In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Mississippi. 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 so far in 2025 in Mississippi include:
- F600 Free from Abuse and Neglect
- F609 Reporting of Alleged Violations
- F656 Develop/ Implement Comprehensive Care Plan
- F689 Free of Accident Hazards/ Supervision/ Devices
Compliance Insights
The IJs in Mississippi so far in 2025 are . . . wow . . . to say the least. Here’s a couple of scenarios which occurred so far that spotlight systemic breakdowns in abuse prevention, staff supervision, reporting and care planning – each with negative outcomes for the resident involved.
IJ Scenario – F600 S/S: J and F609 S/S: J
A facility did not immediately remove a CNA from the facility after it was identified that she physically and emotionally abused a resident. The CNA handled the resident roughly in the shower, sprayed cold water on his face and turned the lights out in the shower room – all while laughing at him. A licensed staff member came into the shower room after hearing the resident yelling, “stop” and told the CNA to stop.
The resident was overheard yelling, “stop!” and that the water was too cold – while the aide sprayed the water in his face and laughed.
She observed the resident yelling that the water was too cold and the CNA telling him he would be okay. It gets worse, but we’ll leave it at the fact that the LPN reported it to the Administrator, who told the surveyor that the LPN only said the water had been set too cold on the shower. Needless to say, it didn’t get reported timely, leading to a reporting citation as well.
IJ Scenario – F600 S/S: J and F656 S/S: J
A facility failed to ensure a resident was free from physical abuse when a Campus Police Officer who responded to a CNA’s request for help with an “unruly” cognitively impaired resident:
- hit the resident with his own shoe
- pushed the resident to the floor and
- attempted twice to use her taser on the resident
Facility staff observed this occurring and did not intervene, which allowed the abuse to escalate. Staff reported that they felt scared to intervene because they thought they might get hurt and that watching someone deploy a taser was frightening. The resident was eventually transferred to the hospital with a hematoma which occurred due to the fall.
The facility also ended up with a scope/severity of J related to F656 for failure to implement comprehensive care plan interventions for a resident with behaviors. The failure to implement care plan interventions led to the Campus Police Officer being called, abusing the resident and the resident sustaining a hematoma.
Here’s what providers need to consider to avoid citations in these areas:
Foster a culture where staff feel safe and obligated to report abuse.
Administrators must take every allegation of abuse seriously and act quickly. In another recent The State of IJs post, we discussed an Administrator’s choice to view reported abuse as grievances and customer service issues instead of reportable allegations of abuse.
- Remember that any individual acting on behalf of the facility needs to know about abuse prevention and de-escalation techniques. It’s probably also a good idea to let the appropriate parties know that you’d prefer a workaround to tasing your vulnerable, confused and cognitively impaired residents. One that doesn’t involve throwing shoes at the resident would also be preferable.
- Behavior care plans need to be meaningful, individualized and address target behaviors. I’m sure providers that we work with are tired of us saying their care plans aren’t great. Care plans are not just a paper compliance thing. They’re a roadmap to help staff provide the care and services they need successfully.
With a generic care plan that didn’t address a resident’s actual behaviors with individualized interventions, there’s no wonder that this new CNA felt the need to call the police when the resident became aggressive when she woke him up abruptly to provide ADL care. As it turns out, staff – but not the aide providing the care – were aware that the resident hadn’t been sleeping well and was not being the best version of himself. Set your staff up for success – especially new staff – and help your organization’s retention success by giving staff the tools, training and education they need to do their jobs.
Received an IJ Citation? We’re 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.
