Based on interview and record review, the facility failed to ensure a resident, who was admitted to the facility for pain management, from a General Acute Care Hospital (GACH) following two spinal fusion (a surgical procedure to connect two or more bones in the lower part of the spine) surgeries, was medicated to control the pain for one of five sampled residents (Resident 1). The facility failed to: 1. Provide Dilaudid (a narcotic medication used to treat moderate to severe pain), for approximately six hours, to Resident 1 who complained of a pain level of 10 out 10 on a 0-10 pain rating scale (where zero= no pain and 10= is the worst pain possible). 2. Follow up with the pharmacy to confirm the pharmacy received the fax order for Dilaudid. 3. …
F697 citations in California
Pain management · Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F697 more often than its own record predicts
1.39 times the share F697 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F697.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F697 findings written in California, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observation, interview, and record review, the facility failed to ensure one of two residents (Resident 19) sampled for pain management received professional treatment when Licensed Nurse S did not assess, evaluate, treat, or reassess Resident 19's migraine pain.This failure resulted in persistent migraine pain for Resident 19 and affected her overall well-being. A review of Resident 19's admission record indicated she was admitted in 08/2024 with diagnoses of Chronic pain (persistent pain lasting longer than 3-6 months), a burn wound to her left thigh, and Migraine with Aura (severe headaches with visual disturbance such as zig-zag lines, flashing lights or blind spots).A review of Resident 19's Minimum Data Set (MDS-a resident assessment tool) dated 11/17/25 indicated no… …
Based on observation, interview, and record review, the facility failed to provide effective pain management for one of five sampled residents (Resident 1) when staff did not manage Resident 1's reports of severe pain.This failure resulted in unmanaged pain associated with a newly diagnosed fractured left arm and caused Resident 1 to feel ignored and distressed.Findings:A review of the facility's policy and procedures titled, Pain Assessment and Management, dated 4/2025, indicated the facility requires a multidisciplinary approach to pain management, including: identifying and assessing pain; recognizing conditions that may cause pain; determining the cause, intensity, duration, type, and characteristics of pain; implementing pain management interventions consistent with accepted standards… …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.79% | 1.08× |
| 2024 | 0.98% | 1.33× |
| 2025 | 1.08% | 1.39× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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