Based on interviews and record review, the facility failed to provide effective and timely pain management to a resident experiencing pain. Resident (R) 10 complained of pain 10 out of 10 (10/10 on the pain scale, indicating severe, intense agony) to the lower back after being in a wheelchair (w/c). The physician ordered an opioid medication at 01:47 PM, which was not administered until 09:00 PM, despite the resident's sustained pain level 8/10, which is severe. The delay in administration of an effective medication, the absence of non-pharmacological intervention, failure to seek higher level of care due to unrelieved pain caused R10 to experience unrelieved severe pain for 7.15 hours. As a result of this deficient practice, residents are at risk of physical harm. …
F697 citations in Hawaii
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
Hawaii cites F697 more often than its own record predicts
1.74 times the share F697 takes of citations nationally.
Of every deficiency written in Hawaii 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 Hawaii surveyors wrote
F697 findings written in Hawaii, 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 record review and interviews, the facility failed to ensure pain management was provided to one of three residents in the sample. The facility failed to monitor and assess pain level with (Resident (R) 56) every shift. This deficient practice may put R56 at high risk for having pain that may affect function, impair mobility, impair mood, or disturb sleep, and diminish quality of life. Findings Include:R56 was re-admitted to the facility on [DATE], with an initial admission date on 05/25/21. …
The short window
Recent years
| Year | Share of Hawaii citations | vs expected |
|---|---|---|
| 2023 | 1.05% | 1.44× |
| 2024 | 1.11% | 1.51× |
| 2025 | 1.36% | 1.74× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Hawaii surveyors cite →
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