In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across New York, our home base. 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 New York (as of September 23, 2025) include:
- F600 Free from Abuse and Neglect
- F689 Free of Accident Hazards/ Supervision/ Devices
- F578 Request/ Refuse/ Discontinue Treatment; Formulate Advance Directives
If you’re a CMSCG client in New York or have listened to any of our survey trends presentations, you know that we are always tracking IJ data. Earlier this year, we discussed that New York was trending towards another banner year for the number of IJ citations, but it remains to be seen as to whether we’ll hit the 2024 all-time high . . . but it could be close. We’ve been reviewing IJ citation trends state-by-state since the summer ended to help facilities be prepared for their next surveys – even though CMS has survey-related data on pause – and it looks like NYSDOH isn’t the toughest of State Agencies out there comparatively, but it’s still a tougher enforcement environment than facilities were used to seeing.
Join CMSCG on December 3, 2025 for our annual year-end NYSHFA | NYSCAL webinar “2025 Survey Trends & Tips.”
We’ll be discussing all the survey details you need to ensure your organization is prepared for 2026, including New York IJ trends and citations. Registration and details are available here.
We’ve been tracking our own New York list for CMSCG clients, and we’re sharing some key trends on the CMSCG Blog for today’s post.
- There’s approximately 35 IJs that we’re aware of as of the end of September
- Per usual, Central New York is leading the charge on issuing those high-level citations.
As part of our Ftag of the Week series on the CMSCG Blog and for various presentations, we’ve also reviewed some of these IJs throughout the year, so you may have already seen some of these citations.
Compliance Insights
F600 Free from Abuse and Neglect
There are multiple F600 citations this year in New York state, and each citation has been a different form of abuse.
- The only isolated IJ at F600 was a staff-resident event where a resident was physically removed from a dining room by a licensed staff, with the altercation continuing in the hallway. To top it off, the resident fell several times while this was occurring.
The other F600 IJs in New York have been cited at a pattern scope and severity (K).
- One citation occurred related to lack of timely incontinence care and wound care and is a pretty ugly read.
- In another IJ scenario, a facility did not provide adequate supervision to prevent a resident’s sexually predatory behavior from occurring and impacting several other cognitively impaired residents.
- At another facility, the F600 Abuse citation came in tandem with an IJ at F609 Reporting when it was identified that staff witnessed an employee physically abuse a resident and did not report it. Other staff were aware of the situation and also failed to report.
IJs at F600 is a favorite of surveyors everywhere in the US – not just New York. CMSCG could probably do a full series on F600 IJ situations alone — and what does that say other than that facilities are not providing enough education in this area especially related to identifying an abuse situation, reporting responsibilities and monitoring what is happening in the facility.
F689 Accidents
Accidents is always one of the top areas cited at a high level in New York, and this year is no exception to that rule. One important area to be aware of is that there have been a couple of IJs related to residents who were on aspiration precautions having a negative outcome.
F578 Advance Directives
F578 is quickly jumping up the list of IJs in 2025 in New York. It’s a high-risk area with a lot of potential for holes in a facility’s systems to be identified. It’s also being tied to F678 CPR at an IJ level, so it’s becoming a two-for-one event that providers need to take measures to avoid. The citations have run the gamut of scenarios, with one instance where a resident with an order for Full Code did not receive CPR timely, was transferred to the ER and subsequently expired. At another facility, a resident had updated their MOLST from CPR to DNR, but there was an inconsistency between the paper record and EMR. When the resident was found without signs of life, staff used the information in the paper chart and initiated CPR until staff checked the EMR and found that there was a DNR order. At another facility, several residents changed advance directives from the hospital which were not addressed in the EMR or with the appropriate identifiers in place. When staff were interviewed, there were multiple inconsistencies about the facility’s protocol and use of identifiers.
Here’s what providers need to consider to avoid citations in this area.
- Ensure your staff know your facility’s specific protocol to follow during an emergency situation and code status needs to be quickly determined, including the procedures for ensuring the appropriate parties are notified when there is a change to a resident’s advance directives preferences so that the appropriate updates can be made.
- If you haven’t done so in a while, conduct a full-house audit of advance directives. You’d be surprised at what you’ll see but be glad that you did.
🚨 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 Immediate Jeopardy citations or want to prevent them altogether, our consultants offer:
- 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 consultation.
