Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to provide pain management in accordance with the resident's
comprehensive care plan, the resident's goals for care and preferences. This failure affects one (R1)
resident of four residents reviewed for pain in the sample of seven.
Residents Affected - Few
Findings include:
R1's current face sheet documents R1 is a [AGE] year-old individual admitted to the facility on [DATE] and
has diagnoses not limited to: multiple sclerosis, encounter for palliative care, malignant neoplasm of colon,
unspecified, unspecified displaced fracture of second cervical vertebra, subsequent encounter for fracture
with routine healing.
R1's MDS/Minimum Data Set, dated [DATE] documents that R1 has a BIMS/Brief Interview for Mental
Status score of 15/15, indicating that R1 is cognitively intact.
R1's physician order set documents in part R1 has an active order for HYDROmorphone HCl
(Hydrochloride) Tablet 4 MG (milligrams) Give 1.5 tablet by mouth every 6 hours for Pain since 02/25/2025.
R1's physician order set documents in part R1 has an active order for Morphine Sulfate (Concentrate)
Solution 20 MG/ML (milliliter), give 0.25 ml sublingually every 1 hours as needed for Pain/difficulty
breathing since 02/11/2025.
R1's physician order set documents in part R1 has an active order for Morphine Sulfate (Concentrate)
Solution 20 MG/ML, give 0.25 ml sublingually every 2 hours as needed for pain/difficulty breathing since
02/11/2025.
R1's current care plan (date initiated 12/06/2024) documents in part R1 is at risk for tremors, damage to
motor and sensory control centers, damage to motor nerve tracts, damage to sensory tracts, pain, related
to the diagnosis of multiple sclerosis. R1 will remain free of complications or discomfort related to Multiple
Sclerosis. Interventions include give medication as ordered. Monitor/document for side effects and
effectiveness (date Initiated: 12/06/2024).
On 05/23/2025, at 10:23 AM, R1 stated that one time the nurses told R1 that the HYDROmorphone HCl
(Dilaudid) Tablet was not available. They waited until the hospice nurse came to tell R1 that he had one
tablet left. R1 stated that it affected him and it agitates R1 because the pain medication helps R1 feel less
pain.
On 5/23/2025, at 10:31 AM, V4 (Certified Nursing Assistant) stated He (R1) does have pain. He pulls
(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 3
Event ID:
145634
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
145634
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Astoria Place Living & Rehab
6300 North California Avenue
Chicago, IL 60659
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 0697
the light for that every time he calls. I'll call the nurse and the nurse will go see him.
Level of Harm - Minimal harm
or potential for actual harm
On 05/23/2025, at 10:41 AM, V5 (Registered Nurse) stated that R1 has multiple sclerosis (MS) and has a
lot of pain issues.
Residents Affected - Few
On 05/27/2025, at 9:42 AM, V6 (Licensed Practical Nurse) stated that she doesn't work too often with R1.
V6 stated that R1 would not feel alright if he didn't receive his scheduled Dilaudid medication. Sometimes if
he is sleeping at 12:00 PM, V6 will return at 1:00 PM. V6 will give R1 the Dilaudid because R1 will tell V6
that he is in pain. V6 stated that the emergency medication box is located on the second floor. V6 stated
that she is not sure if Dilaudid is available in the emergency medication box. V6 stated that she gave the
Morphine PRN (as needed) pain medication in the morning. V6 did not offer it to R1 at 12:00 PM because
V6 stated that she was expecting the Dilaudid to be delivered during her shift. V6 stated that she didn't
check if there was Dilaudid in the emergency medication box because the medication was pending to be
delivered. V6 stated that pain management is important because it is important to make sure the resident is
not feeling pain and do whatever we can to manage his pain.
On 5/27/25, at 2:51 PM, V3 (Assistant Director of Nursing) stated that the nurses on the floor should be
refilling/reordering medications when there is 8 tablets/capsules left. V3 stated that means it is time to
reorder. V3 stated for residents that are under hospice care, usually the hospice doctor provides the
prescriptions. V3 stated that for R1's Dilaudid and Morphine medication refill prescriptions, the nurse on
duty should be reaching out to the hospice provider to notify that they have 8 tablets left. V3 stated the
hospice nurse will take care of refilling the medication through the pharmacy that the hospice company
uses. The pharmacy will deliver that medication to the facility. V3 stated that purpose of a PRN (as needed)
pain medication, is to address the patient's breakthrough pain, or if the resident does not have routine pain
medication. If they ask for pain medication, that's when they give it. V3 stated that if the scheduled pain
medication is not available then the nurses should offer it. V3 stated that R1's conditions which may cause
R1 to have pain is malignancy cancer, unspecified fracture, and multiple sclerosis. V3 stated that it is
important to administer pain medication to a resident experiencing pain because if not, it may affect their
quality of life.
On 05/27/2025, at 3:51 PM, V8 (Hospice Registered Nurse) stated that V8 visited R1 on 04/29/2025. V8
called the pharmacy to refill the Dilaudid medication. V8 stated that he was informed by the nurse on duty
that R1 had three more tablets. V8 stated that this was around 3:00 PM. V8 stated that if the pharmacy
does not deliver it the same day, then they will deliver it the next morning. V8 stated that the nursing staff
did not notify V8 that R1 was running low on Dilaudid prior to 04/29/2025. V8 stated if the nurses call the
hospice 24-hour service line, on the weekend or on Monday, then it can be refilled. V8 stated that if the
Dilaudid medication is not available, then the Morphine can be offered. V8 stated that R1 has multiple
sclerosis and generalized chronic constant pain and missing a scheduled pain medication can affect him
and make him have more pain and agitation. V8 stated that V8 saw R1 several times already. R1 informed
him that R1 missed some Dilaudid doses because staff didn't wake him up during night. V8 stated that
sometimes R1 would call V8 at night. V8 stated that he informed V2 (Director of Nursing) and that is why
there is an order for R1 to be awaken at night to be given the scheduled pain.
On 05/28/2025, at 1:47 PM, via telephone V9 (Registered Nurse) stated that she worked the night shift on
4/29/25, going to 4/30/25, in the morning. V9 stated that they were waiting for pharmacy to deliver R1's
Dilaudid medication. V9 stated that she administered Morphine to R1. V9 stated I told R1 that he didn't have
the Dilaudid. R1 had another option for pain relief. R1 said yes I will take
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145634
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
145634
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Astoria Place Living & Rehab
6300 North California Avenue
Chicago, IL 60659
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 0697
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
that. V9 stated I gave the Morphine to R1 twice that shift. V9 stated that she endorsed it to the next shift. V9
stated that she is aware that Dilaudid is available in the emergency medication box. V9 stated that she
didn't have access to it since V9 works through agency. V9 stated I believe nobody had access that night.
V9 stated that she endorsed to the morning nurse, that they are waiting for hospice to deliver Dilaudid and
to just give R1 liquid Morphine until it gets here. V9 stated that R1 told V9 that the morphine helped him. V9
stated that she mistakenly documented that she administered the Dilaudid to R1 and she is sorry for that.
V9 stated I just clicked it, but I'm sorry I shouldn't have documented it if I didn't administer it.
R1's controlled substance record for HYDROmorphone HCl (Dilaudid) tablet medications documents in part
04/29 at 6:00PM amount remaining is 0 (zero).
R1's controlled substance record for HYDROmorphone HCl (Dilaudid) tablet medications documents in part
dated received 04/30, quantity received 60. 04/30 at 6:00 PM amount remaining is 58.5.
R1's medication administration note dated 04/30/2025 1:00 PM documents HYDROmorphone HCl Tablet 4
MG (milligrams), give 1.5 tablet by mouth every 6 hours for Pain on order, awaiting from pharmacy.
R1's April 2025 medication administration record documents in part R1 did not receive scheduled
HYDROmorphone HCl (Dilaudid) medication order on 04/30/2025 at 12:00PM.
R1's April 2025 medication administration record documents in part R1 received Morphine Sulfate
(Concentrate) Solution 20 MG/ML, 0.25 ml sublingually on 04/30/2025 at 08:42 AM.
Reviewed list of medications in the emergency box stock and it documents that HYDROmorphone HCl
Tablet 2 MG (milligrams) max (maximum) 4 tablets available.
Facility document dated 01/30/2025, titled pain documents in part it is the policy of the facility to ensure that
all residents are assessed for pain in every situation where there is a potential for pain.
Facility document not dated titled resident rights for people in long-term care facilities documents in part
you have the right to safety and good care. Your facility must provide services to keep your physical and
mental health, and sense of satisfaction.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145634
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation 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.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
FAQ · About this visit
Common questions about this visit
What happened during the May 28, 2025 survey of ASTORIA PLACE LIVING & REHAB?
This was a inspection survey of ASTORIA PLACE LIVING & REHAB on May 28, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ASTORIA PLACE LIVING & REHAB on May 28, 2025?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide safe, appropriate pain management for a resident who requires such services."
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 . If you believe any information is inaccurate, report it here.