Based on medical record review, review of a fall investigation, review of hospital records, staff interview, resident representative interview, and review of the facility policies, the facility failed to thoroughly assess and timely treat Resident #74's complaints of severe leg pain following a fall. This resulted in Immediate Jeopardy when Resident #74 experienced an unwitnessed fall while self-transferring on 08/16/21, complained of leg pain for a period of five days from 08/16/21 through 08/21/21, was found to have a right femoral shaft fracture on 08/21/21, and was sent to the hospital on 08/21/21 where she subsequently passed away on 08/23/21. This affected one Resident (#74) of three residents (#11, #36, and #74) reviewed for pain. The census was 73. On 11/16/21 at 3:06 P.M. …
F697 citations in Ohio
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
Ohio cites F697 more often than its own record predicts
1.43 times the share F697 takes of citations nationally.
Of every deficiency written in Ohio 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 Ohio surveyors wrote
F697 findings written in Ohio, 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, record review, interview, national library of medicine review, drug manufacturer review, and policy review, the facility failed to ensure effective pain management interventions were implemented to adequately control resident pain. This affected three (Residents #1, #10 and #30) of three residents reviewed for pain.Actual Harm occurred to Resident #10 on 03/28/26 at 9:30 A.M. when the facility failed to administer the ordered dosage of Lyrica (an anticonvulsant medication and gabapentin used to treat neuropathic pain, fibromyalgia, and partial-onset seizures) and failed to provide any pharmacological or non-pharmacological interventions. This resulted in Resident #10 suffering excruciating pain and extreme nausea. …
Based on record review, staff interviews, and facility policy review, the facility failed to ensure that Resident #77's pain was thoroughly assessed and that pain medication was administered in a timely manner after the resident reported severe pain. This deficiency affected one resident (Resident #77) of three reviewed for pain management. The facility census was 135.Findings include: Review of the medical record for Resident #77 revealed an admission date 03/07/25. Diagnoses pain due to internal orthopedic prosthetic devices, removal of internal fixation device, orthopedic aftercare, cocaine use and nicotine dependence.Review of the care plan dated 05/08/26 revealed Resident #77 was care planned for pain related to immobility, depression, previous orthopedic surgery, muscle weakness,… …
The short window
Recent years
| Year | Share of Ohio citations | vs expected |
|---|---|---|
| 2023 | 0.91% | 1.24× |
| 2024 | 0.92% | 1.25× |
| 2025 | 1.12% | 1.43× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Ohio surveyors cite →
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