Based on interview and record review, the facility failed to provide pain management that met professional standards for 4 of 7 sampled residents by not recognizing pain or evaluating existing pain and the causes (Resident #1) and revise a resident's care plan to address and manage pain (Residents #1, #3, #5, and #6). As a result, Resident #1 had a pattern of significant, untreated pain. Findings include: Per record review, Resident #1 has diagnoses that include morbid obesity, type 2 diabetes, and history of uterine cancer. A 7/23/24 Nurse Practitioner note reveals that Resident #1 was transferred from the facility to the hospital on 7/11/24 for symptoms of a CVA (stroke). …
F697 citations in Vermont
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
Vermont cites F697 more often than its own record predicts
1.23 times the share F697 takes of citations nationally.
Of every deficiency written in Vermont 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 Vermont surveyors wrote
F697 findings written in Vermont, 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 upon observations, interviews, and record review, the facility failed to ensure adequate pain control was provided for 1 of 4 sampled residents (Resident #1). Findings include:Per record review, Resident #1 was admitted to the facility with diagnoses that include chronic pain syndrome and osteoarthritis (a diagnosis affecting joint cartilage causing pain swelling and stiffness of the affected joints). Resident #1 has a BIMS [Brief Interview for Mental Status] score of 14, dated 10/7/25, indicating cognitive function is intact.Per observation on 12/30/2025 at 3:10 PM, Resident #1 vocalized with increased volume help. At 3:13 PM, LNA (Licensed Nursing Assistant) #1 entered the room. Resident #1 stated that they wanted to get into bed and that their back hurt. …
The short window
Recent years
| Year | Share of Vermont citations | vs expected |
|---|---|---|
| 2023 | 2.20% | 3.00× |
| 2024 | 1.27% | 1.73× |
| 2025 | 0.96% | 1.23× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Vermont surveyors cite →
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