In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across California. 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 so far in 2025 in California include:
- F689 Free of Accident Hazards/Supervision/Devices
- F600 Free from Abuse and Neglect
- F684 Quality of Care
However, IJs in California so far have been cited under more than twenty different Ftags, a couple of which we can’t ignore. In today’s post, we’re going to review two IJ citations in areas we haven’t covered yet – F550 Resident Rights and F606 Not Employ/Engage Staff with Adverse Actions.
IJ Citation Example – F550 Resident Rights S/S: J
It’s not often that you see IJs related to F550 Resident Rights, so we had to check it out. This one is an interesting one since it revolves around Advance Directives. We see issues related to this area cited under several tags typically, including F578 Advance Directives and F678 CPR, for example, but this example went a different way.
Per the Statement of Deficiencies, the facility did not protect, promote and honor a resident’s right to not receive CPR in accordance with his/her POLST. The resident’s POLST indicated DNR, but when the resident was observed not breathing, two licensed staff initiated CPR after “an unidentified person” shouted to them that the resident was a full code. Another staff member verified the POLST but then assisted the staff with CPR until the paramedics arrived. The paramedics reviewed the POLST and admission record and informed the staff that the resident had a DNR order. The failure to verify the resident’s code status in the POLST and perform CPR was found to violate the resident’s wish of DNR, which could cause distress to the resident, and his/her family had the CPR been effective.
Compliance Insights – Resident Rights and Advance Directives
Here’s what providers need to consider to avoid citations in this area.
- Ensure staff know your verification protocols. In this case, someone shouted the resident’s code status – incorrectly – and staff just went with it.
- Constantly educate your staff. All licensed and unlicensed staff should receive routine education on advance directives and how to respond during an emergency when a resident’s code status is unclear. Haven’t done a code drill recently? Give it a go.
IJ Citation Example – F606 Not Employ/Engage Staff with Adverse Actions S/S: L
All the HR Directors we know are likely to want to use this example with their staff as a teaching moment for why all the granular HR processes are in place for a reason.
This IJ situation occurred, in part, after a facility knowingly employed a CNA who had a history of a criminal misdemeanor. This unfortunately led to nine residents being sexually assaulted by this CNA – with the potential to impact all residents in the facility. It turned out that the Director of Staff Development, who was responsible for checking references, became aware that the CNA had a record, but he explained his story as being a domestic abuse situation. The Director and Administrator called the CNA who provided further information about the charges and decided to hire him anyway.
This IJ was accompanied by a graphic citation at F600 (S/S: K) where the facility was cited for failure to protect nine residents from actual sexual abuse.
In both SODs, it is stated that this situation caused “residents to have fear, anxiety, inability to sleep, to feel ashamed, embarrassed and at risk for long term psychosocial trauma such as social isolation, emotional instability, post-traumatic stress disorder and suicidal risk.”
Had another CNA not seen this CNA in a resident’s room where he shouldn’t be, this may not have come to light. Once interviewed, multiple residents stated that they were scared to say something, embarrassed, could not forget what happened and indicated that the CNA’s behaviors had been going on for a while. Several residents indicated they had been assaulted several times by the same staff.
Compliance Insights – F606
The entire purpose of F606 being a regulation is to ensure that residents are protected from foreseeable harm – and the facility’s failure to appropriately vet the CNA is a prime example of why there are requirements for background and criminal history reference checks for prospective healthcare employees. Remember that a single hiring misstep like this one can lead to systemic resident harm – and lead to widespread regulatory concerns.
Here’s what providers need to consider to avoid citations in this area.
- Ensure screening is objective and documented. All findings from checks like the State Nurse Aide Registry, licensing boards, etc. must be reviewed and documented. A subjective explanation from an applicant is not the same as reviewing verified records. In this situation, the references were allegedly contacted without response – but no documentation could be provided to validate that.
- Ensure staff are appropriately trained for their duties. Staff who have roles and responsibilities in the hiring process should be well-trained in legal requirements and regulatory requirements, such as disqualifying prospective employees who have histories such as this. Check out our CMSCG Ftag of the Week for F606 here.
Long story short, treat every hiring decision as a frontline defense against potential abuse. This IJ example is about so much more than just paperwork and processes – it’s a reminder of our responsibility to protect the most vulnerable from preventable harm.
Build a Culture of Compliance That Lasts
CMS Compliance Group supports nursing homes with ongoing QA reviews, mentoring/ coaching of new management/ department heads, and documentation strategies that hold up under scrutiny.
Schedule a strategy session at (631) 692-4422 or email us.
