In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Oregon. 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 Oregon are related to F880 Infection Prevention and Control. We’ll review those briefly since infection control is a constant area of vulnerability for nursing homes nationwide and also review an IJ cited at F689 Accidents/ Supervision.
Infection Prevention and Control
IJ Citation Example – F880 S/S: L (widespread)
A facility was cited at F880 Infection Prevention and Control related to failure to ensure staff utilized the appropriate contact precautions to prevent the spread of c-diff for multiple residents. Issues identified include those “killer” observations, as well as a lack of documentation, including:
- No documentation/ progress notes indicating the resident was assessed or the physician contacted regarding the resident’s consistent loose stools/diarrhea. The resident was transferred to the ER for a different concern and was diagnosed with c-diff. The resident was placed on isolation precautions.
- Staff were observed not following appropriate infection control protocols, including no handwashing after leaving the resident’s room, wearing the same gown and gloves in the hallway, etc. The staff member was then observed using hand sanitizer, picking up a water pitcher and going to another resident’s room. On interview, the staff stated he did not know he needed to wash his hands with soap and water after leaving the resident’s room.
Rinse and repeat with several other residents mentioned in the SOD – staff didn’t follow the appropriate protocol while being observed by a surveyor, the medical record did not include appropriate/ sufficient documentation related to the residents with c-diff, and staff were not aware of the facility’s infection control protocols for care of a resident with c-diff. You can understand why this ended up as a widespread (S/S: L) citation.
IJ Citation Example – F880 S/S: L (pattern)
A facility was cited for failure to follow appropriate infection control practices during a COVID-19 outbreak on half of the facility’s units. Fun fact – surveyors began their observations with interviews at 6:59AM and continued through 4:24PM – even buildings with pretty good infection control practices might experience issues with every staff member providing correct answers, but that’s beside the point. Once again, surveyors observed everything that could possibly go wrong, go wrong, including:
- CNA exited a COVID+ resident’s room with her respirator on her face and goggles on top of her head. She removed the goggles with bare hands, returned them to her pocket, removed the respirator and crinkled it up in her bare hand, and then obtained a new respirator from a package of unused respirators while still holding the contaminated respirator in her hand. She placed a new respirator on her face. No hand hygiene was observed.
- Licensed staff entered a COVID+ resident’s room with a plastic bag full of vital signs equipment – and placed all the equipment directly on the resident’s bed. Better yet, she had picked the bag up from the hallway floor. She used the equipment and placed everything back into the bag, except the stethoscope, which she left around her neck. She did not disinfect the equipment at any time, and after doffing her gown and gloves, did not remove her N95 or eyeglasses and kept the stethoscope around her neck. She kept the same respirator on. Then she cleaned the pulse ox and thermometer with an alcohol prep pad.
Compliance Insights
As you can imagine, both F880 SODs go on and on, coupled with interviews and a million inconsistent answers and practices. Remember, it’s getting to be respiratory virus season, so it’s time to start really checking up on your PPE-fatigued staff to ensure they are following your protocol.
Directors of Nursing/ Infection Preventionists, ensure you’re:
- Proactively reinforcing infection control protocols – conduct unannounced audits of staff compliance with PPE and hand hygiene and provide real-time feedback and education.
- Keeping on top of your respiratory illness reporting and ensuring someone has current vaccination status logs for residents and staff.
- Preparing staff for seasonal virus surges – and preparing for potential contingency staffing needs due to staff illness.
Accidents/ Supervision
One other area that we would be remiss not to discuss in today’s day and age is this unfortunate Immediate Jeopardy citation related to F689 Accidents/ Supervision.
IJ Citation Example – F689 S/S: J (Isolated)
A facility was placed in IJ when it was identified that it failed to keep residents free from hazards, appropriately monitor and supervise them, including for residents with a known substance use disorder. The facility failed to ensure that staff possessed adequate knowledge and training regarding substance use. The resident’s admission assessment indicated a history of polysubstance use, but the resident denied current use. The history of polysubstance use did not end up in the resident’s care plan. The resident was found outside the facility unresponsive and staff administered Narcan due to a suspected opioid overdose and called 911.
The facility physician put the resident’s opioid order on hold until he returned and pending a face-to-face meeting. The medication was ultimately changed, which upset the resident. In the meantime, the facility did not implement any monitoring measures to prevent recurrence. The resident was found unresponsive on the floor of the bathroom after being out with friends and was later pronounced dead.
Compliance Insights
Here are some things to think about:
- If someone has a history of a SUD/OUD, it should be indicated in the plan of care. This helps the IDT, including the physician, understand the potential complications that may occur with a resident and plan appropriately.
- Staff told the surveyor that the resident was often “barely rousable” when he returned to the facility, but the facility didn’t have a process to assess residents after being out of the facility. This isn’t optional – it’s a requirement that was added when additional regulatory guidance was added a couple years ago related to residents with SUD or history of SUD. Come up with a plan.
- Another staff member stated that only the RNs had been educated about substance use, not other staff, and that this was a conscious decision. Remember, your RNs are typically the lowest number of employees in the building at any given time – is that the best plan?
🚨 Immediate Jeopardy? We’re the Team You Call First
When a nursing home receives an Immediate Jeopardy citation, every moment counts. CMS Compliance Group has the deep regulatory expertise and hands-on experience to help you respond effectively and restore compliance—fast.
Our IJ consulting services for nursing homes include:
- Immediate Response Support – We help you assess the situation, develop a targeted Plan of Correction, and communicate with surveyors.
- Root Cause Analysis & Documentation Guidance – Get clear, defensible findings that satisfy CMS expectations.
- Post-IJ Recovery – Strengthen systems, retrain staff, and prevent repeat deficiencies.
We’ve supported facilities nationwide through the most serious survey outcomes—and helped them come out stronger.
Call (631) 692-4422 or visit cmscompliancegroup.com to connect with our team.
