Based on observation, interview, and record review the facility did not ensure a residents pain was managed in accordance with professional standards of practice and hospice plan care, for 1 of 3 residents (R1) reviewed for pain. R1's medication regimen was ineffective; he would scream and moan in pain contacting EMS and his daughter for help. This resulted in immediate jeopardy (IJ) when the facility did not have a system in place to manage R1's pain causing R1 unnecessary physical and psychological harm. The immediate jeopardy began on 4/1/25 when R1's pain medication became ineffective and subsequently lacked follow-up of effectiveness, the patient called emergency services for pain medication, and called his daughter crying in pain, and was identified on 4/28/25. …
F697 citations in Minnesota
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
Minnesota cites F697 more often than its own record predicts
1.05 times the share F697 takes of citations nationally.
Of every deficiency written in Minnesota 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 Minnesota surveyors wrote
F697 findings written in Minnesota, 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 interview and document review, the facility failed to ensure pain medications were re-ordered and available for administration per physician orders for 1 of 3 residents (R2), who had chronic pain and utilized pain medication. This resulted in actual harm when R2 was not administered the physicians ordered pain medication before a pre-scheduled surgery prior to leaving the facility for surgery, and arrived at the surgery center tearful and in severe pain. The facility implemented immediate corrective action prior to the survey and was therefore issued at past non-compliance. …
Based on observation, interview, and document review, the facility failed to ensure pain medication was administered timely for 1 of 1 resident (R12) reviewed for pain management. Findings include:R12's quarterly Minimum Data Set (MDS) dated [DATE], indicated R12 had moderate cognitive impairment, had lower extremity impairment on both sides, was fully dependent or required substantial/maximal assistance with many activities of daily living (ADLs), and was fully dependent with transfers and bed mobility. R12's MDS further identified R12 had almost constant pain and received scheduled and as needed pain (PRN) medication. R12's diagnoses included muscle weakness, history of transient ischemic attack and cerebral infarction, and dysphasia (difficulty swallowing). …
The short window
Recent years
| Year | Share of Minnesota citations | vs expected |
|---|---|---|
| 2023 | 0.32% | 0.44× |
| 2024 | 0.47% | 0.64× |
| 2025 | 0.82% | 1.05× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Minnesota surveyors cite →
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