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
interview and document review the facility failed to ensure the rights of residents to be free from abuse in
one of four residents (R1, R7, R8 and R10) in a sample of 10 residents. This resulted in R7 sustaining a
superficial scratch to left side of face near eye.
Findings include:
R7 is a [AGE] year-old male with diagnoses including Parkinsonism, COPD, Schizoaffective Disorder,
Diabetes 2, and Alcohol Abuse. R7 was first admitted to the facility on [DATE]. R7 has a BIMS (Brief
Interview for Mental Status) score of 15/15.
R7 hospital record dated 3/8/25 shows R7 sustained superficial abrasion to the left bridge of nose/near eye.
No other injuries sustained in the altercation.
On 3/11/25 at 2PM R7 stated yes, I had an altercation with R8 out on the smoking patio. R8 started
urinating out on patio and did it on my leg. I pushed him away and he pushed my face with his hand. My
glasses fell off my face and broke on the ground. He poked my eye, and I had a small scratch on my
eyebrow. I went in and told staff. Staff called the police and got R8 from the patio. The police came but I
didn't want to press charges. I didn't get hurt. They sent us both to the hospital and I returned without any
injury except the scratch. I haven't seen R8. I don't want to talk about this anymore. I am safe here. R8
didn't mean it he is just sick so it's not a big deal to me.
On 3/11/25 at 1:56PM V2 (Assistant Administrator) stated we received a call that R7 allegedly received a
scratch. We immediately separated both residents. Both were assessed. There was no serious injury just a
tiny superficial scratch to the face of R7 with no significant injury. R7 was not in pain or distress. We
reported to the State Agency immediately. Chicago Police called. R7 refused to press charges. R7 stated
the patient is sick and no need to do anything. Both were sent to hospital. R7 was sent to hospital with no
significant injury and returned the same day.
On 3/12/25 at 1:40PM V8 (RN/Registered Nurse) stated R7 came in from patio and told me R8 scratched
his face and broke his glasses. I assessed him with a small scratch below his eye. I notified other staff who
came and provided 1:1 to both R7 and R8. The police arrived. Family and doctor was notified. Both
residents were sent to the hospital.
R7 3/11/25 Social Service note states this writer went to speak to R7 to see how he was doing in regard to
an incident that allegedly happened this past Saturday. He (R7) told this writer, I'm fine, and there is nothing
to talk about its over with and I don't want to talk about it anymore. Social
(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 2
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
03/13/2025
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 0600
services will continue to offer support as needed.
Level of Harm - Minimal harm
or potential for actual harm
R8 is a [AGE] year-old male with diagnoses including Bipolar Disorder, Hepatitis C, Nicotine Dependence,
Other Drug Induced Secondary Parkinsonism and Thrombocytopenia. R8 was first admitted to the facility
on [DATE]. R8 has no BIMS (Brief Interview for Mental Status) score non scorable. R8 is care planned for
including Verbally Physically Aggressive Behavior as the result of the 3/8/25 incident, R8 is care planned for
Delusional Behavior.
Residents Affected - Few
Review of facility alleged abuse investigations show that on 3/8/25 at around 4:05 PM Administration
received a call from V3 (RN), Nursing Supervisor who stated that resident R7 has alleged that R8 had
scratched his face. R7 was assessed and had no significant injury. R8 has a diagnosis of Bipolar D/O and
Mild Cognitive Impairment and other medical conditions. R7 was sent to hospital for medical and R8 was
sent to hospital for psych eval. Chicago Police Department was notified, and officer responded, and a
report was filed. NP/nurse practitioner and mother of R7 were both notified. This will serve as the facilities
initial report. Investigation immediately initiated.
R8 3/8/25 progress note states resident noted with verbal and physical aggression towards others.
Un-redirectable, placed on 1:1 monitoring. DR/doctor notified with order to send resident to Hospital
ER/emergency room on involuntary petition for psych evaluation. Order noted and carried out. Resident
became uncontrollable, 911 was called and transferred him to Hospital. Doctor informed. Resident has no
family contact. Report given to Hospital psych intake c/o. Resident face sheet, POS/physician order sheet,
most recent lab results and medication list faxed to 773-xxx-xxxx.
R8 3/8/25 progress note states in addition, resident was transferred to hospital with the assistance of
Chicago Police, report filed.
Facility policy titled Abuse and Neglect Revised 7/12/24 includes statement:
Policy Statement: It is the policy of the facility to provide professional care and services in an environment
that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect,
or mistreatment.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145507
If continuation sheet
Page 2 of 2
