Inspection Reports for The Selfhelp Home Senior Living Community
908 W Argyle St, Chicago, IL 60640, IL, 60640
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
137% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
59 residents
Based on a August 2024 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Census: 59
Deficiencies: 12
Aug 11, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity with catheter care, inadequate assistance with activities of daily living, medication administration errors, improper catheter drainage bag positioning, failure to label and contain oxygen equipment, failure to post daily nursing staffing, unlocked medication carts, improper storage and monitoring of personal refrigerators, and lapses in infection prevention and control practices including COVID-19 isolation protocols.
Deficiencies (12)
| Description |
|---|
| Failure to ensure indwelling catheter drainage bags were covered in a privacy bag affecting resident dignity. |
| Failure to provide adequate ADL care for a dependent resident to maintain personal hygiene and dignity. |
| Failure to administer medications to a resident at the scheduled time. |
| Failure to ensure urinary drainage bag was positioned below the bladder to prevent backflow and infection. |
| Failure to label and date oxygen equipment and properly contain nebulizer mask. |
| Failure to post daily nursing staffing information in a visible and accessible location. |
| Failure to keep medication cart locked when unattended. |
| Failure to maintain temperature logs and proper cleaning for personal refrigerators and freezers. |
| Failure to sanitize medication tray between residents leading to potential cross contamination. |
| Failure to maintain trash receptacle inside isolation room and prevent contamination of PPE bin. |
| Failure to maintain COVID-19 positive resident in isolation and prevent exposure to other residents. |
| Failure to label intravenous sites with date to ensure timely dressing changes and prevent infection. |
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 59
Residents affected: 15
Medication count: 10
Medication count: 4
BIMS score: 14
BIMS score: 6
BIMS score: 15
BIMS score: 14
BIMS score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| V3 | Registered Nurse, Nursing Supervisor | Provided statements regarding catheter care, medication administration, oxygen equipment, infection control, and COVID-19 isolation procedures. |
| V11 | Registered Nurse | Commented on urinary catheter bag positioning and privacy bag use. |
| V7 | Registered Nurse | Discussed medication administration timing and catheter bag privacy. |
| V16 | Registered Nurse | Observed administering medications without sanitizing medication tray between residents. |
| V4 | Registered Nurse | Noted medication cart should be locked when unattended. |
| V24 | Receptionist | Provided information about nursing staff daily schedule posting. |
| V14 | Dietary Manager | Discussed responsibility for personal refrigerator temperature logs. |
| V6 | Registered Nurse Supervisor | Checked personal refrigerators and noted lack of temperature logs. |
| V29 | Primary Physician | Provided instructions regarding medication administration timing for resident R16. |
| V15 | Registered Nurse | Observed wearing PPE for resident on contact/droplet precautions. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Sep 6, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident (R1) who sustained a closed displaced fracture of the left femoral neck after a fall. The investigation focused on the facility's failure to follow fall protocols, provide adequate supervision, and develop specific fall interventions.
Findings
The facility failed to follow their fall protocol, failed to provide adequate supervision, and failed to develop specific fall interventions for one resident reviewed for falls. This resulted in the resident sustaining a serious hip fracture requiring surgical arthroplasty. Staff did not use mechanical lifts to assist the resident after the fall, and fall interventions were not updated post-fall.
Complaint Details
The complaint investigation found that on 4/16/23, resident R1 fell while trying to go to the bathroom and sustained a closed displaced fracture of the left femoral neck. Staff failed to use the mechanical lift to assist the resident off the floor, contrary to fall protocol. The resident required hospital transfer via 911 and surgical repair. The facility did not place new fall interventions after the fall, and supervision was inadequate given the resident's cognitive impairment and fall risk.
Severity Breakdown
Level of Harm - Actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to follow fall protocol, provide adequate supervision, and develop specific fall interventions for a resident resulting in a serious injury. | Level of Harm - Actual harm |
Report Facts
Date of fall: Apr 16, 2023
Date of survey completion: Sep 6, 2023
MDS BIMS score: 10
Years RN experience: 30
Years working at facility: 26
Staff assistance percentage: 25
Staff assistance percentage: 50
Walking distance: 35
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| V4 | Registered Nurse | Nurse involved in fall incident assessment and care |
| V6 | Nursing Supervisor | Provided statements about fall protocol and resident care |
| V5 | MDS Coordinator/Registered Nurse | Responsible for placing fall interventions in care plan |
| V10 | Resident's Former Physician | Provided medical opinion on fall and resident care |
| V7 | Physical Therapist | Provided information on resident's physical and cognitive status |
Inspection Report
Routine
Census: 55
Deficiencies: 9
May 12, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, physical restraints, accident prevention, pharmaceutical services, medication management, food safety, medical record accuracy, infection control, and COVID-19 vaccination status.
Findings
The facility was found deficient in multiple areas including failure to provide private space and proper notification for resident council meetings, improper use of physical restraints, failure to use gait belts during transfers, unsecured controlled medications, presence of expired medications and food, inaccurate resident records, failure to follow infection control procedures including PPE use and hand hygiene, and incomplete COVID-19 vaccination documentation for healthcare personnel.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 9
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to provide residents with private space for resident council meetings and failed to notify resident representative (Ombudsman) with resident council meeting date changes. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents are free from physical restraints for 1 resident (R47) out of 3 reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow policy to use gait belts to transfer residents requiring assistance for 1 resident (R47) out of 4 reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly secure controlled medications in medication refrigerator. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to dispose/discard expired medications in medication carts/medication room/storage. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure the kitchen was free of expired food products. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain accurate resident records for 3 residents (R111, R17, R47). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow enhanced barrier precautions and hand hygiene policies for residents with infection and wound care. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to follow policy on ensuring and monitoring all healthcare personnel COVID-19 vaccination status and failed to ensure complete documentation. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 55
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 52
Residents affected: 3
Residents affected: 1
Staff listed: 178
Staff missing vaccination proof: 6
Residents affected: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| V27 | Activity Director | Named in resident council meeting deficiencies |
| V28 | Ombudsman | Named in resident council meeting deficiencies |
| V24 | Registered Nurse | Named in physical restraint and wound care deficiencies |
| V25 | Certified Nursing Assistant | Named in physical restraint and wound care deficiencies |
| V2 | Director of Nursing | Named in multiple findings including restraint use, medication security, infection control, and vaccination status |
| V4 | Registered Nurse | Named in medication security and expired medication deficiencies |
| V3 | Infection Preventionist | Named in infection control and vaccination status deficiencies |
| V7 | Occupational Therapist | Named in vaccination status deficiency |
| V8 | Occupational Therapist Student | Named in vaccination status deficiency |
Inspection Report
Routine
Deficiencies: 3
Mar 10, 2022
Visit Reason
The inspection was conducted to assess compliance with medication storage and labeling requirements, as well as policies and procedures for influenza and pneumococcal vaccinations.
Findings
The facility failed to ensure bottles of eye drops were dated when opened, affecting two residents. Additionally, the facility lacked proper tracking and documentation of influenza and pneumococcal vaccinations and consents for three residents, and the facility policy did not include a procedure for tracking these vaccinations.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure bottles of eye drops were dated when opened. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to track the status of influenza and pneumococcal vaccinations and consents for residents. | Level of Harm - Minimal harm or potential for actual harm |
| Facility policy has no procedure for tracking influenza and pneumococcal vaccines. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for medication storage: 10
Residents affected by eye drop labeling deficiency: 2
Total residents in medication storage sample: 35
Residents in vaccination sample: 7
Residents affected by vaccination tracking deficiency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN/Registered Nurse (V3) | Observed medication carts and medication rooms; discussed eye drop labeling | |
| Director of Nursing (V2) | Spoke with pharmacist about eye drop storage; interviewed about vaccination follow-up and tracking | |
| Administrator (V1) | Presented storage guidelines for eye drops | |
| Infection Preventionist (V10) | Provided immunization reports; discussed vaccination tracking policies and responsibilities |
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