In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Rhode Island. 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. These examples below are avoidable if a facility ensures that it has a comprehensive system in place to address each regulation and staff consistently follow the established protocols.
Key Areas of Non-Compliance
We’re reviewing three IJ citations from 2025 in Rhode Island that are areas where a facility in any state could be cited.
F604 Right to Be Free from Physical Restraints (S/S = J)
A resident was observed in bed with a bed sheet tied across him or her, which was a restraint not required to treat the resident’s medical symptoms. As part of the investigation, staff admitted that she tied the resident to the bed, so he didn’t move or fall, because she had seen this done in the past and thought it was ok, so the resident didn’t fall. On interview, other staff reported having seen the resident restrained in the bed, including with pillows around him to prevent him from getting out of bed. No one reported this to Administration.
F689 Free from Accident Hazards/Supervision/Devices (S/S = L)
During rounds, an aide found a piece of paper on fire in a resident’s room which was unoccupied at the time. A Code red was initiated, and the fire was extinguished. The investigation of the accidental fire revealed that items, including furniture, were near or in direct contact with the electric baseboard heater. On investigation, the surveyor observed many resident rooms which still had combustible items closer than 6 inches to the baseboard heaters despite the facility having experienced an actual fire.
F757 Drug Regimen is Free from Unnecessary Drugs (S/S = K)
It was identified that a cancer medication was given to the wrong resident for 14 days. We recently reviewed this citation in our “Ftag of the Week” series for F757, which you can view here.
Compliance Insights
Here’s what providers need to consider to avoid citations in these areas.
F604 Physical Restraints
- Accurately assess a resident for the need for physical restraint;
- Provide ongoing staff education on individual resident’s plan of care related to use of a physical restraint;
- Educate staff on devices that can be considered a restraint;
- Educate staff on their responsibility to promptly report a restraining device being used that is not included in the plan of care;
- Responsible staff routinely monitoring for compliance with facility restraint policy
F689 Fire Incident
- Administration needs to ensure that manufacturer’s guidelines to prevent fires are followed for electrical equipment, including electric baseboard heaters;
- A system should be implemented to monitor compliance with combustible materials not being in close proximity to a heat source to prevent a fire;
- Facility responsibility to promptly implement corrective actions to prevent recurrence following a fire incident;
- Ongoing staff education on fire prevention
F757 Unnecessary Medication
- Have a system in place to ensure the medical consultant recommendations for a medication regimen are followed including medical staff review of recommendation, accurate order entry in the correct chart with corresponding medical notes nursing check of orders associated with a medical consult to ensure order transcribed into the correct chart;
- Medication nurse follows correct procedures for checking label, name, order, administration instructions, etc. when administering a medication;
- Ensure consultant pharmacist understands their responsibility to follow facility protocol for completion of monthly drug regimen review to avoid medication errors;
- Ongoing education of nursing staff related to medication administration and order transcription;
- Implement a monitoring system related to new medication orders to avoid errors
🚨 Concerned About Compliance? Let CMSCG Help You Stay Survey-Ready
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Whether you’re facing survey or just want to ensure your organization takes a proactive approach to compliance, our consultants can assist. CMSCG offers:
- 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.
