Inspection·June 12, 2025

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 record review, the facility failed to ensure that residents are free from abuse for one of three residents (R1) reviewed for abuse in a total sample of four residents. Findings include: On 6.11.2025, at 12:37 PM, R1 said, R2 was screaming at me that my television was too loud. The nurse, I don't remember her name, came into my room. She said the television was not too loud. I was sitting on my bed, R2 was standing about 1 ½ feet from me. He hit me with his fist on my left cheek and part of my nose. It happened so fast; the staff couldn't have prevented it. The nurse called for help. CNAs (Certified Nursing Assistants) came and escorted R2 out of the room. As he was leaving, R2 said to me, I'm going to come back and kill you. I didn't sleep all night because of his threat. I feel great now that he isn't here in the facility. I'm okay if he comes back. I have V3's (Assistant Administrator's) phone number. V2 (DON-Director of Nursing) assessed me after the incident. I was interviewed multiple times; I signed my statement after reading it. On 6.12.2025, at 9:59 AM, via telephone, V8 (LPN-Licensed Practical Nurse) said, on that day (6.9.2025), around ten something at night, I was at the nurses' station. I heard a noise. V7 (CNA) was on her way to call me, I met her on the way. She went into the room with me. I got to the room they, R1 and R2, were arguing about the TV being too loud. I tried to separate them. I asked R2 to follow me to the nurses' station, he did. I notified the nursing supervisor. She told me to separate them. Neither resident said anything about R2 hitting R1. On 6.10.2025 at 10:20 AM via telephone, V7 (CNA) said, it was on Monday (6.9.2025) between 10:00 PM and 11:00 PM. R2 was calling me to come see. R2 said R1's television was too loud. I went into their room. R1's television was too loud. With R1's permission, I turned his television down. I left the room, I reported to V8 what happened. She told me to move R2 to the 5th floor to prevent anything further from occurring. Facility's initial incident report of 6.10.205, documents in part: On 6.10.2025, at around 2:00 PM, V1 (Administrator) and V3 (Assistant Administrator) were approached by (R1) who stated that he had a disagreement with his roommate over the loudness of television in their room. During the process, his roommate (R2) made contact to his face. Both parties were immediately separated. R1 was assessed and had no redness, bruises, or discoloration noted to his face. R2 was sent to the hospital for a psych eval. R1's signed statement regarding the disagreement with R2 dated 6.10.2025, (no time) documents: My (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 06/12/2025 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)