In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Arkansas. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these citations can help providers proactively address vulnerabilities and improve care outcomes. It doesn’t matter what state you’re in – these types of events could occur anywhere.
Top Areas of Noncompliance
The most frequently cited Ftag for IJ deficiencies in 2025 in Arkansas is F689 Accidents. This is one of the most frequently cited tags in many states (and the nation) for higher-level citations, so we are providing you with insights on some of the more unique issues in each state. These nuances help providers in the state, but also should make Administration, Nursing Administration and other nursing home staff think about their own systems and how to prevent potential issues.
F689 IJs related to Transportation Safety
It’s important to note that transportation-related concerns resulted in several IJs so far this year from reported events. These types of events are unfortunately more common than you’d expect, but depending on the state, don’t always rise to the level of an IJ. Let’s look at two IJs from Arkansas:
Citation 1 – F689 S/S: J
The first IJ occurred when a resident, who had been positioned in the wheelchair in a manner which would likely restrict his/her ability to breathe, fell backwards in a wheelchair during transport. It was identified that an untrained CNA put a resident in the facility transport van to go to an appointment. The resident fell backwards after the CNA hit a bump, resulting in the resident becoming trapped between the wheelchair and wheelchair lift – resulting in her not breathing. EMS arrived and initiated CPR, but the resident expired in the hospital after the family’s request for a DNR. It was determined through demonstration that the staff had not sufficiently tightened the wheelchair holding straps to safely transport the resident. The CNA confirmed that she had never been trained to transport a resident in a wheelchair other than being shown once how to do so.
Citation 2 – F689 S/S: J
In this second IJ example, a resident was transported to an appointment using a borrowed van which staff had not been trained to use the lift for. The resident rolled off the van lift when the unlocked wheelchair rolled backwards as the lift was being raised and the resident fell to the ground. The resident was, thankfully, not injured but as you can see from the prior example, that is not always the case. The CNA who was responsible for transport stated that she had never been trained on the use of the lift van which had been borrowed from another facility. The Administrator stated that staff were trained verbally, not through demonstration, on how to use the lift.
Compliance Insights
If you’ve got facility staff using any vehicles or assisting residents with getting into or out of contracted transportation:
- Check your Facility Assessment – did you address vehicles? There should be associated training/ competency for any staff who are responsible for this.
- Ensure the list of staff who have received transportation training is accurate and updated when staff members and/or responsibilities change. Do you know if staff drivers’ licenses are still in good standing?
- Define responsibilities between who is responsible when residents are going out and being transported via contacted services. If the ambulette or other driver/staff is supposed to put the resident in the vehicle and ensure everything is secure, then facility staff shouldn’t “help” if they don’t have appropriate training.
Interesting Trend
Facilities in Arkansas have been in IJ situations related to multiple Abuse tags (F600, F609 and F610) this year – but those aren’t the only areas that abuse rose to the level of an IJ in this state. A facility was cited at F656 Develop/Implement Comprehensive Care Plan (S/S: J) related to monitoring a resident who wandered and was at high risk for resident-resident altercations. The SOD stated that the lack of effective interventions resulted in the resident being involved in nine resident-resident events on a secure unit where he was kicked, hit, punched and pushed to the ground.
🛡️ Stay Ahead of IJ Risk with CMS Compliance Group
Avoiding an Immediate Jeopardy citation starts long before surveyors walk through your doors. At CMS Compliance Group, we work with nursing homes to build strong compliance systems that prevent serious deficiencies from occurring in the first place.
Our proactive consulting services include:
- Mock Surveys – Identify gaps across clinical, operational, and environmental areas before they become citations
- Policy & Procedure Reviews – Ensure your documentation supports your practices and meets regulatory expectations
- Staff Training & Mentoring – Equip your team with the knowledge and tools to respond confidently during surveys – and every day
- Quality Assurance Support – Strengthen your internal systems to maintain ongoing compliance
We help facilities move from reactive to ready—because the best way to handle an IJ is to never receive one.
Call 631.692. 4422 or visit cmscompliancegroup.com to schedule a consultation with our team. You can also drop us an email to learn more about how we can assist you.
