In this edition of The State of IJs, we’re spotlighting Immediate Jeopardy (IJ) citations issued to nursing homes across Virginia. 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.
Key Areas of Noncompliance
There’s not a lot of IJs citations in Virginia so far in 2025, but areas being cited include the common IJ-tags, F600 Free from Abuse and Neglect and F689 Free of Accident Hazards/ Supervision/ Devices. In today’s post, we’re going to look at a single facility that ended up with 3 IJs citations (F600, F607, F742) on the same complaint survey this year. There’s a lot to unpack related to this situation, so let’s begin with some background information.
A male resident with multiple psych diagnoses was documented exhibiting inappropriate behaviors, including inappropriate sexual advances towards staff and some residents.
This resident also routinely yelled out in common areas that he was going to “blow up” the facility, “kill everyone,” and “get a gun and shoot everyone.”
As a result, the facility was cited at F600 (S/S: K) for failure to keep residents on two units safe from abuse and neglect when they were exposed to a “hostile environment where verbal threats of physical harm and death” and inappropriate sexual comments were ongoing.
This review, per the Statement of Deficiencies, came about when a resident verbalized to a surveyor and the facility Administrator that the resident had made an inappropriate sexual advance to her. The resident then told the surveyor and Administrator that she had been sexually assaulted multiple times in the past and couldn’t handle the other resident’s behavior.
- During record review and subsequent interviews, this information was validated when it was identified that the resident had reported a history of physical abuse, verbal abuse, emotional neglect, was a victim of sexual violence and had a family member who dealt with addiction issues.
- The male resident who was exhibiting persistent behaviors did direct many behaviors towards this resident, including a complaint that the resident “threatened her life” and she did not feel safe. This event was reported to the RN Supervisor and investigated but not reported. A peer of the female resident reported to the surveyor that the resident was scared of the male resident and that the male resident was often inappropriate with the resident. The resident further stated that she witnessed the female resident being threatened and that her hands started shaking and she would cry.
The facility then also ended up in IJ at F742 Treatment/Svc for Mental/Psychosocial Concerns related to failure to ensure residents with mental disorders and a history of trauma received appropriate care and services – both the male resident and female resident were included.
- All staff who were interviewed indicated that they were aware that the male resident was making targeted sexual comments towards the female resident. When asked about interventions, staff indicated 15-minute checks and offering snacks helped, but most often they had to remove other residents from the dining room since the male resident preferred to stay there.
- The male resident exhibited increasing behaviors without being hospitalized timely. When he returned from the hospital (after it was identified that a reduction in antipsychotic medication may have led to his behaviors), the hospital recommended that the resident be returned to his original, significantly higher, dose of Seroquel. This did not happen.
- The facility had identified the female resident’s past trauma but failed to identify her triggers and how her male peer’s repeated aggression towards her affected her. Interventions to use in those circumstances were not identified.
During the survey, observations were made by the surveyors of the resident ambulating independently throughout the facility without any direct supervision, which allowed the resident to have direct access to the female resident who he was targeting.
Compliance Insights – Abuse Prevention
These events highlight a concerning gap in facility oversight: insufficient evidence that staff took meaningful steps to prevent a resident from repeatedly threatening and disturbing others. While disruptive behavior in communal living environments such as a nursing home is not uncommon, there’s a clear distinction between general agitation and conduct that others perceive as violent or threatening. When multiple residents report feeling unsafe and staff have directly observed the behavior, the facility’s failure to act signals a breakdown in its abuse prevention protocols.
- Facilities must recognize that resident-to-resident altercations are a form of abuse. Re-educate your staff on the facility’s abuse prevention policy, including mandatory reporting requirements. This needs to be routine education, and situations such as this one are a good time for a teaching moment.
- Surveyors expect providers to have systems in place to identify, intervene, and prevent recurrence. In this instance, the lack of documented individualized interventions with evidence of review/ revision when something did not work resulted in continued inappropriate behavior. Care Plans must be reviewed and revised to include targeted interventions that address behavioral risks and protect vulnerable residents.
Compliance Insights – Complaint? Grievance? Abuse?
Let’s discuss complaints and grievances for a moment. Staff responsible for managing the grievance process must be able to differentiate between a general complaint, a formal grievance, and a reportable allegation of abuse. Understanding the difference is key to resident safety, satisfaction, and compliance.
- The Social Worker told the surveyor that another resident had also verbalized being upset about the male resident’s ongoing sexually inappropriate statements and verbal aggression. In this case, the facility’s Administrator reportedly told the Social Worker that complaints about resident-to-resident mistreatment were simply grievances, not allegations of abuse.
That interpretation is problematic. When a resident feels threatened or mistreated by another, and staff are aware of the behavior, the concern must be evaluated through the lens of abuse prevention – and reported if necessary. That’s not the only area where a concern wasn’t followed up.
- A resident reported that a CNA refused to give her a shower and was rude to her. She reported that she called her husband and was crying. She reported the event to a nurse the next day and also cried. The Social Worker said that she felt this led to the level of abuse and neglect, but when she took the grievance to the Administrator, he stated it was a poor customer service issue. It was not investigated or reported.
This failure to recognize and respond to potential abuse, coupled with the facility’s broader lack of protective interventions, resulted in an Immediate Jeopardy citation under F607 Develop and Implement Abuse/Neglect Policies. The Centers for Medicare & Medicaid Services (CMS) expects facilities to have clear protocols for identifying, reporting, and investigating abuse—and to ensure that staff are trained to act accordingly.
Remember – allegations of mistreatment, whether by staff, a resident or another individual, must be promptly investigated and addressed to protect resident well-being and maintain regulatory compliance.
🚨 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.
