Health 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 Page 1 of 3 145507 145507 06/12/2025 Clark Manor 7433 North Clark Street Chicago, IL 60626

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few roommate and me had a disagreement the other night about the TV. He thought I had it too loud, and he wanted me to turn it down. That is when he put his hand up and ran it down my face. I don't think he had any intention to cause harm. The situation is over, he is gone, and I love my room. I don't want to discuss it anymore. R2's signed statement regarding disagreement with R1 dated 6.10.2025, (no time) documents: The other night my roommate had his TV up too loud. I was turning down the TV and (R1) walked up to me. I got startled because he is bigger and waved up my hands. I am a short, little guy. I wasn't trying to hit (R1) or cause any harm. R2 was not available for interview during the survey. R1's face sheet documents R1 is a [AGE] year-old admitted to the facility on 12.16.2024, with diagnoses including but not limited to: Chronic systolic (Congestive) heart failure, Bipolar disorder, current episode manic severe with psychotic features; Gastro-esophageal reflux disease without esophagitis, Major depressive disorder, recurrent, severe with psychotic symptoms; Chronic kidney disease, stage 3A. R1's MDS (Minimum Data Set of 3.25.2025) documents a BIMS (Brief Interview for Mental Status) of 15 denoting R1 is cognitively intact. R2's face sheet documents R1 is a [AGE] year-old admitted to the facility on 7.21.2022, with diagnoses including but not limited to: Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Alcohol abuse, uncomplicated; Other specified diseases of liver, Essential (Primary) hypertension. R2's MDS (Minimum Data Set of 4.16.2025) documents a BIMS (Brief Interview for Mental Status) of 15 denoting R2 is cognitively intact. On 6.10.2025, at 2:30 PM, R1's General Progress Note documents in part: On 6.10.2025 at around 2:00 PM, Administrator (V1) and Assistant Administrator (V3) were approached by R1. R1 stated that he had a disagreement with his roommate over the loudness of the television in their room. During the process, his roommate R2 made contact to his face. Both parties were immediately separated. A complete physical assessment was done for R1. No redness, bruising or discoloration noted on (R1's) face and no other visible injury noted to his body as well. (R2) will be sent out for psych evaluation. On 6.10.2025, at 6:41 PM, R2's Behavior Note documents in part: Resident was alleged of physical aggression towards his peer. Both were separated immediately, and he was placed on 1:1 monitoring. Resident requires immediate hospitalization to prevent harm to self and others. (Physician) was informed. An order was given to send resident to the local hospital emergency department on involuntary petition for psych evaluation. Order noted and carried out. On 6.11.2025, at 7:55 AM, R2's General Progress Note documents in part: Placed a call to (local hospital) emergency department to inquire about resident's disposition and made aware that resident is admitted to the psych unit due to aggressive behavior. R2's Petition for Involuntary/Judicial admission (dated 6.10.2025) documents in part: -Emergency inpatient admission by certificate. The Respondent is currently detained in a mental health facility or hospital. -Person continues to be subject to involuntary admission on an inpatient basis. 145507 Page 2 of 3 145507 06/12/2025 Clark Manor 7433 North Clark Street Chicago, IL 60626

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few -R2 is a person with mental illness who: because of his or her illness is reasonably expected, unless treated on an inpatient basis, to engage in conduct placing such person or another person in physical harm or in reasonable expectation of being physically harmed; a person with mental illness who: because of his or her illness is unable to provide for his or her basic physical needs so as to guard himself or herself from serious harm without the assistance of family or others, unless treated on an inpatient basis; a person with mental illness who: refuses treatment or is not adhering adequately to prescribed treatment; because of the nature of his or her illness is unable to understand his or her need for treatment; and if not treated on an inpatient basis, is reasonably expected based on his or her behavioral history, to suffer mental or emotional deterioration and is reasonably expected, after such deterioration, to meet the criteria of either paragraph one or paragraph two above. (Is) in need of immediate hospitalization for the prevention of such harm. (R2) was alleged of physical abuse towards his peer. He has been placed on 1:1 monitoring until sent to the hospital for psych evaluation. (R2) requires immediate hospitalization to prevent harm to self and others. Administrator and physician were notified. Initial report has been sent to IDPH (Illinois Department of Public Health) with final report to follow. Abuse and Neglect policy (Reviewed/Revised 4.24.2025) documents in part: -Policy Statement: it is the policy of the facility to provide care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. -Definitions of abuse: Abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation or punishment. Abuse assumes intent to harm, but inadvertent or careless behavior done deliberately that results in harm may be considered abuse. 145507 Page 3 of 3