Inspection·August 26, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review the facility failed to ensure accuracy of wound location, failed to document a thorough wound assessment, failed to follow physician orders, failed to ensure that treatment administration is not documented when not performed and/or failed to implement care plan interventions for three of three residents (R2, R3, R4) reviewed for wound care. Residents Affected - Few Findings include: On 8/14/24, IDPH (Illinois Department of Public Health) received allegations that the facility does not take wounds seriously. R3's diagnoses include dementia and xerosis cutis (abnormally dry skin). R3's (8/2/24) BIMS (Brief Interview Mental Status) states resident is rarely/never understood. R3's (8/2/24) functional assessment affirms resident is dependent on staff for ADL (Activities of Daily Living) care. R3's (8/15/24) initial skin/wound notes includes the following: right posterior knee abrasion. 4.0 x 1.0 x 0.1cm (centimeters). 100% epithelial. Periwound: intact, fragile. R3's (8/15/24) POS (Physician Order Sheets) includes right posterior knee: cleanse with NS (Normal Saline), pat dry with gauze, apply xeroform to the base of the wound and cover with border gauze dressing every day shift (Tuesday, Thursday, Saturday) and PRN (as needed). R3's (1/25/21) care plan includes abrasion to right posterior knee, intervention: (8/20/24) cleanse with NS, apply xeroform to base of the wound, secure with gauze 3x per week (Tuesday, Thursday, Saturday) and PRN. R3's (8/20/24) skin/wound notes state right posterior knee improving without complication, wound care will follow until resolved [therefore the wound was not resolved]. On 8/20/24 at 11:16am, surveyor inquired about R3's wound however R3 did not respond. Surveyor inquired if R3 is able to communicate, V4 (CNA/Certified Nursing Assistant) stated Sometime he talk but not really. Two (2) large, scabbed areas (with redness surrounding each) were observed on the back of R3's right lower posterior thigh (not the posterior knee) and there was no dressing present. Surveyor inquired about the appearance of R3's wound, V4 responded It some sore, it look like it was a blister but it dry. Surveyor inquired if a dressing was present on R3's wound, V4 replied When they (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 3 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 08/26/2024 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)