Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency, 1 of them serious (actual harm or immediate jeopardy). 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 - Actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to manage R3's pain by failing to have R3's
Norco pain medication in stock. This failure resulted in R3 going without his medication for more then
24-hours and experiencing excruciating leg, wound, and body pain rated as 8 out of 10 on a numerical
rating pain scale.
Residents Affected - Few
Findings include:
R3's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to:
atherosclerosis of native arteries of other extremities with ulceration, cellulitis of right lower limb, peripheral
vascular disease, pain in right leg, essential (primary) hypertension, low back pain, peripheral vascular
angioplasty status with implants and grafts, muscle weakness (generalized).
Minimum Data Set (MDS) section C (dated [DATE]) documents that R3 has a Brief Interview for Mental
Status (BIMS) score of 14, indicating that R3's cognition is intact.
Care plan (dated 10/16/2024) documents that R3 has an alteration in skin integrity and is at risk for
additional and/or worsening of skin integrity issues related to non pressure chronic ulcer of right leg. Care
plan documents that R3 peripheral vascular disease and is at increased risk of skin integrity issues.
Pain Management Policy (revised 08/2021) documents in part: It is the policy of the facility to facilitate
resident independence, promote resident comfort, preserve and enhance resident dignity and facilitate life
involvement. The purpose of this policy is to accomplish that goal through an effective pain management
program. Around the clock pain management should be considered when the resident has pain 12 out of 24
hours.
Medications Ordering Policy (dated 02/2017) documents in part: Medications and related products are
ordered from pharmacy on a timely basis. Refill requests should be sent in 72 hours prior to the last dose.
On 01/02/2025, surveyor was conducting a complaint investigation related to residents not receiving their
medications. During the complaint investigation, surveyor interviewed R3, to determine if the resident is
receiving all of his medications, as per the physician order. At 9:38AM, R3 stated, I have not had any issues
with my medications. My medications are always on time, and it is given to me daily. The only issue I have is
with my pain medication, Norco. My Norco is not given to me as per the physician order. I can have a Norco
every 6 hours, as needed, and they are not giving it to me because they continuously run out. It's always
when I am low and close to running out of the Norco,
(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 4
Event ID:
146062
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
146062
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Center Home Hispanic Elderly
1401 North California
Chicago, IL 60622
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 - Actual harm
Residents Affected - Few
the nurses wait to the last minute to re-order it. They keep running out of my pain medications and at times I
have to wait for 3 days for the medication to get here. It depends on who the nurse is. Some nurses wait to
the last minute to re-order the medication and I won't get my pain medications for 3 days. They do not take
the Norco from the convenience box; they just give me Tylenol. The nurses won't even try to supplement my
Norco by going to the convenience box, they will just give me Tylenol instead, and make me wait for my
Norco for days. I am waiting for the Norco right now. I was supposed to have the Norco for pain. They have
not given it to me since yesterday, around noon. Right now, they do not have my medication in stock. My
pain level is 8 out of 10. My pain is in the right and left leg. The Norco brought down my pain from 10/10 to
4 out of 10. I also have arthritis in my knee, and I have a wound as well, so I need the Norco to alleviate the
pain. I am experiencing pain that is not being controlled because they don't always have my medications in
stock, and this keeps on happening over and over again.
On 01/02/2025, at 10:18 AM, V4 (2nd floor licensed practical nurse) stated, He (R3) does not have any
Norco currently. I have been giving him Tylenol for pain. I gave R3 Tylenol for pain because R3's Norco is
not in stock. I have to get the script for R3's Norco from the doctor or the nurse practitioner. There is a
convenient box on the 3rd floor. It looks like R3 ran out of Norco yesterday (01/01/2025). The last time that
we gave R3 his Norco is on 01/01/2025 at 11:50 AM. R3's Norco is supposed to be given every 6 hours as
needed for pain. The convenient box is there to replace the medication that we do not have. I never
retrieved any medications from the (medication convenience box), so I am not sure if I will be able to log in.
I did not try to retrieve the Norco for R3 from the (medication convenience box). This morning I gave R3 a
Tylenol for pain, and I did not go to the convenient box to retrieve the Norco.
On 01/02/2025, at 10:20 AM, surveyor inspected the medication cart on the second floor. Surveyor noted
that the medication cart did not contain R3's Norco 10/325 MG (milligrams) medication. At 10:25 AM,
surveyor accompanied V4 (2nd floor licensed practical nurse) to the medication convenience box located
on the 3rd floor. Surveyor observed V4 attempting to log into the (medication convenience box). Surveyor
observed that V4 did not successfully log in and open the (medication convenience box), as V4 did not have
a correct password to retrieve medication. V4 requested the assistance of V14 (3rd floor licensed practical
nurse) to retrieve a Norco 10/325 MG tablet for R3's pain management. Surveyor observed V14
successfully logging into the convenience box. When V14 selected R3's name in the (medication
convenience box), the convenience box was noted to not have the Norco 10/325 MG tablets in stock, and
V14 was not able to retrieve the Norco pain medication.
On 01/02/2025, at 1:02 PM, V2 (director of nursing-DON) stated, I was working on the 2nd floor yesterday
and I gave R3's last Norco tablet around 11:50 AM. There was only one Norco left in the bingo card, and I
re-ordered it after I gave the last pill. The nurses should not wait to re-order the medication. The pain
medication should be re-ordered when there are a few pills left in the bingo card, to avoid running out of the
medications. I re-ordered it right away, but it has not been delivered yet.
On 01/02/2025, at 1:23 PM, V7 (director of clinical services) stated, The pharmacy will automatically
replenish medications that are not controlled every 3 days. The Norco for R3 has to be re-ordered because
it is a as needed (PRN) medication. At this time, R3 is out of his Norco tablets. The policy is that the
medications should be re-ordered before the last pill is used. The nurse is not supposed to wait till the last
pill is given before they order the medication. The nurses on the floor are not supposed to wait to order the
medications when the medications run out, the medications should be re-ordered prior to running out. The
(medication convenience box) is like a convenience box for
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146062
If continuation sheet
Page 2 of 4
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
146062
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Center Home Hispanic Elderly
1401 North California
Chicago, IL 60622
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 - Actual harm
Residents Affected - Few
medications that run out of the resident's medication supply. When nurses run out of the resident's
medications, the nurses can temporarily retrieve the medications from the (medication convenience box),
while they wait for pharmacy to deliver the resident's medication supply. When the medications run out, the
(medication convenience box) is another source of temporarily obtaining medication. R3 has an order for
Norco 10/325 MG every 6 hours as needed. R3's Norco medication ran out yesterday (01/01/2025). R3's
Norco was re-ordered by V2 (DON) on 01/01/2025, after the last Norco tablet was given around noon. R3 is
currently out of the Norco medication. The (medication convenience box) is not currently stocked with the
Norco 10/325 MG medication and that's why R3 did not receive the Norco for pain. The Norco is not
currently available in the (medication convenience box) because the pharmacy did not stock the Norco
10/325 MG in the convenience box. I spoke to the pharmacy, and they said that R3's Norco supply is on the
way to the facility, and it will be here during the evening shift, close to 3:00 PM. The pharmacy should have
stocked the convenience box with the Norco 10 MG, however, they failed to do so and that is why R3 has
not received the pain medication.
On 01/02/2025, at 1:37 PM, V9 (medication convenience box manager/pharmacy) stated, There were 3
residents in the facility who had an order for Norco 10/325 MG tablets. At this time, R3 is the only resident
who has an active prescription for this medication. R3 receives this medication as needed for pain every 6
hours. The (medication convenience box) is not currently stocked with this medication, that's why the nurse
who tried to retrieve the Norco from the convenience box was not able to do so. Once we refill the
(medication convenience box) with the Norco 10/325 MG tablets, the nurses will be able to get the
medication in case the resident's medication runs out. I will send you a master list of the medications that
are supposed to be filled in the (medication convenience box). I will also send you a new (medication
convenience box) list once the Norco 10/325 MG tablet supply have seen refilled. I put the pain medication
as a Stat (immediate) order and it should arrive at the facility today, around 3:00 PM. R3's Norco supply will
also arrive at the facility today, around 3:00 PM.
On 01/04/2025, surveyor received Inventory on Hand (dated 01/04/2025) document by email from V18
(National Director of Clinical Services/Pharmacy) containing. The (medication convenience box) inventory
list documented that the facility has 3 tablets of Norco 10/325 MG in the convenience box.
On 01/07/2025, at 10:0 1AM, V10 (nurse practitioner) stated, R3 takes Norco 10/325 MG for pain,
scheduled for 8 hours. R3 has pain in bilateral legs. R3 has a vascular wound on the left leg, which also
causes R3 to have increased pain. R3 needs the Norco for pain management. When R3 does not receive
the Norco pain medication on time, R3 will request to have it. When R3 does not receive the Norco pain
medication as scheduled or in a timely manner, the resident's pain will increase. R3 does have Tylenol in
between. I order R3's Norco, and I make sure that R3's Norco is filled. I am always here, and the nurses
must let me know ahead of time that a script needs to be written, in order for me to write the script. The
nurses should let me know that the Norco medication needs to be filled, when there are 5 Norco pills left in
the bingo card.
R3's Progress Note (dated 01/01/2025) documents, Resident received last Norco at 11:50 AM. Provider
notified and request new script. Resident has order for Tylenol to be administer PRN while waiting for script
for Norco 10-325 MG.
R3's Physician Orders (dated 01/02/2025) state: Norco Oral Tablet 10-325 MG
(Hydrocodone-Acetaminophen) *Controlled Drug*. Give 1 tablet by mouth three times a day for pain related
to pain in right leg.
Weekly Skin Alteration Review (Wound Nurse) (dated 01/02/2025) documents that R3 has a venous wound
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146062
If continuation sheet
Page 3 of 4
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
146062
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/08/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Center Home Hispanic Elderly
1401 North California
Chicago, IL 60622
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
measuring 5.1 x 4.0 x 0.2.
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
146062
If continuation sheet
Page 4 of 4
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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 January 8, 2025 survey of CENTER HOME HISPANIC ELDERLY?
This was a inspection survey of CENTER HOME HISPANIC ELDERLY on January 8, 2025. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CENTER HOME HISPANIC ELDERLY on January 8, 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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.