Based on resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure effective pain management was provided for one resident, Resident #28 (R28), out of a survey sample of 42 residents. Specifically, the facility failed to administer the resident's prescribed pain medication as ordered. As a result, R28 experienced withdrawal symptoms, causing actual harm and discomfort. The findings included:On 5/17/26 at 10:30 am, an interview was conducted with R28. During the interview R28 stated, my morphine was not available to be given so oxycodone was ordered one time in the morphine place but that didn't help my pain like the morphine did and I had withdrawal symptoms because I went without the morphine. …
F697 citations in Virginia
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
Virginia cites F697 more often than its own record predicts
1.18 times the share F697 takes of citations nationally.
Of every deficiency written in Virginia 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 Virginia surveyors wrote
F697 findings written in Virginia, 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 staff interview, facility documentation review, clinical record review and in the course of a complaint investigation, it was determined the facility staff failed to administer pain medications as ordered for one of 26 residents. The findings include:For Resident #8 (R8), the facility staff failed to evidence the administration of pain medication as scheduled and failed to evidence administering pain medication on time. On the most recent MDS (minimum data set) assessment, discharge assessment with a reference date of 4/24/2026, the resident was assessed as having a PEG (1) (percutaneous endoscopic gastrostomy) tube and receives 51% or more of calories from enteral feeding. …
The short window
Recent years
| Year | Share of Virginia citations | vs expected |
|---|---|---|
| 2023 | 1.19% | 1.61× |
| 2024 | 1.01% | 1.38× |
| 2025 | 0.92% | 1.18× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Virginia surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction