In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Minnesota 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
The most frequently cited IJ deficiencies in 2025 in Minnesota include:
F689 Free of Accident Hazards/ Supervision/ Devices
Many of the IJs in Minnesota in 2025 are about elopements. It’s important to note that elopement-related deficiencies aren’t just citations—they’re red flags that your systems may not be keeping pace with resident needs.
Compliance Insights – Elopement
As temperatures drop, the risks rise even more. Facilities should be proactively reassessing care plans and ensuring that interventions—like wander guards or visual cues—are not only in place but functioning as intended. Now’s the time to audit your environmental safeguards and ensure staff are trained to respond swiftly and appropriately.
F684 Quality of Care
It seems like we’ve been discussing issues with communication in a variety of different ways while we’ve been writing our CMSCG “The State of IJs” blog series. When a resident’s condition changes, silence isn’t just a missed opportunity—it’s a compliance risk. Facilities must ensure that timely, accurate communication flows between frontline staff, providers, and families/representatives to support appropriate clinical response.
Compliance Insights – Change in Condition
If your team isn’t documenting and escalating changes in condition as required, you’re leaving the door wide open for Immediate Jeopardy. Review your change-in-condition protocols and reinforce expectations with nursing staff—especially during shift handoffs and weekend coverage. IJs in Minnesota have been related to everything from failure to comprehensive assess weight gain, monitor and notify the physician timely (resulting in a heart attack and expiration) to failure to identify signs/symptoms of hyperglycemia and rechecking blood sugar, resulting in a resident being admitted to the ICU.
F578 Advance Directives
Compliance Insights – Advance Directives
Advance Directives concerns have been identified in a couple of states, and we’ve covered best practices for advance directives earlier in this series, but here’s an important reminder: if your advance directives documentation isn’t complete, clear and accessible, you’re putting your residents – and your organization – at risk. Ensure your team knows where to find a resident’s most current directive and ensure it’s honored across all shifts.
Another Area to be Aware of
It’s also worth mentioning that there have been a couple of IJs in Minnesota in 2025 related to diversion which were cited at F602 Free from Misappropriation/Exploitation.
F602 Free from Misappropriation/Exploitation
- For one facility, its system to prevent diversion of narcotics clearly wasn’t working after a registered nurse was observed consuming a resident’s narcotic pain medication.
Think I’m kidding? A hospice nurse observed an RN remove the resident’s tramadol from the med cart, put it in a cup, put the drug into her mouth and swallow it and get a cup of water from the water fountain. The resident was scheduled for medication for pre-care management of the resident’s pain and the hospice nurse indicated that the resident was observed grimacing and exhibiting other indications of insufficient pain management.
When the facility looked into issues with discarded drugs, it was identified that 77 tramadol pills, 96 half tablets of oxycodone, 45 clonazepam pills, 19 hydromorphone pills, and 53 hydrocodone pills were missing. The RN was found with more than two dozen tramadol tablets in her home and only admitted to taking the tramadol from the facility. This nurse had signed the Certificate of Inventory and Destruction of Controlled Substances form indicating that she had destroyed 452 tramadol, 96 half tablets of oxycodone, 45 clonazepam, 19 hydromorphone, and 30 hydrocodone pills. Note the discrepancy between the 77 tramadol and the 452 tramadol that the nurse stated she destroyed. Not surprisingly, criminal charges were filed against the nurse.
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- At another facility, over 150 oxycodone of various strength, 1 Adderall, 6 Percocet and 4 Ambien were diverted. This, interestingly, was identified when an RN identified that narcotics were administered via G-tube by a trained medication assistant (TMA). A nurse is required to administer medications via G-tube, so the TMA was performing tasks outside his/her scope of practice.
Upon investigating this concern, it was identified that there was a discrepancy between a resident’s narcotic log and the MAR. The review found additional issues with other residents, as well as documentation with scribbles and no dates or narcotic records indication errors where the facility was unable to provide documentation indicating the narcotics had been disposed of.
Lots of holes were found despite this being audited internally on a daily basis by staff. It was also identified that staff would routinely give the keys to the med cart to this TMA. Interestingly, the surveyors took out the diversion under F602 without too much hoopla around the TMA performing tasks outside her scope of practice related to narcotics.
Compliance Insights – Diversion
- Med cart key control is a compliance must – these keys should only be in the possession of licensed nursing staff. Don’t forget, allowing unlicensed staff access to controlled substances could result in citations in multiple pharmacy-related areas such as F755 Pharmacy Services and F761 Label/Store Drugs & Biologicals.
- Documentation needs to be reviewed to ensure it is legible, accurate, timely and complete. In the one IJ scenario discussed, there were scribbles, missing dates and a lack of documentation regarding narcotics disposal – red flag for diversion and indicative of poor oversight.
- There were discrepancies between the MARs and narcotics logs in both these events. These discrepancies can be either a documentation problem or a diversion problem – both of which could be a negative outcome for the facility.
- Audit, audit, audit. Conduct routine audits of MARs, narcotics logs and disposal records. Monitor staff who are responsible for shift counts, ensure they’re double-locking narcotics boxes and everything in-between. Reinforce accountability and ensure there’s no holes in your system before it becomes a significant issue.
The Best Way to Handle an IJ? Prevent It.
- CMSCG consultants help nursing homes strengthen their compliance infrastructure with targeted mock surveys, staff education, and system reviews.
- Reach out today at (631) 692-4422 or info@cmscg.net.
