In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Alabama. 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.
We’re reaching the home stretch with this IJ series – and still no updates from The Centers for Medicare and Medicaid Services (CMS) on post-pause survey details. There’s several states without any IJ citations available for 2025, so check back on the CMSCG Blog to capture the last few states.
Top Areas of Noncompliance
The most frequently cited IJ deficiencies in 2025 in Alabama include:
- F580 Notify of Changes
- F658 Services Meet Professional Standards
F580 Notify of Changes
If you read the CMSCG Blog, or you’re a CMSCG client, you know that we often discuss the importance of informed consent for the use of psychotropic meds (and all meds for that matter). Not providing informed consent can fall under several tags, and in Alabama, a facility ended up in an Immediate Jeopardy situation related to a change in an anti-anxiety med. This is an unusually high severity for what appears to be a communication failure. Let’s look at what happened.
IJ Citation Example – F580 S/S: J
A facility failed to notify a resident’s responsible party that the resident’s dose of Ativan was decreased from 1mg to 0.5mg. The resident was admitted to the facility with GAD and “diagnoses” of “restlessness” and “agitation” and received 1mg of Ativan at bedtime for anxiety. A GDR of this med was attempted the next month and there was no evidence that the resident’s representative/family was notified. The representative was interviewed via phone and said that he/she was not notified of the decrease. No documentation could be found that the representative had been notified.
Negative outcome to the resident? Immediate Jeopardy at a S/S: of J? It seems like a reach, but this was identified on a recertification survey and wasn’t disputed.
Compliance Insights
Let the above example be a reminder that you just never know who the surveyor you’re going to get is going to be or what kind of case they’re going to make. This facility ended up with seven (7) IJs on this same survey – F600 Abuse/Neglect (J), F609 Reporting (J), F645 PASARR Screening for MD & ID (J), F658 Services Meet Professional Standards (J), F689 Accidents (J), F740 Behavioral Health Services (J) and this J at F580.
For a couple of these tags (F600, F609 and F740), there is some “meat” to the 2567. Here’s what happened. A resident was outside smoking and cursing and calling staff names. The CNA failed to respond to the resident “calmly and gently” and instead, picked up and ashtray and threw it at the resident. The ashtray thankfully missed the resident but did result in a behavior escalation whereby the resident threw an ashtray back at the CNA. The resident missed the CNA – but hit another resident on the head, causing an injury. You can see how that may create an IJ scenario.
However, some of the content of the SODs associated with these IJs are probably some of the shortest in documented history, including the 5-sentence Immediate Jeopardy SOD related to F645, where a resident did not have a new Level I PASRR submitted when a resident received a new diagnosis of PTSD.
Are you reading this and feeling as alarmed as I am? How many times have we accidentally missed submitted a new PASRR and didn’t expect it would end up in IJ? Aren’t communication failures something we commonly deal with, especially when it comes to the family?
Be aware – and remind your team – that facilities have ended up with Immediate Jeopardy citations related to these boo-boos that happen.
Communication is key.
- Ensure that all residents, and their representatives, understand residents’ rights, including communication expectations.
- Regularly review your communication methods to ensure they are appropriate to ensure required notifications are made – and documented. Ensure you have clear protocols surrounding notifications.
- Document every notification attempt – including method, time and person contacted. You’d be surprised how often your staff can verbalize, but not provide, documentation of all the attempts they have made to contact someone outside the facility. You know it . . . document it or you didn’t do it.
🚨 Concerned About Compliance? Let CMSCG Help You Stay Survey-Ready
At CMS Compliance Group, we don’t just identify problems—we help you solve them. Our interdisciplinary team has a proven track record of guiding nursing homes and other post-acute providers through the most serious compliance challenges.
Whether you’re facing Immediate Jeopardy citations or want to prevent them altogether, our consultants offer:
- Mock surveys with detailed findings across all departments
- Post-survey support and Plan of Correction development
- Ongoing quality assurance reviews to keep your systems functioning at the highest standards
Let’s make compliance your organization’s strength. Call us at (631) 692-4422 or contact our team to schedule a consultation.
