In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Texas. 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
You always hear that everything’s bigger in Texas . . . and in this case, that includes the number of Immediate Jeopardy citations. Yes, Texas has a lot of facilities scattered throughout the state, but their surveyors have managed to cite nursing homes for IJ under approximately 35 different Ftags. That amounts to more than 300 IJ citations so far in Texas in 2025. The only bright spot . . . about 17% of those IJs were cited as past noncompliance. The not-so-bright spot? Several providers ended up with multiple tags cited at an IJ-level during the same visit, with a handful of providers receiving up to 5 different tags cited as an IJ at one time.
The most frequently cited IJ deficiencies in 2025 in Texas include:
- F689 Free of Accident Hazards/Supervision/Devices – There have been almost 3x as many citations under this tag than the next most frequently cited Ftag.
- F600 Free from Abuse/ Neglect
- F684 Quality of Care
- F580 Notify of Changes
- F686 Pressure Ulcers
Compliance Insights
F689 Accidents/ Supervision
Key areas cited at F689 include:
Elopements
In many of these cases, the facility was not even aware that the resident had left the building until they were contacted by someone at the location where the resident had ended up – church, the gas station, a tire shop, an apartment complex where the individual used to reside, etc. In one case, a resident eloped and was able to get access to a vehicle at a private residence near the facility. The resident was subsequently involved in an accident and transported to the ER.
If you haven’t stopped to review your elopement protocol and do some auditing as a result of this CMSCG Blog series, we don’t know what to tell you. This high-risk area needs to be routinely reviewed, drilled, and staff knowledge checked. An alarming number of residents throughout the country have just been able to walk out a main entrance door without someone noticing.
Staff not following the plan of care, resulting in injuries
The number of issues identified related to staff taking shortcuts and not performing care per the plan of care is really just too high – and this isn’t just a problem in Texas. Just imagine a scenario where staff didn’t transfer the resident per protocol, resulting in the resident being injured with multiple spinal fractures and admitted to the ICU. That could happen anywhere, any day.
F600 Abuse/Neglect
We’ve discussed abuse and neglect too frequently throughout our The State of IJs series so far. Here are a couple of interesting citations to be aware of:
- F600 S/S: K (Complaint) – A CNA grabbed a resident’s arm and then put her hands on the resident’s neck and choked her. The facility took corrective actions to remove the IJ before the survey but remained out of compliance because it had not ensured that all staff had been trained in behavior management procedures, abuse and trauma-informed care plans. The resident had an identified history of trauma related to domestic violence and physical abuse. On interview, the Administrator indicated that given the resident’s history, this event could have been triggering for her.
- F600 S/S: J (Complaint) – A facility was placed in IJ for failure to coordinate care and services with the hospice provider to ensure the written plans of care included both the most recent hospice care plan and a description of the services provided by the facility to prevent neglect. The Hospice Aide failed to transfer a resident using a mechanical lift and with a 2-person assist, resulting in a fall with major injury (C1 and C2 fractures).
F684 Quality of Care
F684 can either be a stand-along tag, or in some states – as we have discussed in other posts in this series – it’s an adjunct tag. In Texas this year, it’s a bit of both. Many of these citations arose from staff failure to address a change in the resident’s condition sufficiently.
In one case, a facility received two K-level citations for the same resident, F684 and F777 when a licensed staff failed to read an abnormal x-ray result, resulting in the resident experiencing pain with a hip fracture for 2 days before he was hospitalized.
In another facility, a resident’s family told staff that they were concerned about the resident being lethargic throughout the week. There is no documentation of interventions taken by staff, including documenting assessments or notifying the physician after the resident had multiple abnormal vital signs observed. The resident was sent to the hospital and diagnosed with sepsis from a UTI, after the family notified the staff that the resident’s blood pressure was critically low. The facility also received an IJ at F580 (#4 on the top IJ tag list in Texas) for failure to notify the physician when there was a significant change in the resident’s condition.
As we mentioned above related to F689 and all those accidents where staff didn’t follow the plan of care, in too many instances, F684 Quality of Care was also cited at an IJ because staff also didn’t follow the appropriate protocol to not ensure a resident was assessed before picking him/her up off the floor. In one citation, a licensed staff member used a mechanical lift to transfer a resident back to bed without conducting an assessment – the resident had a cervical fracture. In another, a resident who had a fall and sustained a femur fracture and dislodged feeding tube was assisted back to bed by an aide without licensed staff conducting an assessment.
Here’s one last example that’s worth mentioning:
F684 S/S: J (Complaint)
A facility was cited for failure to ensure residents received treatment and care in accordance with professional standards of practice when it was identified that an RN did not monitor a resident when he documented that he was doing vitals on a resident during a timeframe where the resident had expired.
Police arrived after being notified that the resident had expired and stated that based on the resident’s current status, there was no way the resident was still alive when the staff documented taking vital signs. The staff admitted that he did not see her prior to the resident being found by an aide and stated the vital signs uploaded were a mistake.
Getting the picture? You need to monitor what staff are doing and ensure they are providing care per professional standards of practice. Ensure they’re competent, monitor them and conduct observations and drills as necessary.
Received an IJ Citation? We’re Your First Call
CMS Compliance Group helps nursing homes respond to Immediate Jeopardy citations quickly and effectively—with root cause analysis, documentation support, and recovery planning.
Contact us today at (631) 692-4422 or cmscompliancegroup.com.
