In this edition of The State of IJs on the CMSCG Blog, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Wisconsin. 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.
Providers need to be on top of their game when they have a nursing home in Wisconsin as there have been 40+ IJ citations there in 2025 alone. There was only one “L” Scope/Severity cited, nine “K” pattern citations and then obviously a whole lot of “J” isolated Immediate Jeopardy citations. There were only a few facilities with 2 IJ citations identified at the same time – all of the other citations are “stand-alone” deficiencies all over the State. While it is not a topic we are going to cover here, the “L” IJ was cited at F880 infection Control related to a GI outbreak.
Top Areas of Noncompliance
The most frequently cited IJ deficiencies in 2025 in Wisconsin include:
- F689 Accidents
- F686 Pressure Ulcers
- F684 Quality of Care
Compliance Insights
Any nursing home that provides care and services to ventilator-dependent residents or residents with a tracheostomy knows that this resident population is high-risk and a facility needs well trained and qualified staff for this specialty area. One facility was cited at an IJ level during the same early 2025 State Agency visit for issues related to two ventilator-dependent residents – one deficiency was cited at F684 Quality of Care and the other at F695 Respiratory Care / Tracheostomy Care & Suctioning.
F695 Quality of Care
Let’s start with F684. The citation is centered on the failure of the respiratory therapist to provide treatment and care in accordance with professional standards of practice for respiratory therapists. The therapist identified a change in condition while the resident was on a ventilator. A progress note was written regarding this change in respiratory condition (newly short of breath) and the actions implemented at the beginning of the night shift. Here’s what happened – or didn’t happen – next:
- The therapist did not follow up with further assessment to determine if actions taken (increased flow rate) improved the shortness of breath.
- The therapist did not report this change to the RN on duty on the unit or to staff from the oncoming shift.
- The even bigger mistake in this situation was that the physician was not contacted to discuss this change in condition and to elicit the physician’s directives for treatment of this change.
The outcome – the resident was found expired for several hours and their death was pronounced dead by the Pulmonologist a few hours into the day shift. Documentation in the 2567 notes that rigor mortis had set in when the resident was found unresponsive and assessed at that time. Multiple interviews were conducted with staff licensed and certified who worked the night shift as well as others who had worked with and knew the resident. The outcome of these interviews pointed to staff not following established procedures, documentation issues and a significant communication problem as contributory factors in this IJ situation.
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F695 Respiratory/Tracheostomy Care & Suctioning
The citation at F695 Respiratory/Tracheostomy Care & Suctioning citation also pointed to the respiratory care services provided not being consistent with professional standards of practice for the resident sample that included ventilator-dependent residents and residents who had a tracheostomy but were not ventilator dependent. Issues that were included in the citation:
- A resident was not put on their ventilator at night as there was no respiratory therapist at the facility
- Multiple documentation omissions over approximately a one-month period of a respiratory assessment being conducted each shift
- A family member having to hook up one resident’s trach mask to their oxygen as there were no scheduled staff on duty having the knowledge/competency to hook the trach mask up to oxygen.
Concerns were identified regarding licensed practical nurses (LPNs), who were caring for residents when a respiratory therapist was not in the building, that were not working outside of their scope of practice and whether the LPNs were competent to carry out delegated tasks with supervision provided by a competent/trained registered nurse (RN). Needless to say, the licensed nurses in this facility, who worked with the residents requiring respiratory therapy services, have to be competent with skills related to respiratory care including the RNs who are responsible for providing supervision.
Couple this with staff interviews and you can imagine the outcome. During the survey investigation it was determined that only the DON, staff development coordinator and five LPNs participated in a Ventilator Certification course a few weeks before the IJ situation was identified – no RN supervisors received this education. Just imagine the policies referenced and the RN Supervisors voicing that they were not confident about caring for residents on the ventilator unit – how could they feel confident when they had no education or competencies done.
Here’s what providers need to consider to avoid citations such as these.
- Never admit residents who require complex/specialty care if you do not have trained, competent, knowledgeable and qualified staff to provide care and services to meet their individual needs. This also includes having a sufficient number of these trained staff available 24/7. While these deficiencies are related to respiratory services, the concept of having trained and competent staff to provide necessary care is a necessity for any facility.
- Fully train staff before you admit any resident requiring specialty care/services – that means train all staff who will be responsible for caring for the special care population as well as others who may rotate through the unit or be expected to provide oversight supervision.
- Ensure that staff are not working outside of their scope of practice. You have a responsibility not to assign responsibilities that are outside of licensed nurses’ or respiratory therapists’ scope of practice.
- Provide ongoing education to your clinical staff on communication between disciplines, shifts and the medical staff. Monitor documentation that is meant to validate that care and services were provided and notification of change in condition is provided when indicated.
Stay Survey-Ready with CMS Compliance Group
Avoiding citations starts with strong systems. Our mock surveys, policy reviews, and staff training help nursing homes identify risks before surveyors do.
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