Inspection visit

Health inspectionMay 12, 2023

SELFHELP HOME OF CHICAGOCMS #1460099 citations on this visit

9 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0565 Honor the resident's right to organize and participate in resident/family groups in the facility. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide residents with private space for resident council meetings, and failed to notify resident representative (Ombudsman) with resident council meeting date changes. These failures have the potential to affect all 55 residents living in the facility. Residents Affected - Some Findings include: On 5/9/2023 at 10:10 AM, V28 (Ombudsman) said the facility sends her a calendar (schedule) for resident council meeting, then when she gets here, the meeting has been changed or already happened, and no one at the facility lets her know of the changes. On 5/11/2023 at 1:15 PM, V27(Activity Director), said she sets and she puts together residents who will attend resident council meetings for the residents, because that is what she was told to do, and the facility had to have resident council meetings. V27 said the residents who attend resident council meetings have dementia, and do not talk much during resident council meetings, and the meetings are not private because staff have to be present in all meetings to take/write the meeting minutes for the residents. V27 said the residents who attend the meetings do not verbalize any needs. V27 further said she sends V28 (Ombudsman) the calendar for the year's resident council meeting dates, and if V27 moves or changes the meeting dates, she does not see the need inform V28, because V28 has not verbalized to V27 that she (V28) would like to attend resident council meetings, and she (V27) has never seen V28 in the facility; therefore, V27 does not think V28 wants to attend the resident council meetings. V27 commented residents who are alert can verbalize their needs to their social workers, therefore, they do not need to attend resident meetings because their needs are met. V27 said the current resident president has been sick for the last two to three months, and has not been able to attend to resident council meetings. V27 said she has not recruited another resident for resident council president, but was thinking of recruiting R34 as the resident council president. On 05/10/23 at 10:57 AM, in R261's (resident council president) room, R261 stated the Activities Department arranges for resident council meetings, and are present in all meetings, which are held once a month. R261 was observed to have a difficult time speaking and spoke in a whisper, and was observed with a private care giver in her room. R261 stated she has not been attending resident council meetings due to decline in health,and said she did not know who the Ombudsman is. R261's MDS (Minimum Data Set) section C (Cognitive patterns), dated 2/14/2023, documents R261's BIMS (Brief Interview for Mental Status) score is 8 out of 15, meaning R261 is cognitively moderately impaired. R261's medical diagnosis includes, but is not limited to, unspecified Dementia. On 05/10/23 at 11:05 AM, during resident council meeting, R43 said there were fewer meetings because the resident council president was sick. R43's MDS (Minimum Data Set) section C (Cognitive (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 17 Event ID: 146009 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 05/12/2023 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 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some patterns), dated 4/11/2023, document R43's BIMS (Brief Interview for Mental Status) score is 13 out of 15, meaning R43's is cognation is intact. n 05/10/23 at 11:05 AM, during resident council meeting, R24 waited for V27 to leave the room (V27 had been requested to reave the room during resident council meeting; V27 left the room but was within ear shot of the resident council meeting room) to take residents downstairs, and said to surveyor, Staff is always present in all meetings and residents find it hard to say anything negative or say their concerns for fear of what they say coming back to them. R24's MDS (Minimum Data Set) section C (Cognitive patterns), dated 2/7/2023, document R24's BIMS (Brief Interview for Mental Status) score is 14/15, meaning R24's is cognation is intact. Policy titled: Resident council policy, no date, documents: -Staff members may not attend Resident Council meeting unless given a formal invitation from the Council -Resident Council Meetings are private and confidential -Annual elections shall be held in order for the residents to vote for council officials FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 2 of 17 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 05/12/2023 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview ,and record review, the facility failed to ensure residents are free from physical restraints for 1 resident (R47) out 3 residents reviewed for restraints, in a sample of 15. Residents Affected - Few Findings include: On 05/11/2023 at 10:45 AM, R47 was at the nurse's station, behind the desk. R47's wheelchair was pushed close to the desk, with her bilateral lower extremities underneath the desk, preventing her from being able to stand up. R47 was restless and trying to get up. There was no nurse or CNA (Certified Nursing Assistant) at the desk monitoring R47. R47 was placed behind the desk, with her wheelchair locked, and left by herself. On 05/11/2023 at 11:00 AM, V25 (Certified Nursing Assistant) stated, We place (R47) behind the desk because she is a high fall risk, so we put her behind the desk so that she doesn't get up. On 05/11/2023 at 11:17 AM, V24 (Registered Nurse) stated she is the nurse for R47. V24 stated they usually put R47 at the nurse's station because she tends to get up on her own. V24 stated R47 has had multiple falls and needs to have close observation because she tends to get up. V24 stated they make sure to lock the wheelchair when they put R47 behind the desk of the nurse's station. V24 stated the intention of locking the wheelchair is to make sure the wheelchair does not move. On 05/11/2023 at 2:15 PM, V2 (Director of Nursing) stated R47 is at high risk for falls. V2 stated, She will get up so we put her by the desk to watch her because she will try to get up. She has to be watched one on one all the time. She cannot verbalize her thoughts because she has dementia. R47's Facesheet (10/1/2022) documents in part: unspecified dementia, hemorrhage, sequelae of cerebral infarction, dysphagia, restlessness, and agitation. R47's MDS Section C, Cognitive Patterns (2/7/2023) documents in part: BIMS (Brief Interview for Mental Status) score - 99. Enter 99 if resident is unable to complete the interview. This means R47 is not cognitively intact. R47's care plan had no documentation of placing R47 behind the nurse's station, so close to the desk where she cannot get up. Facility's abuse policy (undated) documents in part: It is the policy of Self Help Home that each resident will be free from abuse. Abuse can include verbal, mental, physical, sexual abuse, corporal punishment or involuntary seclusion. The resident will also be free from physical or chemical restraints imposed for purpose of discipline or convenience and that are not required to treat the resident's medical symptoms. Facility's Physical Restraints policy (undated) documents in part: Resident of the Self Help Home will be assessed and provided for an appropriate assistive device to attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. The use of physical or mechanical method, material or equipment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 3 of 17 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 05/12/2023 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 0604 Level of Harm - Minimal harm or potential for actual harm which restricts freedom of movement for convenience and/or to discipline is prohibited in this facility. Physical restraints include but not limited to leg restraints, arm restraints, hand mitts, soft ties or vests, lap cushions, and lap trays that resident cannot remove easily. Also included is using devices in conjunction with a chair, such as trays, tables, bars or belts in which the resident can not remove easily and/or prevents the resident from rising. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 4 of 17 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 05/12/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, facility failed to follow their policy to use gait belts to transfer residents who require limited to extensive assistance with partial, toe-touch, or non-weight bearing restrictions for 1 (R47) resident out of 4 residents reviewed for falls in a sample of 15. Findings include: On 05/11/2023 at 10:45 AM, R47 was at the nurse's station behind the desk. R47's wheelchair was pushed close to the desk, with her bilateral lower extremities underneath the desk, preventing her from being able to stand up. R47 was restless and trying to get up. There was no nurse or CNA at the desk monitoring R47. On 05/11/2023 at 11:00 AM, V25 (Certified Nursing Assistant) transfered R47 from her wheelchair to her bed, without using a gait belt. V25 held R47 underneath her armpits and lifted R47 from her wheelchair and sat her down on her bed. On 05/11/2023 at 11:15 AM, V24 stated, (R47) is actually one person assist. Everyone is required a gait belt for transfer. We received an in-service about using weight belt. The CNA might have forgotten. The CNAs are also being in-serviced for using gait belt. Gait belt is important to use because you get a good grip on the belt and resident to prevent the resident from falling. (R47) has fallen before, so using a gait belt on her is very important. V24 stated R47 is an extensive assist resident. On 05/11/2023 at 2:15 PM, V2 (Director of Nursing) stated, You assist residents by how much they can help. A lot of times if they are non-weight bearing, they need more assistance. We use a gait belt to help those who are extensive assist. R47's care plan documents in part: I had an actual fall on 9/9/2022, 9/15/2022, 1/1/2023, and 2/17/2023 where I stood up from my wheelchair, lost my balance and fell. Staff to make sure that someone is keeping an eye on me since I tend to get up when I am sitting in the wheelchair. Get her up when restless. R47's MDS section G, Functional Status (2/7/2023) documents in part: Transfer, how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. R47 was scored at a 3 for transfer. The coding chart explains that a score of 3 means the resident is extensive assist. Facility's Transfer-Non Mechanical Lift (7/2018) policy documents in part: It is the policy of the Self Help Home to use gait belts to transfer residents who require limited to extensive assistance with partial, toe-touch, or non-weight bearing restrictions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 5 of 17 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 05/12/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to properly secure controlled medications for 3(R261, R27, R36) residents reviewed in a sample of 15 residents. Residents Affected - Some Findings include: On 5/9/2023 at 1:00 PM, surveyor with V4 (Registered Nurse-RN) while inspecting 7th floor medication room, observed medication refrigerator not locked, with padlock hanging on the side of the fridge lock handle. Inside the medication fridge was observed: Inside the fridge were observed R261 medications as follows: -Two full vials, plus half a vial of Morphine Sulphate (liquid), 30mL, 5mg/mL -One vial of Lorazepam 2mg/mL R261has medical diagnosis that include but not limited to: Severe Aortic Stenosis, polymyalgia rheumatica, sarcopenia, nondisplaced fracture of lateral malleolus of left fibula, initial encounter for closed fracture. R261's Physician orders dated 2/15/2023 document: - Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate). Give 0.25 ml by mouth every 2 hours as needed for moderate pain (1-5) -Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate). Give 0.5 ml by mouth every 2 hours as needed for severe pain (6-10) -Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate). Give 0.25 ml by mouth every 1 hours as needed for dyspnea/air hunger/SOB(Shortness of breath) or RR (Respirations)>(greater than)24/min (hold if RR falls below 12/min) There were 4 pens of insulin basaglar labeled with R27's name in the fridge. R7's medical diagnosis includes but not limited to: type 2 diabetes mellitus with diabetic nephropathy. R27's physician orders dated 8/2/2023 document: -Basaglar KwikPen Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 8 unit subcutaneously in the evening for DM(Diabetes) Type 2 Four unopened pens of Trulicity pens were observed in the fridge labeled with R36's name. R 36's medical diagnosis includes but not limited to: type 2 diabetes mellitus without complications, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R36's Physician orders 11/12/2022 document: -Dulaglutide Solution Pen-injector 3 MG/0.5ML (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 6 of 17 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 05/12/2023 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 0755 Inject 0.5 milliliter subcutaneously one time a day every Sat for DM(Diabetes) 2 Level of Harm - Minimal harm or potential for actual harm V4 said fridge for medication should be locked because there are controlled medications in the fridge like morphine. V4 further stated the policy is to lock the medication in the fridge with a double lock for security reasons to prevent medications from being mishandled and or misused. Residents Affected - Some On 5/10/2023 at 10:37AM, V2 (Director of Nursing -DON) said all narcotics in the fridge in the medication room should have been double locked and said, There is the lock for the fridge, then the main door, and both the fridge door and the main door should be locked because there are controlled medications in the medication room and the medication fridge should be double locked with only the nurses having the key to prevent mishandling. Policy titled Controlled Substance Storage, dated 10/25/2014, documents: -Schedule 11-V and other medications subject to abuse or diversion are stored in a permanently affixed, double -locked compartment separate from all other medications as per state regulation. -Controlled-substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 7 of 17 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 05/12/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to dispose/discard expired medications in one two medications carts/medication room/storage reviewed. This failure has the potential to affect 21 residents receiving medications from the 7th floor medication cart/storage room, in a sample of 55. Findings include: On 5/09/2023 at 12:34 PM, surveyor with V4(Registered Nurse-RN), while inspecting medication cart on 7th floor observed expired medications on the cart: 1. Insulin Lispro, labelled with R27's name, with opened by date of 3/27/2023, and another insulin Lispro vile opened, and with expiration date of 4/27/2023. V4 said, Once insulin is opened, it stays for 30 days, and then should be discarded. After 30 days, the opened insulin is no longer potent and should be discarded. Once the insulin is opened, the manufacture's expiration date is surpassed by the date the insulin was opened and should be discarded after 30 days. R27's medical diagnosis include but not limited to: type 2 diabetes mellitus with diabetic nephropathy, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. R27's physician order sheet dated 4/28/2023 document: Insulin Lispro Solution Inject as per sliding scale: if 201 - 250 = 1 unit; 251 - 300 = 3 units; 301 - 350 = 5 units; 351 - 400 = 7 units below 60 & above 400 call MD, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with diabetic nephropathy. 2. Omeprazole 20mg bottle labelled with R21's name was observed with worn off label that was not legible, no open by date, no instructions visible. V4 said she does not know when the medication expires and stated, This medicine for (R21) comes as a mail order. V4 further said there is no expiration date on the bottle of medication, and she said, I don't know when it will expire or when it was opened. This medication should have an opened by date, expiration date and/or instructions for administering the medications. R21's medical diagnosis include but not limited to type 2 diabetes mellitus without complications, pure hypercholesterolemia, unspecified. R21's Physician order sheet, dated 1/14/2023, documents: Omeprazole Oral Tablet Delayed Release 20 MG (Omeprazole) Give 1 tablet by mouth one time a day for anticholinergics 3. Bottle of Acetaminophen 325 mg per tablet (house stock) with expiration date of 3/2023. V4 said expired medications should not be in the medication cart, and should be discarded. V4 said giving expired medications to residents can cause adverse effects on the resident. On 5/10/2023 at 10:37 AM, V2 (Director of Nursing -DON) said, Expired medications must be discarded and should not be available in the medication cart to decrease the risk of being given to residents. Expired medications lose potency and can affect a resident who receives it negatively. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 8 of 17 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 05/12/2023 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 0761 Policy titled ID1 Storage of Medication, dated 05/01/2028 documents: Level of Harm - Minimal harm or potential for actual harm -The expiration date of the vial or container will be [30] days unless the manufacturer recommends another date Residents Affected - Some -All expired medications will be removed from the active supply and destroyed in the facility, regardless of amount remaining. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 9 of 17 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 05/12/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure the kitchen was free of expired food products. This failure has the potential to affect 52 residents residing in the facility receiving food from the kitchen. Findings include: On 5/9/23, surveyor observed: Refrigerator #1: -Horseradish with beets; opened 3/7/23 -Lingonberries stirred with sugar; opened 3/28/23 -Nonfat yogurt; expiration date 4/25/23 -Cottage cheese; expiration date 5/7/23 Walk-in refrigerator (kitchen): -Feta cheese; opened 3/19/23; expiration date 1/3/23 -Light and Fit Nonfat yogurt; expiration 4/28/23 Dry storage containers/bins: -Polenta; prep date 11/10/22; use by date 1/11/23 -CousCous; prep date 3/3/23; use by date 3/30/23 Milk refrigerator (basement): -Lowfat yogurt; best by 4/14/23 On 5/10/23 at 1:21 PM, V34 (Dietary Supervisor) stated, There should be no expired food items in the kitchen. We do FIFO (first in first out) method, where we use the old item first. The team lead and person that gets deliveries and everyone in the kitchen is supposed to check the dates. When staff opens something from the refrigerator or shelf, they put the open date and the 6 day period for the discard on the item and check for the manufacturer expiration date. Expired foods can lead to food poison, diarrhea/dehydration, illness, stomach cramps in the resident. 5/10/23 at 1:36 PM, V35 (Cook) stated,When food is expired, I put it in the garbage. It's no good. The resident can get sick if food is expired. When something is opened, put the opened date on it and the date at 6 days. After 6 days it's thrown out. I check the manufacturer date first, if expired then throw it away. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 10 of 17 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 05/12/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm On 5/10/23 at 2:38 PM, V36 (Director of Dining Services) stated, Of course, there should not be expired foods in the kitchen. If food is expired, there is a risk of somebody getting sick, diarrhea, vomiting, hospitalization. Opened items are labeled with the date opened and 6 days forward. On the sixth day it should be used or thrown out by the end of the day when the kitchen closes. So not to use expired items, all kitchen staff that handles food is responsible for labeling and discarding if expired. Residents Affected - Many Facility policy Refrigerated Food, 2017, documents in part: Refrigerated food prepared in the healthcare community is labeled with the date to discard or to use by. This includes leftovers. The discard/use by date will be a maximum of six days after preparation. Refrigerated Potentially Hazardous Food (PHF) or Time/Temperature Controlled for Safety (TCS) foods are labeled with the date received and if not opened, are discarded by the manufacturer's expiration date. If opened, the cold food item is labeled with the date opened and the date by which to discard or use by. Facility policy Storage of Refrigerated Foods, 2018, documents in part: Food in the refrigerator is covered, labeled and dated with a use by date. Facility policy Storage of Dry Goods/Foods, 2018, documents in part: Opened products are labeled, dated with the use by date and tightly covered to protect against contamination from insects and rodents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 11 of 17 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 05/12/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on observation, interview, and record review, the facility failed to maintain accurate record of residents for 3 out of 15 residents (R111, R17, and R47) for a total sample of 15 residents reviewed for resident's record. Findings include: 1. On 05/09/2023 at 12:25 PM, V3 (Infection Preventionist/IP) was asked about R111, and what the facility is doing to prevent spread of Lyme's disease. V3 said, (R111) had Lyme's disease diagnosis upon admission. (R111's) Lyme's disease is still active and is still being treated with antibiotics. Yes, there is a poster for enhanced barrier precautions near the door of (R111) for staff to use proper PPE including gown and gloves. Documents were requested from V3 (IP), including care plan. V3 presented R111's care plan that does not reflect the following documentation: Dated 05/01/2023 staff to wear gloves and gowns (Enhanced Barrier Precautions) during high-contact resident activities to reduce transmission of resistant organism. V3 was asked about the removal in the care plan of documentation related to wearing of PPE (personal protective equipment) for a resident with Lyme's disease infection. V3 said, I think (V16, Minimum Data Set Coordinator) just made modification today. I do not know why V16 removed it. At 12:40 PM. V16 said, I modified (R111's) care plan today (05/09/2023) as resolve. V16 was asked why she (V16) removed it, Yes, it was after I knew that you were requesting it, that I resolved and removed it. If you want, I can just click and unresolve it. Further review of R111's care plan was found that performance of proper handwashing techniques, to minimize microorganism transmissiond dated as initiated on 05/02/2023d was also resolved and removed on the same date, 05/09/2023, after request. 2. R17 diagnoses include but are not limited to: end stage renal disease, dependence on renal dialysis. On 5/10/23 at 11:37 AM, V2 (Director of Nursing) stated, (V20's, Medical Doctor) last note (for R17) was 4/20/23. There was nothing about putting dialysis on hold just to decrease to once a week. (V20) wrote the note today (5/10/23) to suspend the dialysis. The nurse put in the order today to put dialysis on hold. There was no order prior to today. (R17) last went to dialysis 4/24/23. I did not know dialysis was put on hold. (R17's) daughter told me about putting dialysis on hold. I called (V20) to see if (V20) was aware that dialysis was on hold. (V20) said (V20) was aware. (V20) discussed with the nephrologist. I asked (V20) to put it in writing. The order was put in today after getting a verbal order from (V20). R17 Physician Order Summary documents in part: Dialysis 1x/week (Monday only) on hold for now; order date 5/10/23 (the day surveyor discussed R17's dialysis treatments with V2). R17 Physician Progress Note, effective date 5/10/2023, documents in part: Pt had discussion with nephrologist. As patient is not having fluid pulled during dialysis and with weight downtrending, plan is to hold dialysis indefinitely and monitor weights, swelling and electrolytes. On 5/10/23, surveyor requested the most recent dialysis communication between the facility and the dialysis center. Surveyor was presented a communication dated 4/24/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 12 of 17 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 05/12/2023 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 3. On 05/11/2023 at 11:00 AM, surveyor observed V24 (Registered Nurse) and V25 (Certified Nursing Assistant) change R47's wound dressing. R47 has a stage three pressure ulcer on her sacrum. On 05/11/2023 at 11:51 AM, V27 (Minimum Data Set/ MDS Coordinator) and V17 (MDS Coordinator) stated R9 and R22 are the two residents with wounds. Those are only two residents with wounds. The form 672 is updated every Friday. The Matrix is updated every Friday. At this time, Surveyor informed V27 and V17 that R47 also has a wound. Surveyor handed V27 and V17 the full resident matrix. V17 stated, (R47) is not included in the matrix. I may have clicked the wrong resident when updating the matrix. Event ID: Facility ID: 146009 If continuation sheet Page 13 of 17 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 05/12/2023 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 0880 Provide and implement an infection prevention and control program. 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 follow enhance barrier precautions procedure by not wearing proper PPE (personal protective equipment) for 1 resident (R111) that currently treated for Lyme's disease infection, and the facility failed to follow policy for hand hygiene during treatment of wound for 1 resident (R47), in a sample reviewed for Infection Control. Residents Affected - Few Findings include: R111 is [AGE] years old, initially admitted on [DATE] with diagnosis of Lyme's Disease. R111 was unable to be interviewed. R111 has a BIMS (Brief Interview for Mental Status) of 2, indicating R111 is cognitively impaired. R111 has an order for antibiotic (Ceftriaxone) to inject intramuscularly for Lyme's disease until 05/22/2023. R111's care plan by V (Infection Preventionist) for Infection reads as follow: Dated 05/01/2023 staff to wear gloves and gowns (Enhanced Barrier Precautions) during high-contact resident activities to reduce transmission of resistant organism. Dated 05/02/2023 perform proper handwashing techniques, to minimize microorganism transmission. On 05/09/2023 at 11:43 AM, in the hallway, isolation setup was seen in a plastic compartment with drawers full of PPE (personal protective equipment). V5 (Registered Nurse) stated, This (holding the compartment and placing it near R111's door) is for (R111); he has Lyme's disease. (R111) is currently on contact isolation, and (R111) is currently taking antibiotic for Lyme's disease. V5 was asked about Lyme's disease and said, I think it is a bacterial infection that is why (R111) is taking an antibiotic. (R111) used to have peripheral line, but now his antibiotic is being administered through IM (intramuscular) injection. Nursing staff needs to use gown, gloves, mask, and face shield. V5 was asked where is R111? V5 went into his (R111's) room and could not find R111. V5 then became anxious, and asked V6 (Certified Nursing Assistant) the whereabouts of R111. V5 said, Do you know where (R111) is? V6 replied, (R111) is at therapy on 8th floor. After few minutes, R111 was seen exiting elevator with a staff assisting R111, without any PPE. V6 then assisted R111 to go to his room, also without PPE. After few minutes, V5 came back and said, I just want to clarify, (R111) is not in contact isolation, but on enhanced barrier precautions (pointing at a poster near the door of R111's room). V5 was asked to read the poster. V5 said, Everyone must: clean their hands, including before entering, and when leaving the room. Providers and staff must also wear gloves and gown for the following high-contact resident care activities, including transferring. V5 was asked about R111 assistance during transfers and ambulation. V5 said, Yes, (R111) needs close contact and assistance during ambulation and transfer related to his cognition. And based on that paper, staff needs to wear gown and gloves. On 05/09/2023 at 12:25 PM. V3 (Infection Preventionist) was asked about R111, and what the facility is doing to prevent spread of Lyme's disease. V3 said, (R111) had a Lyme's disease diagnosis upon admission. (R111's) Lyme's disease is still active and is still being treated with antibiotics. Yes, there is a poster for enhanced barrier precautions near the door of (R111) for staff to use proper PPE including gown and gloves. Lyme's Disease Transmission per CDC (Centers for Disease Control and Prevention) information dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 14 of 17 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 05/12/2023 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 0880 01/20/2023, in part reads: Level of Harm - Minimal harm or potential for actual harm The Lyme disease bacteria causing human infection in the United States, Borrelia burgdorferi and, rarely, B. mayonii, are spread to people through the bites of infected ticks. Borrelia burgdorferi is spread primarily by the blacklegged tick (or deer tick, lxodes scapularis) in the northeastern, mid-Atlantic, and north-central United States, and by the western blacklegged tick (l. pacificus) in the Pacific Coast states. Borrelia mayonii is rarely found in ticks and has only been detected in blacklegged ticks in the north-central United States. Residents Affected - Few 2. On 05/11/2023 at 11:11 AM, V24 (Registered Nurse) assisted by V25 (Certified Nursing Assistant), performed dressing change to R47's coccyx pressure ulcer. During whole procedure, V24 and V25 were not seen performing hand hygiene. V24 said, I did perform hand hygiene near the Nurse's Station. V24 was seen touching/contacting high touched area including treatment cart, door, and other surfaces from the Nurse's station going inside R47's room prior to dressing change. V24 was then asked why hand hygiene was not performed after taking off old dressing, cleaning wound, and putting a new dressing? V24 said, Yes, I should have performed hand hygiene, but I forgot. Hand Hygiene policy dated 07/2018, in part reads: It is the policy of the facility to perform hand hygiene in accordance with national standards from the Centers for Disease Control and Prevention and the World Health Organization. Hand hygiene is to be performed: Prior to caring for a resident. When moving from a contaminated body site to a clean body site such as when changing a brief or wound dressing. After caring for a resident including after removing gloves. And after contact with resident environment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 15 of 17 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 (X3) DATE SURVEY COMPLETED A. Building 05/12/2023 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 0888 Ensure staff are vaccinated for COVID-19 Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow their policy on ensuring and monitoring all HCP (Healthcare Personnel) Covid-19 vaccination status, and failed to ensure all HCP had complete documentation and records as to Covid-19 vaccination status. Residents Affected - Many These failures have the potential to affect all 55 residents living in the facility. Findings include: On 05/09/2023 at 10:54 AM, V3 (Infection Prevention) submitted a document titled Covid-19 Staff Vaccination Status for Providers that listed 178 staff. V3 said it represents staff that are employees of facility. V3 was asked if the list includes contracted staff, agency staff, and providers. V3 said, Not all are included. Another request was made to V3 to provide list the names of contracted companies, how often services are provided that includes, all therapist, nurses, nursing assistants, hospice staff, medical doctors, and other HCP (healthcare personnel). V2 (Director of Nursing) asked, Only for this week? V2 was requested to include at least few months before or since last survey for contracted staff that worked in the facility. V3 then submitted 2 separate lists, first list included nursing staff that are contracted to agency. The second list, was for rehab, therapists, volunteers, hospice, nurse practitioners, medical doctors, dentists, and care givers. Then another list was submitted by V2, with a title List of Contract Agencies. V2 said, Not all staff on this list of agencies are included on the list (referring to the 2 lists of HCP/Healthcare Personnel), because they did not work for a long time. On 05/09/2023 at 1:36 PM, V7 (Occupational Therapist) and V8 (Occupational Therapist Student) were seen on the floor. V7 said, Yes, me and (V8) are therapist. Yes, we perform direct care to residents. Upon checking all the lists provided by facility, V8 was not included. Prior to formal and comprehensive review of Infection Control and Prevention, V3 was instructed to bring all proof of vaccination for all HCP/healthcare personnel for verification. On 05/10/2023 1:09 PM. V3 (Infection Preventionist) was asked if she (V3) brought all proof of vaccination for staff employees and contracted employees. V3 said, Yes, I have it. V3 was informed that review will be comprehensive, and proof of vaccination will be asked to be presented during review. V3 said, I understand, vaccination card or proof of vaccination will be presented during review. V3 was then asked to present the following HCP/healthcare personnel proof of vaccination: 3 facility employees, scheduled to work, as documented on staffing schedule for the current week were V9 (Certified Nursing Assistant), V10 (Certified Nursing Assistant), and V11 (Certified Nursing Assistant). V3 checked her binder, and was not able to find the information. Every time I mentioned the name of HCP/healthcare personnel, V3 was using her phone by texting/messaging. V3 was asked what was she doing? V3 replied she was informing V2 (Director of Nursing) about my request. Since V3 was unable to provide information for the first 3 staff, V12 (Certified Nursing Assistant), V13 (Certified Nursing Assistant/Agency) and V14 (Certified Nursing Assistant/Agency) were also requested to present proof. V3 was not able to present proof upon checking multiple binders. V3 said, To be honest, for all of those staff you were asking, I cannot find their vaccination cards in the binders. I think it is with Human Resource because they collect their vaccination cards. Yes, me and (V2) are supposed to collect all proof of vaccination. And I agree, even if the staff matrix for Covid vaccination (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 16 of 17 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 05/12/2023 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 0888 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many documents that staff received full vaccination, anyone can just record it. Most important is proof of vaccination. V3 was also informed V8 was not included on the list while seen in facility. V3 said, I think I knew who you are taking about. I think (V8) is new. That is why we do not have any vaccination information regarding (V8). Further review of the list provided by facility that includes medical doctors/physicians was compared to primary care physician doctors that was listed on the floor census. Many of medical doctors were not includes on the list including V17, V18, V19, V20, V21, V22, and V23. On 05/11/2023 at 09:52 AM, V2 (Director of Nursing) said, Yes, there are many doctors not included on the list. I know they should be included. Per facility testing documentation, V38 (Certified Nursing Assistant) was tested positive for Covid-19 on 04/04/2023. On 05/11/2023 at 10:41 AM, V2 said, I have bad news for all of you; we have 1 resident that has tested Covid-19 positive. (R112) tested positive. (R112) is exhibiting symptoms so we did Covid-19 testing. I will give you update, because we are now starting to do contact tracing. R112's notes, dated 05/11/2023, reads: Covid-19 testing via anterior nares swab, done. Result positive. Employee Covid-19 Vaccination Policy, dated as revised 09/25/2022, in part reads: Employees have a shared responsibility to assist in the prevention of the spread of infection to residents, co-workers, and the community by taking reasonable precautions, including Covid-19 vaccinations to reduce the transmission of Covid-19 disease. As a result, in keeping with Executive Order that skilled nursing facility employees be fully vaccinated. Under scope, all employees and volunteers at the facility and therapy contractors. All current facility employees, in all classifications (full-time, part-time, temporary/interns, etc.) are required to receive Covid-19 vaccination(s). Employees are required to provide proof of vaccination. Interim Guidance for Managing Healthcare Personnel with SARS-CoV-2 Infection or Exposure to SARS-CoV-2 Updated Sept. 23, 2022, in part reads: Healthcare Personnel (HCP): HCP refers to all paid and unpaid persons serving in healthcare settings who have the potential for direct or indirect exposure to patients or infectious materials, including body substances (e.g., blood, tissue, and specific body fluids); contaminated medical supplies, devices, and equipment; contaminated environmental surfaces; or contaminated air. HCP include, but are not limited to, emergency medical service personnel, nurses, nursing assistants, home healthcare personnel, physicians, technicians, therapists, phlebotomists, pharmacists, dental healthcare personnel, students and trainees, contractual staff not employed by the healthcare facility, and persons not directly involved in patient care, but who could be exposed to infectious agents that can be transmitted in the healthcare setting (e.g., clerical, dietary, environmental services, laundry, security, engineering and facilities management, administrative, billing, and volunteer personnel). For this guidance, HCP does not include clinical laboratory personnel. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 146009 If continuation sheet Page 17 of 17

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Citations

9 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0565GeneralS&S Epotential for harm
F565 - The resident has a right to organize and participate in resident groups in the
Honor the resident's right to organize and participate in resident/family groups in the facility.
0604GeneralS&S Dpotential for harm
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
0689GeneralS&S Dpotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0755GeneralS&S Epotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0761GeneralS&S Epotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0888GeneralS&S Fpotential for harm
Ensure staff are vaccinated for COVID-19

FAQ · About this visit

Common questions about this visit

What happened during the May 12, 2023 survey of SELFHELP HOME OF CHICAGO?

This was a inspection survey of SELFHELP HOME OF CHICAGO on May 12, 2023. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at SELFHELP HOME OF CHICAGO on May 12, 2023?

Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to organize and participate in resident/family groups in the facility."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·May 12, 2023