Inspection·July 1, 2025

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and document review the facility failed to maintain an effective pest control program so that the facility is free of rodents on 3 of 4 resident floors. Residents Affected - Some Findings include: On 6/26/2025 at 09:52 AM, R1 stated, that she has seen mice in the room by a bed. R1 said, that since she has been residing at this facility, there have always been mice seen in the resident's rooms. R1 stated, that she was moved from another room before multiple times and each time, she saw mice in the room. R1 stated that the mice could be seen sometimes running from one resident's room to the other, mainly at night, but she seen it during the day too. On 6/26/25 R1's room was observed with mouse droppings on the floor behind the bedside cabinet and under the heat/air conditioning unit. On 6/26/2025 at 10:32 AM, Observed R3 laying in the bed, dressed, and groomed appropriately, wearing shoes in the bed. No insect or roaches noted on the bed or the clothes. R3 stated, that he has seen mice recently, in his bathroom. R3 said that the mice ran from under the bathroom door and slide under the room's door, into the hallway. R3 stated that he does not like the mouse trap being in the room. On 6/26/25 R3's room was observed with mouse droppings on the floor in corner next to bed. On 6/26/25 at 11:05 AM R8 stated I see mice in my room all the time at night. On 6/26/25 at 11:05 AM R8's room was observed with mouse droppings on the floor and behind the bed and under heating / air conditioning unit. On 6/26/25 at 1:15 PM R11 stated yes I see mice in my room at night. They come in here from the hallway. On 6/26/25 at 1:25 PM R12 stated I see mice in at night. I don't like seeing mice in my room. On 6/26/25 at 1:25 PM R12's room was observed with mouse droppings on the floor next to window. On 6/26/25 at 1:40 PM R13's room was observed with mouse droppings on the floor next to the heating/air register. A hole was observed next to the register at the baseboard. Facility Policy titled Pest Control Revised 8/16/24 states It is the facility policy to ensure that (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 07/01/2025 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)