In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Oklahoma. 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. Surveyors in this mid-western state are out there monitoring care and services and looking at the data, there are quite a few IJ citations – as in the range of 30+.
Top Areas of Noncompliance
The most frequently cited IJ deficiencies in 2025 in Oklahoma include:
- F600 Abuse/Neglect & associated F607 – Develop & Implement Abuse Related Policies
- F689 Accidents
- F684 Quality of Care
Compliance Insights
The top three area of IJ citations are not surprising to any of us . . . So, this edition of the State of IJs is going to take a look at a “J” scope/severity deficiency related to F657 – Care Plan Timing and Revision from Oklahoma. A high-level deficiency in care planning certainly is not common, depending on the state but when the findings relate to an F600 Abuse citation, you can understand the link and the State Agency issuing this citation.
The deficiency stems from the facility’s failure to update a resident’s care plan related to sexually inappropriate behaviors. The actual inappropriate behavior was a male resident placing his hand under a female resident’s shirt and rubbing the breast area, which was reported to the State Agency. This male resident had a history of a similar incident with another female resident The resident was sent to a behavioral health hospital after the first and second incident – the fly in the ointment here is that staff did not update the care plan to prevent reoccurrence after the first incident. The resident had a significant medical history of cerebral infarction, hemiplegia and hemiparesis, bipolar disorder, anxiety, sexual dysfunction, unspecified psychosis and depression, which should have set off alarm bells with the interdisciplinary team that a protective plan should have been put in place for vulnerable females and an at risk to abuse care plan in place for this resident based on his history.
Not sure your staff “get” how to address abuse risk?
CMSCG can help. Learn more here.
The IJ situation was actually identified while the male resident was in the hospital for the second incident. The facility updated the care plan to address the behavior and developed interventions to prevent reoccurrence with a plan to further update the care plan when the resident returned from the hospital.
The facility implemented corrective actions to address the IJ situation including education of the MDS Nurse related to updating resident care plans to match resident preferences, behaviors of sexual nature with interventions implemented to address the behaviors – sorry but the entire interdisciplinary team should have received this education and maybe they did, but that is not apparent. Remember, no single staff member should have sole responsibility for developing and updating the plan of care. Other corrective actions included identifying residents with inappropriate sexual behaviors and care plan updates for the identified residents. Also, this is something that that should already have been in place.
From information documented related to this IJ, it is apparent that the facility staff were aware of the resident’s behavior as he was medicated with a hormone medication daily for sexual dysfunction for approximately 6-7 months in 2024. Shouldn’t the use of this medication alone have the IDT scrambling to implement a behavior management care plan to address the behavior with interventions to protect vulnerable residents?
This citation is an example of a real “gotcha” – especially since on interview, the DON indicated that the staff was monitoring the resident when he was out of his room related to his behaviors. Documentation related to this monitoring provided for review did not fully support that this was consistently happening. Think about this deficiency from a different perspective – would F657 been cited if the facility had acknowledged the resident’s sexual behaviors, implemented a care plan with behavior management interventions and consistently carried out the interventions?
Protect Residents. Strengthen Compliance.
CMS Compliance Group’s consultants help nursing homes build resilient compliance systems that not only meet regulatory standards—but also proactively reduce abuse risk. Through targeted mock surveys, focused staff education, and comprehensive system reviews, we support safer, smarter care environments.
Reach out today at (631) 692-4422 or info@cmscg.net.
