion for his wheelchair. Braden Scale and Clinical Evaluation dated 4/21/2024 documents R91 is high risk for pressure ulcer development score 12. On 4/16/2024 at 2:30PM reviewed R158 record physician order sheet dated 4/24/2024 documents, SKIN: Mattress: Low Air Loss Mattress due to prevention of decubitus. R158 Braden Scale and Clinical Evaluation dated 4/28/2024 score is 8 high risks. On 5/14/24 at 8:11 PM R44 was observed sleeping on a specialty bed. R44 heel protectors were observed off of the resident and on the bedside table. On 5/15/24 at 10:01 AM R44 was in bed and heel protectors were observed on the bedside table. R44 was awake and lying in bed. V33 (Staffing Coordinator) was at R44's bedside. V33 stated that heel boots are only used at night. R44 confirmed that he only wears the heel boots at night. On 5/16/24 at 8:40 AM R44's skin care and pressure injury prevention orders were reviewed with V4 (RN/ADON). V4 (RN/ADON) stated that bilateral heel protectors were ordered to be on R44 any time R44 is in bed. The heel protectors should be on R44 while R44 is in bed. V4 (RN/ADON) stated that R44 gets up in the chair two to three times a week. Aside from being in the chair, the heel boots should be on. V4 (RN/ADON) stated that the risk to R44 if the heel boots are not on, is that R44's skin will break down. He is at risk for skin breakdown. On 5/16/24 at 8:43 AM V27 (Wound Nurse) stated that R44 has no wounds but is at risk of skin breakdown. V27 (Wound Nurse) stated that prevention measures for R44 are the low air loss mattress, moisture barrier cream, frequent turning, and heel protectors. V27 stated The heel protectors should be on when he is in bed. On 5/14/24 at 02:14 PM record review shows a provider order dated 4/19/2024 by V39 (Physician) and entered by V4 (RN/ADON). The order states: Bilateral heel protectors while in bed. On 5/15/2024 at 1 PM review of R44 care plan dated 4/29/2024 includes the following focus areas: R44 has impaired mobility function related to diagnoses adult failure to thrive. R44 is on bed mobility program. I am assessed to be at risk for pressure sore development, based on Braden score of 13 related to: occasional bladder and bowel incontinence and fragile skin. Currently my skin status is intact. Review of policy titled Physician Orders adopted 11/10/2014 and revised 7/28/2023 states in part: Policy Statement: It is the policy of the facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders. The facility shall ensure to follow physician orders as it is written in the POS. Procedures: 5. The nurse may question and clarify physician orders that are not clear and or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 9 of 21 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 05/17/2024 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)

F 0686 questionable. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 10 of 21 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 05/17/2024 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow physician order policy for prescribed gastrostomy tube feeding rate. This failure affected one (R4) resident reviewed for tube feeding in a sample of 35. Findings Include: On 05/14/24 at 01:26 PM, observed R4 lying in bed with HOB/head of bed elevated, and tube feeding infusing. Observed 1.2-liter (L) bottle of Jevity 1.2 hung with label listing date (05/14/24) and hang time (9:00 AM). Observed tube feeding infusing at 55 milliliters (ml) per hour (hr.). On 05/14/24 at 01:57 PM, V15 (Registered Nurse) stated V15 knows R4 well and has taken care of R4 before. V15 stated V15 follows R4's tube feeding orders listed in R4's electronic health record (EHR) ordered by R4's physician. V15 stated R4 is NPO (nothing by mouth) and receives Jevity 1.2 at 55 ml/hr via gastrostomy tube. V15 stated V15 hung R4's tube feeding bottle at 9:00 AM this morning and set the rate at 55 ml/hr. On 05/14/24 at 02:00 PM, surveyor went with V15 to view R4's tube feeding rate and R4 stated R4's tube feeding was infusing at 55 ml/hr with Jevity 1.2. On 05/14/24 at 02:04 PM, V15 reviewed R4's orders in R4's EHR and stated R4's tube feeding rate was changed on 05/10/24 to 75 ml/hr. V15 stated 75 ml/hr is what R4's current order is and this is the rate R4 should be receiving. On 05/15/24 at 12:56 PM, V3 (Director of Nursing) stated the nurses follow the orders in the resident's EHR. V3 stated if R4's tube feeding order says the rate should be run at 75 ml per hour then that is what the rate should have been set at. V3 stated it was an oversight and that nurse V15 (Registered Nurse) is a good nurse. On 05/16/24 at 8:52 AM, V34 (Registered Dietitian) stated for residents who are NPO they receive one hundred percent of their nutrition via a tube feeding and if a resident receiving tube feeding is losing weight, V34 would make a recommendation to adjust the tube feeding volume to provide to more calories. V34 stated the nurses should be following the doctor's order for the tube feeding rate and if the rate was not followed as ordered this would affect their total calorie intake. V34 stated R4 has had a significant weight loss over three-month period from (2/2024) to (5/2024). V34 stated R4 weighted 162.8 pounds in (2/2024) and currently weights (5/2024) 150 pounds. V34 calculated that this is a 12.8-pound weight loss or -7.9% weight change in three months. V34 stated due to R4 losing weight V34 recommended to increase the rate of R4's tube feeding from 55 ml/hr to 75 ml/hr to provide more calories. R4 has diagnosis including but not limited to Gastro-Esophageal Reflux Disease Without Esophagitis, Presence Of Aortocoronary Bypass Graft, Gastrostomy Status, Schizoaffective Disorder, Bipolar Type, Dysphagia, Oropharyngeal Phase, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, Hypertension, Chronic Obstructive Pulmonary Disease, Unspecified Atherosclerosis Of Native Arteries Of Extremities, Bilateral Legs, Congenital Stenosis And Stricture Of Esophagus, Other Iron Deficiency Anemias, Deficiency Of Other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 11 of 21 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 05/17/2024 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Vitamins, Ventricular Tachycardia, Xerosis Cutis, Pressure Ulcer Of Right Buttock, Stage 2, Pressure Ulcer Of Sacral Region, Stage 2, Diverticulosis of Intestine, Part Unspecified, Without Perforation Or Abscess With Bleeding. R4's Order Summary Report dated 05/14/24 documents in part, diet NPO (nothing by mouth) dated 01/26/24 and enteral feed order Jevity 1.2 rate 75 ml/hr x23 hours and infuse until total volume of 1725 ml is reached per day dated 05/10/24. R4's Enteral Feeding care plan documents in part R4 requires enteral feedings as the primary source of nutrition due to malnutrition. R4's Nutrition care plan documents in part, provide tube feed prescription Jevity 1.2 @/at 75 ml/hr x 23 hours and infuse until 1725 ml total volume reached per day. R4's Tube Feeding care plan documents in part, provide enteral feeding as ordered. R4's MDS (Minimum Data Set) from 04/08/24 BIMS (Brief Interview for Mental Status) was 0 indicating R4 is rarely/never understood. Section K - Swallowing/Nutritional Status documents in part nutritional approaches - feeding tube and proportion of total calories the resident received through tube feeding 51% of more. R4's Medication Administration Record dated 05/01/24-05/31/24 documents in part, enteral feeding order(G-tube) start date 05/10/24 Jevity 1.2 rate 75 ml/hr x23 hours and infuse until total volume of 1725 ml is reached per day signed off on by V15 on 05/11/24, 05/12/24, 05/13/24, 05/15/24 day shift. R4's Weight/Tube Feeding assessment dated [DATE] completed by V34 documents in part, weight loss is unintentional and undesirable since BMI (Body Mass Index) is underweight for advanced age and recommending to increase Jevity 1.2 from 55 to 75 ml/hr x 23 hours. R4's Monthly Weight Report printed 05/14/24 at 17:40 documents R4's weight [DATE].8 lbs (pounds) and May 2024 150 pounds. Facility policy titled, Physician Orders dated 07/28/23 documents in part it is the policy of this facility to ensure that all resident/patient medications, treatment and plan of care must be in accordance to the licensed physician's orders and the facility shall ensure to follow physician orders as it is written in the POS. Facility policy titled, Enteral Tube Feeding Care dated 07/28/23 documents in part as procedure nurse will check the POS/MAR the order for enteral feeding interventions: feeding formula, type: bolus/continuous, rate and duration. Facility Job Description titled Registered Nurse dated 08/24/18 documents in part, will administer medications within the scope of practice of the R.N. Licensure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 12 of 21 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 05/17/2024 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)

F 0725 Level of Harm - Minimal harm or potential for actual harm Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Based on interview and record review, the facility failed to have sufficient staffing on the weekend. This failure affects all 245 residents residing in the facility reviewed for lack of staff. Residents Affected - Many Findings include: Review of staffing data submitted via the Payroll-Based Journal (PBJ) system revealed the facility had been triggered for weekend staffing data is excessively low. On 05/14/2024, V2 (Assistant Administrator) provided surveyor with the facility's Payroll-Based Journal (PBJ) report dated 10/01/2023 to 12/31/2023. Facility document, dated 02/01/2024, titled Facility Assessment Tool documents in part, Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies. Plan (please list the actual plan being used in your facility, as below are examples that may not fit your facility's staffing plan and status. Please check as well that your building is compliant with Illinois' Minimum Staffing calculation). RN (Registered Nurse) or LPN (Licensed Practical Nurse) Charge Nurse: 10 for Days and Evenings, and 5 Nights shift, 1:29 LN ratio Days and Evenings 1:58 LN. facility's Payroll-Based Journal (PBJ) report reviewed for the following weekend dates: 10/15/2023, 11/04/2023, 11/05/2023, and 12/17/2023. 10/15/2023 documents that there were 23 licensed nurses working with total hours of 182.25. 11/04/2023 documents that there were 19 licensed nurses working with total hours of 182.5. 11/05/2023 documents that there were 23 licensed nurses working with total hours of 179. 12/17/2023 documents that there were 23 licensed nurses working with total hours of 198.25. Facility's document dated 10/15/2023 titled Daily Nursing Staff Report documents that 24 nurses worked with total hours worked were 186. Facility's document dated 11/04/2023 titled Daily Nursing Staff Report documents that 24 nurses worked with total hours worked were 192. Facility's document dated 11/05/2023 titled Daily Nursing Staff Report documents that 24 nurses worked with total hours worked were 192. Facility's document dated 12/17/2023 titled Daily Nursing Staff Report documents that 24 nurses worked with total hours worked were 192. 05/16/2024 at 9:59 AM V33 (Staffing Coordinator) states that she is responsible to make sure there are enough staff working on the units. V33 states that both nurses and CNAs (Certified Nursing Assistants) work 8-hour shifts. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 13 of 21 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 05/17/2024 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)

F 0725 Level of Harm - Minimal harm or potential for actual harm On 05/16/24 at 11:25 AM V33 states that first floor 1 nurse 7-3 3-11, 2nd floor we have two nurses, 3rd floor two nurses, 4th floor two nurses, and 5th floor two nurses. V33 states that there should be nine nurses on 7am-3pm shift, nine nurses on 3pm-11pm shift, and five nurses on the 11pm-7am shift. V33 states that there should be a total of 23 nurses providing resident care in a 24-hour period. Residents Affected - Many Facility census dated 05/14/2024 documents that a total of 245 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 14 of 21 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 05/17/2024 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and records review, the facility failed to follow their policy on controlled drug count by failing to accurately count and reconcile controlled medication record/log for three (R220, R492, R211) of six residents in a sample of 35 reviewed. Findings include: R220 current face sheet documents R220 is a [AGE] year-old individual with medical diagnoses that include but not limited to: bipolar disorder, current episode mixed, severe, without psychotic features, attention-deficit hyperactivity disorder, unspecified type, generalized anxiety disorder, osteomyelitis, unspecified. R220's POS (Physician Order Sheet) documents Active 10/11/2023 - Lyrica Capsule 150 MG (Pregabalin) -Give 1 capsule by mouth two times a day for Nerve pain related to chronic pain syndrome Active 10/11/2023-clonazePAM Oral Tablet 0.5 MG (Clonazepam) -Give 1 tablet by mouth three times a day related to generalized anxiety disorder Active 04/17/2024-Adderall Oral Tablet 20 MG(Amphetamine-Dextroamphetamine) - Give one tablet by mouth three times a day for. R492 current face sheet documents R492 is a [AGE] year-old individual with medical diagnosis that include but not limited to: other specified arthritis, multiple sites, other low back pain, other low back pain. R492's POS documents: Active 5/11/2024 -Pregabalin Oral Capsule 75 MG (Pregabalin) Give 1 capsule by mouth two times a day for pain. R211's current face sheet documents R211 is a [AGE] year-old individual with diagnosis that include but not limited to: schizoaffective disorder, bipolar type, dementia in other diseases classified elsewhere, severe, with psychotic disturbance, and her POS (Physician Order Sheet) documents: admitted to Unity Hospice 8/3/23. Review of R211's POS does not document an order for Morphine Sulfate 200mg/ML solution. On 5/14/2024 at 11:48am during medication cart and storage room inspection on first floor with V17(Licensed Practical Nurse-LPN), the medication narcotic count logbook was observed not signed off as given for R220 for medications administered: Lyrica Capsule 150 MG (Pregabalin), was not signed off (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 15 of 21 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 05/17/2024 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few as given, and medication counted at hand was 5 tablets remaining but narcotic sheet showed 6 tablets remaining and last signed as given on 5/13/2024 at 5pm , clonazepam Oral Tablet 0.5 MG (Clonazepam) count was 19 tablets, narcotic sheet showed 20 tablets remaining and was last signed as given on 5/13/2024 at 5pm, Adderall Oral Tablet 20 MG(Amphetamine-Dextroamphetamine)remaining 16 tablets, narcotic sheet showed 17 tablets remaining and last signed as given on 5/13/2024 at 5pm. V17 stated she gave the medications to R220 this morning, but did not sign the medications as given on the narcotic count book. V17 stated she should have signed off the medications as soon as she gave them to keep a true count of the medication to prevent confusion and to monitor the controlled medications. R492's Pregabalin Oral Capsule 75 MG (Pregabalin) count was five tablets on the bingo card, while the medication count sheet/log documented six tables on hand. The narcotic sign off sheet documented the medication was last signed off as given on 5/13/2024 at 5pm. V17 stated she gave the medication this morning but not sign it off yet. V17 said she is supposed to sign off the medications as given as soon as she gives it. On 5/14/2024 at 12:44pm, V4(Assistant Director of Nursing-ADON) said all controlled medications should be signed off on the narcotic book by the nurse who administered the medication as soon as they are given to prevent medication being given again and to prevent the medication from being misused. V4 stated signing the narcotic as soon as given helps prevent misuse and keeps proper counts of the medications. On 5/15/2024 at 12:47pm during inspection of 3rd floor medication carts and medication storage room with V30(Registered Nurse-RN), observed in the medication fridge was R211's medication Morphine Sulfate 200mg/ML solution. The medication bottle was open and in the bottle was 5mL of medication in the bottle. V30 stated R211 was V31(Registered Nurse-RN) resident for the day. During review of R211 narcotic log with V30 showed the narcotic log was not completed, there was no documentation of how much of R211's medication was remaining and R211's medication Morphine Sulphate was observed opened, and in the bottle was 5ml of the medication in the bottle. V30 stated there is no log R211 has received the medication. On 5/15/2024 at 12:50pm, V31 said she has not administered to R211 any Morphine Sulfate during her shift. V31 stated medications such as morphine sulphate should be monitored to prevent misuse. V31 stated she does not know if R211 has been prescribed morphine sulfate. On 5/15/2024 at 1:35pm, V4 (ADON) and surveyor observed R211's medication and medication sheet. V4 stated all controlled medications are supposed to be logged in the medication log sheet and if the medication is discontinued, it should be discorded/wasted to prevent medication errors, medication being misused. V4 stated she did not know why R211's morphine was opened, yet R211's morphine was discontinued and R211 is no longer on the medication. V4 stated if the medication is open and not logged in the narcotic book, it is not known what the contents in the medication bottle is since there is no way of tracking the medication, and this can lead to medication errors and misuse. Facility policy titled Controlled medications count, dated 7/27/2023 documents: -After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication was taken. -After administration of the controlled medication, the nurse will sign off the eMAR. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 16 of 21 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 05/17/2024 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)

F 0755 -If the controlled medication needs to be wasted, another nurse should witness the wasting of the controlled medication. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 17 of 21 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 05/17/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to a.) ensure food items were labeled and dated per facility policy, b.) keep food storage areas clean, c.) conduct hand washing in between handling dirty and clean plate ware/equipment, d.) thaw frozen meat under running cold water. These failures have the potential to affect all 242 residents receiving food prepared in the facility's kitchen. Findings include: On 05/14/24 at 9:33 AM, during initial kitchen tour V5 (Culinary Development Specialist) stated everything should be labeled and dated with an open and use by date. Dry good items are labeled with the received/delivery date and dated with an open and use by date once the item is opened. V5 stated there are different use by dates depending on what the item is. V5 referred to a sign posted on the outside of the walk-in refrigerator which listed different use by dates titled Visual Aid Use by Dates. On 05/14/24 at 9:40 AM, observed in the walk-in refrigerator the following: 1.) Opened gallon of Coleslaw Dressing labeled with received date 04/17/24, opened date 04/26/24, use by date 06/26/24. Black speckled material observed around ridges of the lid to the Coleslaw Dressing. V5 stated, that is mold and it should be thrown out despite the expiration date still being within use by range. 2.) Opened 5-pound bag of shredded mozzarella cheese wrapped tightly in plastic. Not labeled or dated. V5 stated because the item is not labeled/dated there is no way to know how long the item has been in there and it may not be safe to still use. 3.) Black material imbedded into the folds of the refrigerator door seal/gasket. V5 stated that is mold and should not be there. V5 stated that needs to be cleaned and should be part of the cleaning process. On 05/14/24 at 10:00 AM, observed in dry storage area an opened container of Worcestershire Sauce labeled with delivery date 10/19/22. There was no opened date or use by date on the container. V5 stated this product should be thrown out after 6 months from when it was opened because bacteria can grow in it. V5 stated because there is no opened date on it, and therefore it should be tossed. On 05/14/24 at 10:13 AM, surveyor and V5 observed two employees working in the dish machine area. Observed one staff was bringing in the dirty carts and breaking them down and the other staff (V6, Dietary Aide) was observed putting dirty trays and lids into the dish washer and grabbing the cleaned items from the dish washer without performing hand hygiene in between. V5 stated the dish machine area is staffed with two to three people. V5 stated if there are two people working in the dish room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 18 of 21 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 05/17/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many then the person handling the dirty items needs to wash their hands before handling the cleaned items to prevent cross contamination. V5 stated V6 should have washed V6's hands before touching the cleaned items. On 05/14/24 at 10:20 AM, V6 (Dietary Aide) stated there are supposed to be three people working in the dish room but if they do not have the staff there are only two. V6 stated, I am supposed to wash my hands after putting the dirty items into the dish machine and before pulling the cleaned items out of the dish machine. On 05/15/24 between 10:50 -11:28 AM, observed V26 (Chef) prepare pureed lunch meal items in the kitchen using two sets of blender container/lid/blades. On 05/15/24 at 11:35 AM, V26 (Chef) stated V26 needed to puree dinner rolls because they do not have a mix. Observed V25 (Kitchen Supervisor) bring the two dirty blender container/lid/blades to the dish room for cleaning. On 05/15/24 at 11:36 AM, observed V25 place the two dirty blender containers/lids/blades into dish racks and place the dish racks into the dish machine. On 05/15/24 at 11:39 AM, observed V25 remove two cleaned blender containers/lid/blades in dish racks out of the dish machine. Observed V25 pick up the blender containers and lids with V25's hands looking inside and then turning them upside down and placing them back into the dish rack. V25 did not wash V25's hands in between touching the dirty and cleaned blender items. On 05/15/24 at 11:50 AM, observed V26 retrieve a blender container/lid/blade from the dish room area and add dinner rolls to the container to begin the puree the dinner rolls. On 05/15/24 at 11:55 AM, observed large plastic bag containing meat sitting in a sink filled with water. There was no running water from the faucet into the sink containing the meat. V25 stated the meat was cubed steak and it was being defrosted. V25 stated usually they defrost items ahead of time in the refrigerator for a couple of days but in an emergency, they defrost items under cold running water in the sink. V25 stated the cubed steak should be defrosted under cold running water and someone just turned off the water. V25 stated if the frozen meat is left sitting in a sink full of water without running cold water over the product, then the water in the sink could be at room temperature which means it could reach the danger zone temperature between 41-135 degrees F. On 05/15/24 at 12:29 PM, V23 (Regional Director of Operations) stated when staffing the dish room there should be one person assigned to the dirty side of the dish machine and another person pulling out the cleaned items from the dish machine. V23 stated if there is only one person working the dish machine then that person would need to wash their hands after handling the dirty items and before handling the cleaned items. V23 stated handwashing is needed due to infection control concerns to prevent cross contamination. On 05/14/24, facility provided list of diet orders for all residents in the facility printed 05/14/24 at 11:20 AM from the facility electronic health system. Diet order list indicates there are three residents receiving nothing by mouth (NPO). Facility provided policy titled Receiving dated October 2019 documents in part safe food handling procedures for time and temperature control will be practiced in the transportation, delivery and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 19 of 21 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 05/17/2024 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many subsequent storage of all food items, and all food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. Facility provide policy titled Labeling Processes Standards and Procedures dated 2024 documents in part, TCS (Time/Temperature Control for Safety) refrigerated food label requirements these food labels intended for storage must include item name, preparation date, use-by-date (within 7 days of preparation or opening commercially prepared TCS foods), and employee initials. Facility provided document titled Visual Aid Use by Dates dated 2019 documents in part, Commercially Prepared Ready-To-Eat (RTE) Foods - opened shredded cheddar/mozzarella use by date 14 days after opening and RTE Non-Temperature Control for Safety (TCS) Food - condiments, sauces use by date 30 days after opening. Facility provided policy titled Hand & Arm Hygiene dated 2021 documents in part, employees must wash hands before handling clean dishes, utensils, and glasses and after handling dirty equipment and utensils. Facility provided policy titled Food Handling - Thawing dated 2024 documents in part thawing under cold running water steps: run cold water continuously over the product and maintain an air gap between faucet and water. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 20 of 21 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 05/17/2024 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)

F 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure dumpster was covered to prevent the harborage and feeding of pests, insects, and rodents. This deficient sanitation practice has the potential to affect all 245 residents who reside in the facility. Residents Affected - Many Findings include: On 05/15/24 at 8:35 AM, upon entry to the facility observed one of four lids opened to the north facing dumpster outside the facility. The lid was wide open. On 05/15/24 at 12:36 PM, during observation of the outside garbage dumpsters with V24 (Visiting Food Service Manager) observed one of the four lids opened to the south facing dumpster. The lid was wide open. V24 stated the lid should be closed so that garbage does not fly out and pests do not get inside. On 05/16/24 at 11:53 AM, during observation of the outside dumpsters with V40 (Housekeeping Director) observed one of the lids to the south facing dumpster propped open with garbage and boxes. V40 stated the lid should be fully closed but it may be unavoidable if the dumpsters are completely full. The other three lids to the south facing dumpster were opened and observed that the rest of the south facing dumpster was completely empty. V40 observed the empty dumpster sections and stated, oh, yes that is avoidable then. V40 stated the staff should have put the trash in one of the other empty sections of the dumpster because clearly there is room and that way the lid could be fully closed flat. V40 stated the lids should be closed all the way. V40 stated the way the dumpster is now rodents could jump in and start feeding on the food thrown away by the kitchen. On 05/16/24 at 11:40 AM, V40 (Housekeeping Director) stated the lids of the dumpster should be closed after the Floor Technician puts the trash into the dumpster to prevent anything from flying out or any animals' such as rodents climbing inside. V40 stated the garbage inside the dumpster could attract rodents and/or pests and if the lids are left open, they could get inside and feed on the garbage inside. V40 stated we do not want rodents or pests close to the building for sanitation reasons because they can carry disease. Kitchen policy titled, Environment dated October 2019 documents in part, the Dining Services Director will insure (ensure) that all trash is properly disposed in external receptables (dumpsters). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145507 If continuation sheet Page 21 of 21