Based on observations, interviews, and record reviews, the facility failed to provide effective pain management for 3 of 3 residents (R1, R2, and R3) reviewed for pain in a sample of 4. This failure resulted in R1, who has a diagnosis of Multiple Myeloma and at the end-of-life stage, not receiving an ordered narcotic pain medication for 6 hours and R1 experiencing intense pain and suffering prior to her death.This failure resulted in Immediate jeopardy, which was identified to have begun on [DATE] when the facility ran out of R1's oral Dilaudid pain medication resulting in R1 experiencing uncontrolled pain. V1 (Administrator), V21 (Regional Clinical Coordinator), V2 (Director of Nursing, and V3 (Assistant Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 2:10PM. …
F697 citations in Illinois
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
Illinois cites F697 more often than its own record predicts
1.30 times the share F697 takes of citations nationally.
Of every deficiency written in Illinois 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 Illinois surveyors wrote
F697 findings written in Illinois, 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 implement non-pharmacological or pharmacological pain relief interventions and conduct a comprehensive pain assessment for one of three residents (R1) reviewed for pain in the sample of four. These failures resulted in R1 crying and experiencing excruciating pain to the lower back and legs for over seven hours before being sent to the hospital emergency room for treatment. Findings include:The facility's Pain Management and Assessment policy and procedure dated 10/24 documents, To provide a broad spectrum of treatments for pain management as they apply specifically to older people and with specific recommendations to aid in decision making about pain management. …
Based on observation, interview, and record review, the facility failed to administer pain medication in accordance with physician orders and failed to ensure transportation to two scheduled pain clinic appointments for two of six residents (R5 and R6) reviewed for medication administration from a sample of 13 residents. Findings include: 1.R6's Electronic Health Record (EHR) documents R6 has multiple diagnoses including Chronic Pain Syndrome 4/30/26 and Rheumatoid Arthritis 1/16/26. R6's Minimum Data Set (MDS) dated [DATE] documents R6 is cognitively intact. R6's EHR contains a physician order dated 4/13/2026 for Oxycodone-Acetaminophen (opioid pain reliever) oral tablet 5-325 milligrams (mg). Give one tablet by mouth every eight hours as needed for pain related to Chronic Pain Syndrome. …
The short window
Recent years
| Year | Share of Illinois citations | vs expected |
|---|---|---|
| 2023 | 1.22% | 1.67× |
| 2024 | 1.01% | 1.38× |
| 2025 | 1.02% | 1.30× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Illinois surveyors cite →
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