In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Kentucky. 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 Kentucky include:
- F689 – Free of Accident Hazards/Supervision/Devices
- F656 – Development/Implement Comprehensive Care Plan
- F655 – Baseline Care Plan
Compliance Insights
F689 is not a surprise as being at the top of the most frequently cited deficiencies, but F656 Comprehensive Care Plans and F655 Baseline Care Plans are certainly not your typical fare in the IJ realm. What it says for the Kentucky State Agency is they are using the circumstance surrounding an IJ event that is being cited and tying it to how a facility did not develop or implement a care plan that meets regulatory requirements.
We are going to take a look a scenario that resulted in four (4) IJ citations at a Scope/Severity of “J.” The citations were given at F580 Change in Condition, F655 Baseline Care Plan, F684 Quality of Care, and F760 Residents are Free of Significant Medication Errors, but our look is going to revolve around how the facility was cited at an IJ level for baseline care planning.
The baseline care plan deficiency was the result of the facility failing to develop and implement baseline care plan for two (2) residents within 48 hours of admission to the facility. Both residents had identified care concerns that should have been care planned for at the time of admission.
- One resident had an active infection requiring antibiotic therapy, which was to be administered via PICC line, so there was an obvious need to initiate a plan for care of the PICC line. Lastly, this resident had a worsening change in condition, and the facility nursing staff did not notify the physician.
- The second resident, who was assessed as at risk of developing pressure injuries, had an unstageable wound on their left heel identified by the therapy staff the day after admission. The citation indicates that at the time of the surveyor’s visit the baseline care plan was still in effect but was not addressed or updated to include the existing skin breakdown.
Surveyors, as always, reviewed the associated policy for a Baseline Care Plan (BCP) from 2023 and noted that the care plan was to include the “minimum healthcare information necessary to properly care for a resident.” It also directed that the BCP would be developed and implemented within 48 hours of a resident’s admission. Staff interviews noted that the LPN, who admitted the resident, was not aware that it was her responsibility for initiating the BCP for residents. The LPN also stated that the MDS Nurse initiated and revised care plans as needed. It may be that the policy did not clearly assign responsibility for initiating the BCP or that the LPN had not had sufficient education on their responsibility regarding BCPs.
A surveyor interviewed an RN, who stated that the admitting nurse or Unit Manager initiated the BCP based on the resident’s diagnosis and discharge paperwork. The RN further indicated that the care plan needs to be initiated the day of admission for current needs to prevent a decline including an infection or skin breakdown and be reviewed by the supervising nurse or MDS nurse within 48 hours. The RN was aware that the plan of care should have been revised for both of the surveyor-identified concerns.
The MDS nurse was fully aware that the BCP should be initiated within 48 hours of admission, but stated that when residents are admitted late on the evening shift or on the weekend, nursing management was to review the BCP within 48 hours. The MDS nurse further stated the BCP should include health and safety concerns to prevent a decline in resident health and should include any special needs. This nurse also indicated that she did not know why either resident’s BCP were not completed to include each resident’s needs at the time of admission. And the story goes on, the Interim DON stated the process is for the admitting nurse to initiate the BCP within 48 hours with interventions that address the resident’s immediate needs. The Interim DON was not able to identify the “process breakdown” for ensuring that BCPs were complete. The interview process continued to include the Executive Director, who verbalized the process that should be in place, and indicated that the development of the BCP within 48 hours was important to ensure safe and appropriate care for all residents.
Regardless of staff members’ knowledge level of what should occur related to the development and implementation of the BCP, it did not happen for the two residents cited in this deficiency. Perhaps it would be beneficial to review the policy to ensure that it addresses all components of the regulation, take a look at assigned responsibilities associated with policy, provide necessary staff education and then monitor/audit staff adherence to the policy. The Guidelines section of this regulation state “Because the BCP documents the interim approaches for meeting the resident’s immediate needs, professional standards of quality of care would dictate that it must also reflect changes to approaches, as necessary, resulting from significant change in condition or needs, prior to the development of the comprehensive care plan.” It might be worthwhile to check the BCP of a resident with a change in condition within days of their admission to see if your team met the mark on developing and implementing the BCP for the identified resident. I hope that you will like what you see.
🛡️ Stay Ahead of IJ Risk with CMS Compliance Group
Avoiding an Immediate Jeopardy citation starts long before surveyors walk through your doors. At CMS Compliance Group, we work with nursing homes to build strong compliance systems that prevent serious deficiencies from occurring in the first place.
Our proactive consulting services include:
- Mock Surveys – Identify gaps across clinical, operational, and environmental areas before they become citations
- Policy & Procedure Reviews – Ensure your documentation supports your practices and meets regulatory expectations
- Medical Record Review Audits – Onsite and remote-based auditing to help identify concerns which should be addressed to improve quality of care and services
- Staff Training & Coaching – Equip your team with the knowledge and tools to respond confidently during surveys
- Quality Assurance Support – Strengthen your internal systems to maintain ongoing compliance
We help facilities move from reactive to ready—because the best way to handle an IJ is to never receive one.
Call (631) 692-4422 or visit cmscompliancegroup.com to schedule a consultation with our team.
