In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Louisiana. 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.
Top Areas of Noncompliance
The most frequently cited IJ deficiencies in 2025 in Louisiana include:
- F600 Free from Abuse and Neglect
- F689 Free of Accident Hazards/Supervision/Devices
- F835 Administration
IJ citations were also given multiple times for F609 Reporting of Alleged Violations.
Of concern is that more than 75% of the citations at a scope/severity of L all had a “matching” scope/severity of L citation at F835. As pointed out in another recent blog in The State of IJ series -think of the points associated with these high-level citations.
Let’s take a peek at some of Louisiana’s IJs. The first citations are a review of how the State Agency applied the reasonable person concept.
F600 Free from Abuse and Neglect & F609 Reporting of Alleged Violations
These tags were cited during a standard survey related to a female resident being identified as having been sexually and psychologically abused by a male staff member. The resident was both cognitively impaired and blind. The staff member’s inappropriate actions were witnessed by the resident’s roommate and a staff member who did not report the observation in a timely manner. When the observation was finally reported to an LPN, the LPN informed the reporting staff member that it should have been reported sooner. I should mention here that the male staff member also assaulted the LPN on two occasions before the LPN reported it to Nursing Administration. When the LPN reported what had happened to her and the identified resident, the male staff member was monitored and not immediately removed from duty while an investigation took place! As documented in the SOD, it could be determined the reasonable person would have experienced severe psychosocial harm as a result of sexual abuse, since a reasonable person would not expect to be treated in this manner in their own home or a health care facility.
We can all easily see the tie-in to F609 for failure to report this abuse to the State Agency and to law enforcement authorities meeting compliance timeframes.
F835 Administration
This tag has been cited in Louisiana at a scope/severity of J, K and L under varying circumstances. There were K and L level citations involved lack of appropriate and timely implementation of preventative and corrective measures related to resident-to-resident abuse. Another K level (widespread) citation addresses a resident with a known protective order and open EPS case against family members being removed from the facility by two unknown family members. These family members were allowed to take the resident outside from the locked unit. When the CNA went outside to check on the resident, the resident, who was an elopement risk, was gone. The resident was found two days later. The resident was not wearing a security device, and all members of the interdisciplinary team did not have knowledge of the resident’s EPS case, etc.
Another interesting application of F835 was related to a dietary/kitchen staff member using a Clorox bleach solution for cleaning the blender used during puree meal preparation. This worker was advised by the surveyor to dispose of the meals on two occasions during meal prep, but this staff member continued to prepare meats the same way and then placed these meats on the serving/steam tame for meal plating – all of this obviously observed by the surveyor. The Administrator intervened and the meats were properly disposed of. Any vulnerabilities in your kitchen?
Administration was also cited for failure to oversee effective implementation of physician lab orders for one resident and at an L scope/severity for failing to have a system in place for safe temperatures of coffee and other hot liquids served to residents. Failure to have a sound system for management of hot beverages to avoid burns will always be high profile and many result in IJ deficiencies. It is never a good situation when a bowl of hot soup or hot coffee spills on a resident’s lap or some other part of their body. Oh, did I forget to say no one shared information on the burn that occurred months earlier with the Administrator; so, no corrective actions were implemented to prevent burn injuries prior to the IJ situation being identified? What was the Director of Nursing the Regional Supervisor thinking? What happened to doing an RCA and convening an ad hoc QAPI meeting in a timely manner?
I think you have the picture that it is the Administrator’s responsibility to have systems in place that are compliant with regulations, train the staff in their responsibilities and monitor compliance at the administrative level. Are you looking and asking the right questions of your staff? Does your staff understand your expectations of compliance?
Compliance Insights
Here’s what providers need to consider to avoid citations in this area.
- Understand the importance of survey readiness on a day-to-day basis. IJs are cited during standard surveys as well as during complaint surveys. If your staff complete their job duties and responsibilities on a shift-to-shift basis, a facility is usually in a good position to avoid high-level survey deficiencies.
- Review IJ citations, or any survey citation, with your staff so that they understand what “went wrong” and educate them on the correct procedure/protocol that should be followed to avoid a future citation in the same area. Survey citations are not “top secret”, and it is surprising how many staff are unaware of survey results and what they are supposed to be doing to reach and maintain compliance. My question is – did you identify the right staff members to be educated on the Plan of Correction? Don’t always think “minimum” because it is easier – easier is not always the best solution.
- Remember that communication is key in every well-run organization. How good are your communication systems?
