In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across New Mexico. These citations represent the most serious level of noncompliance, where resident safety is at immediate risk. Understanding the patterns behind these IJ citations can help providers proactively address vulnerabilities and improve care outcomes.
Top Areas of Noncompliance
The most frequently cited IJ deficiencies in 2025 in New Mexico include:
- F684 Quality of Care
- F760 Residents are Free of Significant Med Errors
Compliance Insights
F684 S/S: K and F760 S/S: K
One facility was cited at a S/S: K (pattern) for both F684 and F760 related to failure to monitor one resident for signs and symptoms of a stroke and to treat a resident with blood thinners as ordered.
- For the first resident, who had a history of a stroke which had occurred a year prior to admission to the facility, it was determined that the facility was not treating the resident for his history of CVA, including monitoring for signs/symptoms of a stroke.
Remember, a resident’s clinical history doesn’t expire on admission. Surveyors will look for evidence that the facility has identified risks and implemented appropriate monitoring measures and interventions. Whether it’s a history of stroke, a history of trauma or a history of substance use disorder, it should be acknowledged for the potential future impact it could have on the resident’s care.
For the second resident, the admitting nurse was interviewed after the Medical Director’s interview where he/she stated someone in the facility had “dropped the ball” related to the admission order. During an interview with the admitting nurse, it was identified that the blood thinner was on the resident’s admission orders from the hospital, but she had missed the order. This resulted in the resident not receiving a blood thinner for approximately 4 months. The facility was cited at F684 Quality of Care for this resident related to its failure to administer the blood thinner as ordered by the physician.
Reading this and thinking uh-oh? Well, maybe it’s time to do some auditing to ensure the system you think is operating robustly related to verifying, transcribing and initiating all medication orders on admission is working as designed. As you can see, a single missed order can have serious regulatory repercussions – and while thankfully in this case, there wasn’t a negative outcome to the resident, missed orders can have significant clinical consequences as well.
Another citation we want to touch on in this post is another F684 Quality of Care citation, where the facility was also cited at a scope and severity of K (pattern).
F684 Quality of Care
Multiple issues were identified in this pattern-scope scenario:
- 3 residents were not treated when a change in condition was identified
- For one resident, a new wound was not reported to the physician, delaying initial treatment and a PA did not evaluate the wound before initiating treatment orders.
- A resident was discharged to an assisted living facility instead of the hospital despite showing significant signs of a change in condition.
How could we not look at what happened with the third resident? That resident had a scheduled discharge and was exhibiting a change in condition after a worsening sacrum wound was identified without follow-up from the facility.
- The resident skipped her dialysis session because she did not feel well.
- The resident’s wound was reported as green and smelling.
- The day of discharge, the resident’s daughter stated her mother looked horrible and was sweating” and staff could not tell her why.
- She was in a significant amount of pain when the staff tried to transfer her to a chair, and again when she was being transferred to the car. She refused the car transfer. The resident ended up propelling herself in her wheelchair to the assisted living facility which was up the street. This alone should have been follow-up on, but that does not appear to be the case.
Post-discharge, the resident was in too much pain to sit up, and went to a scheduled dialysis session, but was sent to the ER due to low heart rate. She was admitted with a diagnosis of septic shock and expired in the hospital a week later.
During the surveyor’s investigation, it was determined that the wound had not been reported to the Medical Director and treatments had not been implemented. The deterioration in the resident’s wound without appropriate physician notification, notification to the Medical Director or notification to the resident’s family was part of the reason the facility was also cited at F580 Notify of Changes at a S/S: J. The Medical Director stated on interview that he/she was not aware of the wound and that the resident should not have been discharged to a lower level of care with that type of wound which required care.
But Wait, There’s More . . .
Additional Ftags with IJ-related citations in New Mexico in 2025 include F610 Investigations, F689 Accidents/Supervision, and F835 Administration.
It’s sad to even think that this could be a thing, but the following is a reminder for Administration and Nursing Administration that you really need to know what your staff are doing when you’re not in the building.
F610 Investigations S/S: J and F835 Administration S/S: J
An Immediate Jeopardy was called when it was determined during a complaint investigation that an RN decided to use a deceased resident to play a prank on staff. The resident had expired during the night and when staff arrived on shift the following morning, the RN requested that the aide go into the resident’s room and take vital signs on the decreased resident. As the aide was doing this, she heard the RN outside the room laughing. The RN told her not to tell anyone so he could play the prank on someone else. EMS ended up needing to be called because the aide had a panic attack over what happened.
The Administrator, on interview, stated that he/she had not reported the event because it was a “staff thing” and alleged that staff had said they were using the deceased resident as a “teachable moment” for new staff. The Administrator stated that this shouldn’t have been done since the aide was young.
- The facility was cited at F610 S/S: J for failure to identify that staff using a deceased resident to carry out a prank on another staff member was abuse/mistreatment of the resident. The event was not thoroughly investigated, and the RN was not removed from duty because he was already scheduled to have several days off.
- The facility was also cited at F835 S/S: J when administration failed to recognize the mistreatment, dehumanization and disrespect to the resident when she was used by staff to prank another staff member after she was deceased.
The SOD further stated that administration’s inability to adequately identify mistreatment of residents – even deceased residents who remained under the care of the facility – and establish an appropriate standard of practice by implementing appropriate corrective actions left residents as risk for serious adverse outcomes. The compliance insight for this one? Don’t ever let something like this happen in your building without follow-up and appropriate actions being taken with involved staff.
🛡️ Stay Ahead of IJ Risk with CMS Compliance Group
Avoiding an Immediate Jeopardy citation starts long before surveyors walk through your doors. At CMS Compliance Group, we work with nursing homes to build strong compliance systems that prevent serious deficiencies from occurring in the first place. Our proactive consulting services include:
- Mock Surveys – Identify gaps across clinical, operational, and environmental areas before they become citations
- Policy & Procedure Reviews – Ensure your documentation supports your practices and meets regulatory expectations
- Staff Training & Coaching – Equip your team with the knowledge and tools to respond confidently during surveys. Got a new department head? We can help.
- Quality Assurance Support – Strengthen your internal systems to maintain ongoing compliance
We help facilities move from reactive to ready—because the best way to handle an IJ is to never receive one.
Call (631) 692-4422 or visit cmscompliancegroup.com to schedule a consultation with our team.
