of F697 citations were written at actual harm or above. The mark is the share across all tags, 5.4%.
Citations in 2025845
Every F697 citation surveyors wrote nationally that year.
Facilities cited800
Distinct nursing homes with at least one F697 finding.
The harm level
How severely F697 is cited
21.7% of citations found actual harm or worse (level G and above).
Citations by CMS scope and severity. Rows are harm level, columns are how widespread the finding was.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
J411.2%
K310.9%
L—
Actual harm
G62418.9%
H220.7%
I—
No harm, potential for more than minimal
D2,24768.0%
E33910.3%
F—
No harm, potential for minimal
A—
B—
C—
Every recorded F697 citation, by the harm level and scope the surveyor assigned.
In the surveyor’s words
What an F697 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
J · Immediate jeopardy, isolatedJune 3, 2026
Based on grievance forms, clinical record review, family interview, staff interview, and facility policy review, the facility failed to timely and effectively manage resident pain for 1 of 1 residents reviewed for pain management (Resident #94) and for 3 residents via grievance reports (room [ROOM NUMBER]-A, Resident #59, room [ROOM NUMBER]). The facility failed to assess and intervene upon the report of Resident #94 having acute pain and failed to initiate a new order for morphine pain medication in a timely manner on 3/23/26. The resident experienced severe, avoidable pain as evidenced by non-verbal pain indicators and family reports. …
Based on interview and record review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 4 residents (CR#1) reviewed for pain management. The facility failed to provide CR#1 an adequate supply of scheduled hydrocodone-acetaminophen 10-325 mg during a 72-hour therapeutic leave, resulting in medication being unavailable for 4 scheduled doses. During that period, CR#1 reported pain of 8 on a scale of 0 to 10 (0 being no pain 10 being the worse pain), that interfered with her ability to sleep and function. This failure placed residents at risk for unmanaged pain and diminished quality of life. …
D · No harm, potential for more than minimal, isolatedSeptember 11, 2026
Based on select facility policy, clinical record review, and staff interview, it was determined the facility failed to attempt non-pharmacological interventions and failed to evaluate the severity of pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one of 19 residents reviewed (Resident 8).Findings include:A review of the facility policy, Pain Management (last reviewed October 1, 2026), indicated the facility will ensure residents are assessed for pain or potential for pain to attain or maintain the highest practicable level of well-being. …
B · No harm, potential for minimal, patternMay 24, 2019
Based on clinical record reviews, review of facility documentation and interviews for one of three sampled residents (Resident #322) reviewed for pain management, the facility failed to document the location of the pain and/or effectiveness of the pain medication administered to ensure the management interventions were appropriate. The findings include:
Resident #332's [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #332 had some memory and cognitive impairments, required extensive one (1) to two (2) person assistance with activities of daily living, received scheduled and as needed pain medications, the pain was frequent and had a moderate intensity. A physician's orders [REDACTED]. …
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Cited in the same inspection, not caused by one another.
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