In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes in Georgia in 2025. 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
Currently, the most frequently cited IJ deficiencies in 2025 in Georgia include:
- F835 Administration
- F600 Free from Abuse/Neglect
- F656 Develop/Implement CCP
Compliance Insights
F835 Administration is one of those tags that some surveyors love to add on, and in other states, it’s not really cited. This year in Georgia, a review of F835 citations identified a couple instances which are alarmingly similar – and an area where all facilities need to pay attention.
Citation 1
Administration did not provide “protective oversight” of the facility when it didn’t ensure staff followed appropriate policies and procedures to prevent accidents or hazards for issues rising to the level of Harm and/or Immediate Jeopardy. The facility was put into IJ related to a resident choking to death on a sandwich (F677 ADL Care S/S: J, F656 CCP S/S: J). As it turned out, the resident’s MDS and care plan did not address risk of dysphagia and the need for supervision while eating.
Citation 2
Administration did not effectively and efficiently manage the facility when a resident receiving an altered diet was provided with a sandwich, resulting in him being sent to the ER and admitted to hospice, where he expired. The facility was put into IJ for F656 Care Planning and F684 Quality of Care in addition to F835.
Situations such as these are what has resulted in F656 Care Planning being cited at IJ levels. Ensure responsible staff are auditing – diet consistencies, tray accuracy, etc. Staff should ensure residents who are eating in their rooms are also provided with appropriate supervision – monitor to ensure staff are actually monitoring.
F835 has also been cited in several abuse-related situations, including:
- Failing to ensure a complete, thorough investigation of an allegation of resident-resident sexual abuse was completed, resulting in a resident being transferred to the ER for evaluation of a sexual assault
- Failing to take appropriate action regarding allegations of staff-resident physical and verbal abuse and failing to prevent three residents from sexual abuse by a peer.
F600 Free from Abuse/ Neglect is understandably also being frequently cited if we look at the situations discussed in this post related to F835. Remember that it is Administration’s overall responsibility to ensure residents are safe from abuse and neglect. Make it evident that the facility takes all allegations of abuse seriously by reporting, ensuring they are discussed routinely as part of the QAPI process, and that staff receive routine education on abuse prevention. Ensure all staff understand their responsibility to help prevent abuse and report all allegations of abuse, neglect or mistreatment timely.
Received an IJ Citation? Make CMSCG Your Your First Call
CMS Compliance Group helps nursing homes respond to Immediate Jeopardy citations quickly and effectively—with root cause analysis, documentation support, and recovery planning.
Contact us today at 631.692.4422 or cmscompliancegroup.com.
