In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across North Carolina 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 North Carolina include:
- F600 Free from Abuse/Neglect
- F684 Quality of Care
- F689 Free of Accident Hazards/Supervision/Devices
- F580 Notification of Changes
I am sure that if you have been following this series you would have picked up certain trends in citations across the US. What jumps out to me is the number of F600 citations, which should be a significant concern to all providers. Please make sure that you monitor your staff’s interactions with your residents as well as residents’ interactions with each other. Everyone needs to understand what appropriate interactions are.
CMSCG has dissected a number of deficiencies in the above areas, so today we are exploring some IJ citations which are probably not so common.
F607 Develop / Implement Abuse/Neglect, etc. Policies
Let’s get started with looking at a few citations in North Caroline related to F607 Develop / Implement Abuse/Neglect, etc. Policies. The first scenario addresses a facility’s failure to implement their abuse policy in the area of protection. There was a resident-to-resident physical abuse incident where a resident physically picked up another resident and threw the resident out of his room – the resident fell to the floor and hit his head. The plan was to place the abuser on 30-minute monitoring checks, which was ineffective. Another resident was ambulating past the abuser’s door and was pushed with the abusive resident. The abuser, at that point, balled his fist and told the resident that if they walked over here again “I will do it again.”
Following the second abusive event witnessed by the nurse, the facility did not implement a plan to protect other residents on the dementia unit. Background information determined that the 30-minute monitoring was not promptly implemented for the alleged perpetrator. Compounding the issue was the fact that when the nurse who reported the first incident to the DON only told her the victim had an unwitnessed fall and the nurse did not know what happened. It was not until the next day when the DON received the Incident Report that she was aware of the actual circumstances of the incident. The 30-minute monitoring did not go into effect until that time.
As the investigation progressed, it came to light that the perpetrator redirected the resident away from his room. The nurse who documented that the resident “shoved” stated that she should probably have not used that word. The Administrator did direct implementation of 1:1 monitoring after the second incident but also shared that this intervention should probably have been initiated after the first incident days earlier.
Want to know what else went on with the perpetrator? The NP started the resident on Seroquel daily for “behavior management” and a diagnosis of adjustment disorder with depressed mood — doesn’t look like an acceptable rationale for initiating an antipsychotic to me. The ordered psych consult was delayed as the physician was ill, but the perpetrator was seen several times by the psych NP. Additional protective interventions were implemented, but the survey team noted in the Statement of Deficiencies that the initial evidence was insufficient and it “remains present and ongoing.” Now is the time to think about how well your facility staff would fare during an assessment of your staff implementing the facility’s Abuse Policies.
I think a peek at another F607 deficiency cited at a scope/severity of “K” that was part of a Complaint Survey where five (5) IJs were cited one (1) “J” and four (4) “Ks” involving abuse, notification of change, quality of care and competent nursing staff. The “J” was for F600 Abuse. The citation addressed the facility’s failure to implement their abuse policy for employees who worked in the capacity of a licensed nurse. The facility did not screen and verify the applicant’s credentials prior to hiring them as a licensed nurse. Put simply, this person performing the duties of a licensed nurse had no documented education or a nursing license. The “nurse” used information that they had found online with a name similar to theirs. This employee worked in the facility as a licensed nurse for approximately three (3) months before they were terminated. Here are some of the issues that were identified related to this time period when this employee was on duty:
- This employee did not assess or report to the physician a significant change where there was bruising that they identified on the resident’s shoulder with no known cause – the resident was on anticoagulant therapy. The resident was seen on the following shift by the physician. The bruising continued and three (3) days later, a large subpectoral hematoma was identified during a CT scan; there was also superficial contusions to the left hip/flank.
Tied to this was a CNA not implementing the abuse policy for reporting injuries of unknown origin related to the bruises on the resident arm and chest with discomfort when being positioned.
- On another occasion, a Med Aide reported to this employee, who they believed was a nurse, the finger stick blood sugar reading results that indicated a dangerously high blood sugar. There was no evidence that the physician was notified, and the resident was not provided with treatment for the high blood sugar level.
During this short time of employment, there were two (2) instances of a resident with severe cognitive impairment and receiving anticoagulant therapy sustaining a fall event. The employee (unlicensed to act as a nurse) was not qualified to complete the necessary assessment following a fall and certainly was not qualified to make decisions using their “nursing judgment.”
The employee fraudulently presented themself as a licensed nurse prior to hire and was able due to inadequate screening and verification of credentials to be employed to act as a licensed nurse. You can certainly understand this being cited as an IJ as the risk for any resident under the care of this “nurse’” to have a negative outcome was significant.
Compliance Insights
Administrators need to ensure that personnel folders are periodically reviewed for completeness, including evidence that potential new hires are appropriately screened and all credentials verified.
It would also not hurt to review with your staff the Abuse Prevention protocol.
Build a Culture of Compliance That Lasts
CMS Compliance Group supports nursing homes with ongoing QA reviews, interdisciplinary coaching, and documentation strategies that hold up under scrutiny.
Schedule a strategy session at (631) 692-4422 or email us.
