The State of IJs – 2025: Nursing Home Immediate Jeopardy Citations in Massachusetts

In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Massachusetts. 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 Massachusetts include:

1. F726 – Competent Nursing Staff
2. F689 – Accident Hazards/Supervision/Devices

Compliance Insights

F726 Competent Nursing Staff was cited at all IJs levels, which means that there was a significant concern with competencies in a few nursing homes in Massachusetts.

Issues that were identified related to a Nursing staff not being competent were related to:

• Staff on the ventilator unit were not using the correct PPE for resident who required Enhanced Barrier Precautions (EBP) – couple that with the Unit Manager not being able to verbalize the facility’s hand hygiene protocol for residents on EBP. Remember, we are referring to a ventilator unit where all residents would require EBP. You can understand why the facility’s citation was a “K” as there was an on-going spread of C. auris.

You can also fully understand based on the snippet of information provided as to why the facility received three additional citations at a “K” level for F835 Administration, F865 QAPI Program and F880 Infection Prevention and Control.

• Nursing staff were not trained and able to demonstrate competency and skills related to behavioral /mental health services outlined in the Facility Assessment. The IJ situation was identified during a standard survey regarding lack of unit licensed nursing staff who were schedule for work on three consecutive days not identifying, assessing, and intervening for a resident admitted with Suicidal Ideation and made repeated statements of wanting to commit suicide. The resident had a known history of mental illness and repeated suicide attempts. The Administrator acknowledged on interview that the staff should have been trained on behavioral health as the facility had a “significant number of residents that have behavioral health concerns.”

I don’t understand how staff did not intervene – even using the “reasonable person” concept and recognizing that this person was in psychological distress yet alone having a state surveyor on the unit and observing the total lack of appropriate actions being taken. The lack of appropriate actions by staff was referenced in the CMS-2567 when the surveyors referenced the Board of Registration in Nursing Standards of Conduct. By the way, the other cited IJ for this facility was at F740 Behavioral Health Services.

• The 3^rd IJ situation is another tag-team of four (4) IJs cited at an “L” scope and severity during a Complaint Survey that included not only F726, but F773 Lab Services Physician Order/Notify of Results, F835 Administration and F880 Infection Prevention and Control. This situation was related to lab results for a resident who tested positive for Group A Streptococcal (GAS) that required treatment with antibiotics. The results were not reported to the physician until three (3) days later.

The background to this citation is that the epidemiologist for the DPH had contacted the facility the day prior to the resident who tested positive being tested due to one of the unit’s previous residents who passed away being positive for GAS. The Infection Preventionist knew what should have been done but, unfortunately, all protocols were not followed, including a CNA (who also tested positive) being allowed to work before they had been on an antibiotic for 24 hours. You get the gist of this – a total system failure, including a staff member not knowing why the resident was on Contact Precaution and the DON not checking to see if the CNA had been on an antibiotic for 24 hours. Bells and whistles should be going off in the head of everyone reading this blog . . . you can never underestimate the importance of adhering to Infection Control protocols, communicating infection control-related information and monitoring for staff compliance.

• Rounding out the IJ citations related to F726 is a citation regarding the licensed nursing staff being competent in immunosuppressant therapy. The citation includes significant information on the type of education/training the staff received related to immunosuppressant therapy. The surveyors were able to identify at least three (3) nurses who “who could not recall any education.” When the inservice records were reviewed with staff development, there was no evidence of inservice training on the use/monitoring of immunosuppressant therapy until things went sour with this resident.

The resident was a heart transplant resident who had been recently hospitalized for heart failure exacerbation and was receiving heart rejection medication, which requires dose adjustments when the therapeutic level is abnormal. An ordered lab test was found to have been completed three (3) days after ordered. The record also indicated that that the lab tests were not reported to the heart transplant team and the resident’s cardiologist requested a hospital transfer as the resident had not had immunosuppressant drugs for the last two weeks. The Nurse Manager, who admitted the resident, had resigned and could not be reached to be interviewed. The hospital transfer papers included an order for a tacrolimus level on a specific date, which was not done.

Here’s what providers need to consider to avoid citations in this area.

• Don’t admit residents who your staff are not trained to care for.
• Have a policy in place for the care to be provided for specific health conditions that are listed in your Facility Assessment.
• Ensure that staff are competent and have the necessary skills needed, especially for residents with complex medical conditions – when a resident is being admitted who requires certain services or equipment, make sure that you have the equipment and provide “refresher” education.
• Infection Prevention and Control is never going away, so you need a plan to provided ongoing education.

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