In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Montana. 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. There are approximately 60 nursing homes currently in Montana so, if you expected that number of IJ citations would be low, you would correct. So far in 2025, the Montana State Agency has only cited one (1) IJ.
The only cited IJ deficiency in 2025 is a S/S of “J” at F678 – Cardio-Pulmonary Resuscitation.
Compliance Insights
I don’t believe that there is an Operator, Administrator or Director of Nursing who does not have some level of interest in what occurred in another facility related to CPR. CMSCG staff certainly reviews all such citation to learn about the circumstances –- what was the hole in the system — so that we can use this information to help our clients avoid a similar situation occurring in their facility. After all, doing CPR when staff shouldn’t have and not doing CPR when staff should have is a concern for every facility. CPR situations when something goes wrong are definitely considered “high profile.”
This IJ centered on the facility not ensuring that the nursing staff had the necessary skills and training for CPR for two (2) staff members for two residents who expired in the facility as well as significant concerns related to needed CPR equipment being readily available for use in an emergent situation.
The IJ highlighted that the facility did not have any type of system to ensure that CPR certification for the licensed nurses were kept current or make CPR training/certification available. During the surveyor’s investigation there were a number of concerns identified regarding CPR:
- The facility had no record of each nurse’s CPR certification status or any way of knowing when the nurse needed to recertify
- One of the nurses, who performed CPR, was not CPR certified and hadn’t been for two years
- One nurse interviewed said the facility never inquired about CPR certification, but the staff member kept it current on their own
- Another staff member stated she was not CPR certified and never had been
- The policy for CPR, which just so happened to be undated, stated that staff will maintain CPR certification for health care providers. However, the onboarding process did not include obtaining a copy of a staff member’s CPR certification for the employee’s file.
Couple all of the above concerns and you have the makings of a potentially negative outcome for a resident. Now compound the potential for a negative outcome with the following contributing factors:
- Per staff interviews and observations, there was one emergency crash cart available, and the findings indicate that it was not “readily” available as staff in one of the situations included in the citation had to run to the other side of the building to locate the crash cart.
- The citation provides details of the location and noted that the cart “was not easily accessible”
- There was a second crash cart kept in a utility, but the cart was not used because it was not accessible – it was blocked by all types of equipment
- The facility used the last Ambu bag during one of CPR events -– the reordering of supply system being used that was described was not sound, there were also no barrier devices for mouth-to-mouth resuscitation; one staff member shared that she carried her pocket (face mask) barrier in her pocket
- There was no system that included accountability by an assigned staff member to check and restock the crash carts or to test equipment
- State law does not require an AED in a nursing home so one was not available, and the corporate policy was not to have an AED in the building. However, during interview, a staff member stated that the facility did not have an AED because no one knew how to use it.
We can all see the picture painted in this deficiency. The surveyor added in an additional bit of information to help us truly see how having comprehensive CPR-related systems in place, staff trained and knowledgeable of what to do in an emergency and having all necessary equipment readily available for use are crucial for a resident who indicated that they wanted CPR. During one of the two cases that were part of the IJ situation, the EMS response team responding to the call went to the wrong building and had to call the facility again for the address (don’t ask me how that happened). A staff member shared that there was a “complete delay in care from us and from EMS.”
It appears to be evident that the facility staff wanted to do what is right related to initiating CPR from the amount of information shared with the surveyor by staff, but it was clear that they had recognized weaknesses that needed to be addressed by the Operator.
Lots of food for thought in this IJ . . . consider when was the last time you did a “code” drill so that in an active code situation where CPR must be initiated the scene in the room is not described as “chaotic” and “unorganized.”
Turn Survey Outcomes Into a Compliance Comeback
Whether you’ve received a citation or just want to improve, our team helps nursing homes rebuild stronger systems and prevent repeat deficiencies.
Let’s talk. Call (631) 692-4422 or visit cmscompliancegroup.com.
