In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Missouri. IJ 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.
Top Areas of Noncompliance
The most frequently cited IJ deficiencies in 2025 in Missouri include:
- F689 Accidents
- F600 Free from Abuse/Neglect
- F684 Quality of Care
In this post, we’re going to look at two different abuse-related IJs where not only was F600 cited at an IJ, a tag from a Behavioral Health regulatory group was also cited.
Scenario 1 – F600 S/S: J and F740 Behavioral Health S/S: J
A facility was cited for failure to ensure residents were free from abuse by a resident who yelled, cursed and threatened others (F600) and for failure to provide a behavioral management program for that resident (F740). It was reported that the resident bullied others and that his peers refused to go to activities or eat in the dining room to avoid being around this resident. The resident had behaviors of speaking rudely to his roommate, eating off other residents’ plates and being verbally aggressive and disrespectful to staff. Review of the resident’s record lacked evidence that there was a behavior management plan in place for the resident, in accordance with the facility’s behavior conduct guidelines. No evidence was observed that the program’s effectiveness was being routinely assessed, monitored and evaluated.
The surveyor found that staff failed to develop and implement an effective care strategy that focused on preventing the resident’s behaviors through on-going Social Work counseling after other interventions had failed. The facility also failed to consistently report behaviors to the physician and psychiatrist, closely monitor the resident when behaviors occurred for the safety of others, and ensure that the IDT consistently followed up on the resident’s behavior. There was no documentation indicating that the physician or psychiatrist were notified of the resident’s behaviors, including when there was an escalation where the police were called occurred. It was also identified that the resident’s behaviors triggered a peer’s PTSD – which the facility also did not address.
Scenario 2 – F600 S/S: J and F741 Sufficient/Competent Staff – Behavioral Health Needs
You’ll probably read this and think it’s a made-up example, but trust us, it’s not. Both IJs are associated with one resident, and it’ll be pretty obvious why.
A resident, who was documented as becoming aggressive when he demanded his medications earlier than were scheduled, requested his meds from staff. Staff told him it was too early, and surprise, he became extremely agitated. The resident was apparently so intimidating that the staff member passing meds ran and locked herself in the clean linen closet. Meanwhile, the resident’s assigned 1:1 and a licensed staff member watched from a distance as the resident moved down the hallway, stared into his peer’s room for a few minutes, then raised his arms and ran into his peer’s room and hit him in the head, causing a hematoma.
The licensed staff member who hid in the closet stated during the investigation that she was not confident that the assigned aide and licensed staff member would be able to handle the resident’s behavioral escalation, so that is why she hid. After the resident hit his peer, they then intervened to prevent him from striking the other resident again. On interview, the licensed staff member did not explain why he/she did not attempt to intervene prior to the first strike.
The Administrator stated that staff were afraid of the resident due to his size and strength and did not know why they didn’t call a code for assistance since the resident had a history of physical aggression with peers.
After this event, the resident’s unit was changed. However, instead of going to his new unit willingly, the resident returned to his prior unit, sat on the floor and refused to get up. Staff attempted to pull him to a standing position and were unsuccessful. The next plan? The licensed staff placed a blanket on the floor, physically rolled the resident onto the blanket and then the aide and licensed staff dragged the resident down the hall, through the lobby and to his newly assigned room.
The next plan? The licensed staff placed a blanket on the floor, physically rolled the resident onto the blanket and then the aide and licensed staff dragged the resident down the hall, through the lobby and to his newly assigned room.
One aide stated that he told the licensed staff that they should just let the resident remain on the floor and after the resident was dragged to his other unit, he asked the licensed staff if he should provide a statement since what happened “wasn’t right” – he was told no. The resident was noted to appear anxious and nervous while this was happening, but he was not aggressive. After being moved to the new unit, the resident became increasingly anxious, so staff administered an IM antianxiety med. The charge nurse felt this was the only way the resident would be “safe.”
Compliance Insights
These examples provide unfortunate insight into how much more work some facilities need to do related to behavioral health training and accident prevention. In both cases, lack of appropriate behavioral interventions resulted in resident-resident altercations. In the first example, the overall lack of care planning and providing appropriate services to the aggressive resident was identified as a problem, but you could see how these gaps could be the result of insufficient competency and training in behavior management. In the second scenario, it was pretty obvious that there were multiple failures and that staff were not adequately trained to meet this resident’s need. Given that the assigned 1:1 and charge nurse stayed two doors away from the resident, it’s no wonder another resident was injured.
Here’s two questions to ponder once you wrap your head around the citations you’ve just read. They may make you think twice.
Are your staff actually competent to care for residents with behaviors – or is this one of those annual trainings to check a box?
Too often, we see residents who likely should not have been admitted to a facility due to behavioral health concerns who are admitted anyway. Just like you wouldn’t admit someone on a vent or someone who requires IV antibiotics if your staff weren’t competent to care for them, you need to consider the strength of your staff training. As the nursing home population shifts to being younger with more behavioral concerns, your staff’s education and training needs to shift.
There’s no reason your staff should be locking themselves in a closet to hide from a resident. Empower them with knowledge and training. Think about the potential for a different outcome if a code had been called so more assistance could have been provided – even that training may have prevented a resident from being injured. It’s also important to ensure your staff feel safe doing their jobs. There’s still a labor shortage out there, which is why we’re seeing so many Sufficient Staffing citations, so you’ve got to differentiate your facility as a good place to work. Not providing staff with the tools to do their jobs is not a great way to make the facility great.
When’s the last time you reviewed your use of PRN Psychotropics?
This is a good indicator of your staff’s competency. If staff are constantly resorting to requests for PRN meds versus individualized behavioral interventions, this is not only potentially problematic in other regulatory areas (we’re looking at you, chemical restraints and informed consent requirements) but likely warrants an IDT review. We were recently conducting a mock survey and identified that there were multiple instances of PRN IM antipsychotics and antianxiety meds ordered without informed consent for “agitation” and “restlessness.” Not only was there no informed consent or appropriate rationale for use, the Administrator and Medical Director were unaware that there was a “loophole” in the EMR where consent and other documentation was not being triggered prior to ordering IM meds. Don’t make assumptions – audit your systems and understand your staff’s actual capability to meet the needs of your residents.
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