In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Utah. 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
There aren’t enough IJ citations in Utah so far in 2025 to trend them, but the following tags have been cited at an IJ-level:
- F689 Accidents/Supervision (S/S: K) – related to a facility’s unsafe smoking program
- F600 Free from Abuse/Neglect – One event was staff-resident abuse, and another we are going to discuss in this post.
- F609 Reporting of Alleged Violations – No surprise that when there’s an F600 citation or two, we’ll likely also run across F609 for failure to report.
Today’s IJ resulted in two tags being cited at a scope and severity of “J” (isolated). We’ve discussed abuse citations throughout our IJ series on the CMSCG Blog, but this scenario has a different spin on the idea of abuse occurring due to caregiver burnout. The twist? The caregiver was also another resident in the facility – so we ended up with resident-resident abuse that was related to two married residents.
F600 Free from Abuse/Neglect & F609 Reporting of Alleged Violations
Resident 1 had a diagnosis of Alzheimer’s and MDD, and per documentation, was recently experiencing a decline. Resident 2, who was Resident 1’s spouse, was admitted to the facility with PTSD and MDD. Resident 1 had resided on the Memory Care Unit, but when Resident 2 was admitted, the two residents were given two separate rooms with a shared bathroom elsewhere in the facility.
One evening, Resident 1 was non-compliant with changing into her pajamas while in the bathroom with a CNA providing assistance. Her spouse came into the bathroom and aggressively tried to “force” her to change her clothing. Resident 1 was “pushed” but did not fall in the process. The CNA intervened and Resident 2 left the bathroom. It should be noted both residents spent a lot of time in one room together, as this was their customary routine. Once Resident 1 changed her clothes with staff assistance, she returned to her bedroom and Resident 2 was there. An RN had come in during this event, and the CNA told the RN they needed to speak later.
It was then time for Resident 1 to receive her evening medications. She refused and indicated to Resident 2 that she wanted him to help. Resident 2, who was obviously frustrated, took the spoon with the medications and jammed it into his spouse’s mouth.
The CNA explained all that had occurred to the RN and a decision was made to call the police. The police arrived after both residents were asleep in their separate rooms. Staff initiated check-ins on the residents after the event and decided not to move Resident 1 back to the Memory Care Unit at that time to not disrupt either resident.
The following day, staff discussed with the residents the prior day’s concerns. Resident 1 did not remember what had specifically occurred, even though she had been witnessed crying and staff consoled her the prior night. Resident 2 stated that he didn’t realize he had done anything wrong, recognized that he was frustrated and asked if he could have a chance to do better before the residents were separated. He agreed to go to caregiver support sessions.
The facility allowed the two residents to remain in their current living situation – which obviously could have resulted in a repeat abuse situation. Despite staff stating they were doing frequent rounding and that the residents were supervised, when the surveyors arrived onsite for their investigation, the door to Resident 1’s room was closed and the residents were in the room together alone.
Compliance Insights
Here’s some things to consider.
- Always, always, always protect residents after an allegation of abuse. This is important for every resident, but especially those residents who may not be able to speak up if there is a concern or validate what occurred when they are interviewed and how they felt as a result of the incident.
Remember, surveyors can use the “reasonable person” concept, if needed, to determine if there was a negative psychosocial outcome for a resident. You should apply that principle, too, when conducting your interviews and reviews following an abuse allegation.
- Document and revise your plan of care. There was no evidence of the frequent/ increased rounding which staff stated they were doing after the event. No changes were made to either residents’ plan of care until the IJ was called. That was a gap of several months without changes.
- Staff called the police – but didn’t complete an Incident Report/A&I. No one notified the Administrator. The Administrator did not become aware of the event until the surveyors arrived for the complaint survey several months later.
The Administrator stated that management had recently become aware that staff were not reporting all incidents. This is a situation that we hear – and see – all too often when CMSCG consultants are reviewing reportable cases with a facility’s staff. Staff need consistent reminders and reinforcement of their reporting responsibilities – especially night and weekend staff. If staff had the inkling that they should call the police, they knew something was wrong. Why not tell the Administrator? Why not initiate an Incident Report?
On interview, the staff downplayed the “push” and the “shove” actions of Resident 2, but at the time it occurred, obviously someone thought something was wrong. It’s better to report this and then upon investigation be able to rule out abuse than for staff not to follow through and protect Resident 1 from further potential abuse. As part of the IJ Removal Plan, the residents were separated, therapy referrals were made and Resident 2’s visits would be supervised to protect Resident 1. The plan also indicated that if Resident 1 did not adjust well to the new living situation, she would be moved back to her room next door to her husband’s and put on 1:1 supervision until Resident 2 received caregiver burnout counseling and showed an ability to maintain a “consistent kind and patient demeanor during care.”
The facility was able to offer and convince the resident to attend caregiver support sessions that they held at the facility. This is something that providers should look into as an option for family members who are having difficulty adjusting to their loved ones’ placement in a facility.
We’ve seen many anxious/aggressive/unhappy (whatever word you’d like to use) sons, daughters or other family members who could potentially benefit from help adjusting to the change while they learn to trust that facility staff are taking good care of their loved one and that they can take a step back. Oftentimes, they’ve dedicated significant time to caring for their loved ones in the community, and the sudden “extra” time and perceived lack of control can create stress.
Help them – and help your staff – with the adjustment and offer structured services which could potentially take the place of the dozen phone calls your Social Workers and Nurses Stations receive in a day with a worried loved one on the phone. Added bonus? You may even see a reduction in the number of complaints and grievances you receive.
Turn Survey Outcomes Into a Compliance Comeback
Whether you’ve received a citation or just want to improve, our team helps nursing homes rebuild stronger systems and prevent repeat deficiencies.
Let’s talk. Call (631) 692-4422 or visit cmscompliancegroup.com.
