In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across New Jersey. 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.
The State of IJs on the CMSCG Blog is a limited-edition series. To view all posts in this series, you may need to sign up for a complimentary registration to our website. Registration is available for nursing homes and related organizations. Register here.
Top Areas of Noncompliance
The most frequently cited IJ deficiencies in 2025 in New Jersey include:
- F689 Free of Accident Hazards/Supervision/Devices
- F600 Free from Abuse/Neglect
- F610 Investigate/Prevent/Correct Alleged Violation
Other Ftags you need to pay attention to where IJs have been cited this year in New Jersey? F609 Reporting, F808 Therapeutic Diet and even F908 Essential Equipment. Unfortunately, there are also a handful of F835 Administration IJ-level citations too, but we’re seeing an uptick in F835 citations in many states.
Compliance Insights
This year in NJ, a lot of these citations are coupled together, which really racks up the points for a facility.
Not familiar with the number of points associated with a deficiency?
Here’s the scope and severity grid from the CMS Five-Star Users’ Guide. Download the July 2025 guide here.
Complaint Survey: F600 S/S: K, F609 S/S: J, F610 S/S: J, F835 S/S:K
In this example, a facility was cited at F600 Free from Abuse/Neglect, F609 Reporting, F610 Investigations and F835 Administration on the same complaint survey. Those citations all stemmed from a cognitively intact resident’s allegation of staff-resident physical abuse after CNA roughly handled a resident’s fractured leg. The licensed staff receiving the complaint documented bruising on the resident’s leg and alleged that she notified the Supervisor. On interview, both the Supervisor and Director of Nursing denied having knowledge of the allegation and therefore did not investigate or report the event. The surveyor also took out Administration at F835 for the Administrator’s failure to ensure all staff – including himself – implemented the facility’s abuse policies and procedures. Specifically, the facility:
- did not protect all residents from an alleged perpetrator pending the allegation of staff-resident physical abuse.
- did not thoroughly investigate the allegation of abuse.
- did not report the allegation of staff-resident physical abuse to the NJDOH.
During a client visit last week, the topic of “notification” came up. The ADON brought up a point worth discussing when it comes to reporting. She said that staff think that by mentioning something to her, that’s sufficient for notification. Is it enough to mention something in passing when someone is writing other documentation, waiting on hold on the phone, etc.? There’s a potential pitfall waiting to happen.
Remind staff that not only do they need to be timely when they’re reporting something, especially an abuse allegation, they need to make sure they have the full attention of the individual that they’re reporting it to. That way appropriate action can be taken, including implementing new interventions or taking corrective actions.
Closing the loop is important. In the IJ scenario that was just discussed, the licensed staff was leaving early so it seems like the expected level of communication did not occur, and then that caused a larger communication failure. The reporting process doesn’t always start with the person responsible for reporting – it’s another staff member who needs to ensure the right people are informed timely. Building a culture of responsible communication is important for success – and more importantly, for the safety of your residents.
Recertification/Complaint Survey: F609 S/S: J (Past Noncompliance) and F610 S/S: J
Another facility was cited at F600 and F610 after staff at an outside facility observed a resident’s escort verbally abusing a resident – and recording the interaction with their cell phone. Video from the outside facility showed the resident’s escort yelling and cursing at the resident in the entrance to the office, where the resident appeared visibly upset and verbalized that they thought the escort was kidnapping them. Thankfully, the staff at the facility made the escort leave and alerted the nursing home that a new escort needed to come. The DON recommended that the police should be called and sent new staff. The escort was interviewed, deleted all of the videos and was terminated.
Sounds like they got everything, right? NJDOH didn’t think so. The facility was cited for failing to conduct a comprehensive interview, as it didn’t:
- interview the transport driver – who instead of helping the resident, took the escort’s phone and continued recording the resident.
- Interview the staff at the outside consult facility who reported the witnessed abuse to the facility.
- Attempt to identify or interview any other residents who had been accompanied to outside appointments by the same escort.
🚨 Concerned About Compliance? Let CMSCG Help You Stay Survey-Ready.
At CMS Compliance Group, we don’t just identify problems—we help you solve them. Our interdisciplinary team has a proven track record of guiding nursing homes and other post-acute providers through the most serious compliance challenges.
Whether you’re facing survey or want to ensure you’re not missing anything important – like an allegation of abuse that may have slipped by, CMSCG can help. We provide:
- Mock surveys with detailed findings across all departments
- Post-survey support and Plan of Correction development
- Ongoing quality assurance reviews to keep your systems functioning at the highest standards
Let’s make compliance your organization’s strength. Call us at (631) 692-4422 or contact our team to schedule a complimentary consultation.
