Health inspection·March 10, 2022

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to track the status of influenza and pneumococcal vaccinations and consents for three residents (R29, R37, and R40), in a sample of 7 residents. Residents Affected - Few Findings include: 1. On 3/09/22 at 9:25 AM, R29's electronic immunization record had no influenza or pneumococcal vaccines documented. No consents for either vaccine were found in the electronic medical record. R29 was not listed on the influenza or pneumococcal immunization report provided to the surveyor by V10 (Infection Preventionist). R29 was admitted on [DATE]. 2. On 3/09/22 at 10:34 AM, V10 stated V10 is still working on obtaining the Influenza/Pneumococcal consents for the residents requested 3/08/2022. V10 stated R37 is from the assisted living portion of the facility, and V10 will have to obtain the consents from them. R37 is currently in the short-term rehab. On 3/09/22 at 11:53 AM, R37's electronic immunization record had no influenza or pneumococcal vaccines documented. No consents for either vaccine were found in the electronic medical record. R37 was not listed on the influenza or pneumococcal immunization report. R37 was admitted on [DATE]. 3. On 3/09/22 at 11:54 AM, R40's electronic immunization record had no influenza or pneumococcal vaccines documented. No consents for either vaccine were found in the electronic medical record. R40 was not listed on the influenza or pneumococcal immunization report. R40 was admitted on [DATE]. On 3/09/22 at 3:10 PM, the surveyor asked V10 (Infection Preventionist) if there is a specific policy on tracking of influenza and pneumococcal vaccination status for residents. V10 stated, I don't believe there is a specific policy. V10 stated the immunization report provided to the surveyor was run from the electronic medical record, and that's where the consents and immunizations are documented. The surveyor asked V10, how do you know who is due for a pneumonia or influenza vaccine? V10 stated the floor nurses are responsible for checking the vaccination status. V10 stated, Moving forward, I can take over the task and create a more streamlined process. On 3/10/2022 at 10:16 am, the surveyor interviewed V2, DON (Director of Nursing) and asked if a resident declines influenza/pneumococcal vaccination and is eligible to receive the vaccine, what is the expectation for following up with the resident? V2 stated they do follow up with the residents or the resident's family yearly to see if they want to be vaccinated. So, the expectation for someone who refused vaccination in the past is to follow up the next year. The surveyor asked who is responsible for making sure residents are up to date with the influenza and pneumococcal vaccinations? V2 stated the nurses on the floor check the vaccination status, and audits are done from the electronic medical record. V2 stated V2's supervisor has an admission audit form. V2 stated V2 also talks with the staff, especially for new admissions, to make sure that they have current vaccinations. V2 stated V10 (Infection Preventionist) offered to take over the responsibility of tracking influenza and pneumococcal vaccinations and consents. The surveyor asked V2 what is the importance of making sure that influenza and pneumococcal vaccinations are up to date? V2 stated, Aside from compliance, we want to make sure our residents are protected. V2 stated a lot of the residents in the facility are immunocompromised so the best way to protect them is to make sure they have been vaccinated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 2 of 3 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 146009 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/10/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Selfhelp Home of Chicago 908 West Argyle Street Chicago, IL 60640 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 0883 The facility policy titled Influenza and Pneumococcal Immunizations for Residents, dated 7/2018, has no procedure for tracking of influenza and pneumococcal vaccines. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 3 of 3