In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across South Dakota. 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 South Dakota include – drumroll – F600 Free from Abuse and Neglect and F689 Free of Accident Hazards/ Supervision/ Devices.
Today we’re going to discuss two IJs related to safety and maintenance.
F689 Free of Accident Hazards/ Supervision/ Devices (S/S: L)
During a recertification survey observation of a facility’s tub room, an active water leak was observed which was dripping behind a 120-volt electrical box in the whirlpool’s control panel. There was standing water on the floor under electrical wires and piping for the control panel. An electric cord which reached from above the control panel to the floor was observed lying in standing water. On interview, a CNA indicated that she had told the facility manager about the leak but had not filled out a work order. The facility manager told the surveyor that it may have been missed since it wasn’t on the maintenance log.
Compliance Insights – Environmental Hazards
This wasn’t just a maintenance issue—it was a direct threat to resident and staff safety. The presence of water near electrical components creates a high-risk scenario for electrocution, fire, or equipment failure which could have impacted staff or a resident. The tub was actively being used by staff despite this concern. Here’s some thoughts on how to prevent issues such as the one just discussed.
- Verbal reports are not enough. Ensure your organization has a clear – and enforced – protocol for documenting and tracking environmental hazards and maintenance concerns. Staff should not rely on informal communication since it can lead to concerns being missed. Educate staff regarding expectations for reporting safety concerns.
- The maintenance log/ associated documentation is not just a work order tracker – it’s a helpful compliance tool. Just like we tell every other discipline – if it wasn’t documented, it didn’t happen . . . well, sometime if it’s not documented, no one fixes it.
F700 Bedrails (S/S: J)
Siderails are always going to be reviewed during survey, and in this case during a recertification survey, several concerns were identified during surveyor observations. This IJ citation ended up being an isolated scope and severity (“J”) despite surveyors identifying multiple concerns, including how the bed rails were installed, maintained, and assessed for entrapment risk. There were also significant documentation gaps, including missing or pre-filled consents, no evidence of attempted alternatives, and no clear education provided to residents or families about the risks and benefits of bedrail use. Here’s what triggered the IJ:
- Bedrails were not securely attached.
- Mattresses couldn’t be elevated properly when grab bars were moved.
- Gaps greater than five inches were found between the mattress and the headboards – posing a clear entrapment hazard.
There were many issues with the facility’s practices which led to these findings, including:
- No formal process to assess entrapment risk
- Bed zone measurements weren’t completed when grab bars were installed
- Mattresses and bedframes were not compatible, but still in use
- Therapy didn’t assess all residents’ beds – or their ability to safely use the installed devices
Compliance Insights – Bedrails
Here’s some reminders about bedrails. Use of bedrails seems simple . . . until it’s not. There can be serious consequences to their use when facilities don’t have good systems in place for safety and risk management. Reminders:
- Bedrail use must be clinically justified, consented to, and regularly reassessed. Many consent forms reviewed during this survey were consented to by the physician.
- Entrapment evaluations should include actual measurements of bed zones—not assumptions.
- Pre-filled consents don’t cut it. Facilities must show that alternatives were attempted and that residents/families were educated on those alternatives. CMSCG consultants routinely see consent forms that don’t include sufficient information to meet regulatory requirements.
- If your policy says therapy or maintenance is part of the process, make sure they’re actually involved – and that it’s documented.
If you don’t think bedrails are a concern, take another look at the IJ related to bedrails from the Illinois that was discussed as part of this series on IJs.
The Best Way to Handle an IJ? Prevent It.
Our consultants help nursing homes strengthen their compliance infrastructure with targeted mock surveys, staff education, and system reviews.
Reach out today at (631) 692-4422 or info@cmscg.net.
