In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Florida. 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 Florida include:
- F600 Free from Abuse and Neglect
- F684 Quality of Care
- F689 Free of Accident Hazards/ Supervision/ Devices
- F580 Notify of Changes
- F880 Infection Prevention and Control
F600 Free from Abuse and Neglect
In some states, you see multiple tag trends related to the same issue, such as adding-on F684 Quality of Care or F835 Administration when there’s a concern identified by a surveyor so it can really pack a punch. Well, in Florida, surveyors are really into the “add on” IJ at F600 Abuse and Neglect, especially related to neglect, in addition to the Ftag where the issue was also identified.
- F689 Accidents + F656 CCP + F600 S/S: J for Neglect – Facility failed to protect a resident’s right to be free from neglect by not ensuring a cognitively impaired resident who was dependent upon staff to feed at meals was provided supervision and services related to the resident’s difficulty swallowing and history of CVA. Staff left a covered food tray in the resident’s room, and the resident consumed part of the meal unsupervised and without assistance. The resident was found unresponsive after staff were alerted by the resident’s roommate that she had choked. The resident expired in the hospital. The surveyor identified that the facility failed to prevent the resident from choking by not providing supervision during the meal and not checking the resident’s care plan prior to providing the meal to the resident.
- F690 Bowel/ Bladder S/S: J + F600 S/S: J for Neglect – Facility failed to protect a residents’ right to be free from neglect when it did not appropriately monitor a resident’s urinary output after insertion of an indwelling catheter and failed to monitor the resident’s change of condition. Staff did not take the resident’s vital signs or assess the resident, and the resident became unresponsive, had no urinary output and was bleeding when transferred to the hospital. The facility also got two “J” level tags at F726 Competent Nurse Staff and F835 Administration for this issue.
- F710 S/S: K + F726 S/S: K + F773 S/S: K + F867 S/S: K + F600 S/S: K for neglect: Are you adding up those points in your head? Yikes. A facility was cited for failure to protect residents’ right to be free from neglect when it was identified that all residents sampled related to seizure medication management and follow-up lab orders for seizure medication therapeutic levels. A resident experienced several seizures, including one where she needed to be transferred to a higher level of care because of the seizure. Labs were not consistently documented as completed and the physician was not notified of abnormal labs, including prior to the resident’s most recent seizure. Review of other documentation found that the resident was refusing meds, that labs were not being routinely checked and that a neurology consult ordered by the physician was not completed.
Enough, you say? We get it. Just remember – there are a lot of areas which can also be tied into neglect, such as the facility that not only got an IJ-level citation at F584 Environment, but also F600 Abuse/Neglect and F835 Administration related to not ensuring safe and comfortable air temperature ranges were maintained after the central air on multiple units was not working. We discussed IJs related to F584 in several posts as part of our “The State of IJs” series – only in those situations, it was related to the building being too cold. Keep it all in mind when you’re considering your responsibilities related to a safe, comfortable environment.
Compliance Insights
Here’s what providers need to consider to avoid citations in these areas.
Strengthen Interdisciplinary Communication
Many IJ situations, like some of the examples above, but also real-life examples we’ve shared from throughout the country this year, arise from communication breakdowns. Whether it’s missed lab results, change in condition that’s not reported, or lack of follow-through on physician’s orders, communication systems always benefit from another look. Make it a habit to review how information flows – or doesn’t – between disciplines, including nursing, medical, therapy and administration.
Elevate Accountability for Care Plans
Another area we’ve discussed several times throughout this CMSCG Blog series is care planning. Hold staff accountable for what’s in residents’ care plans and ensure staff can show you or explain to you how they are implementing that plan of care. Conduct a spot check like we do on a mock survey – ask direct care staff what they know about the plan of care for a resident with complex needs, such as swallowing difficulties. If there’s a disconnect, address it – fast.
Foster a Culture of Continuous Improvement
This isn’t just buzzwords. Don’t treat compliance issues as a one-time event. Use mock surveys, post-survey reviews and ongoing quality assurance to keep your systems sharp and staff on top of their game. Encourage and monitor staff to view compliance as part of their daily routine . . . not just something to worry about when a surveyor walks in.
Ready to Strengthen Your Compliance Program?
Don’t wait for Immediate Jeopardy citations to disrupt your operations. Partner with our team to proactively identify risks, close compliance gaps, and build a culture of continuous improvement. We offer:
- Mock surveys with actionable findings
- Post-survey support and Plan of Correction development – and assistance with implementation, if needed
- Ongoing quality assurance reviews
Let’s make compliance your organization’s strength—not just a checkbox.
Contact us today at (631) 692-4422 or email info@cmscg.net to schedule your consultation.
