**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the facility's policies, it was determined the facility failed to ensure each resident or the resident's representative received adequate notice before transfer or discharge for four out of five residents (Resident (R) 3, R4, R13, and R14). The facility initiated a transfer/discharge based on the facility's inability to meet the resident's needs. However, upon complaint investigation, it was determined by interview and record review that the transfer/discharge was due to the facility needing to move the residents out of their rooms to make space for a new rehabilitation unit. Residents 3, R4, and R13 were selected based on their least likely to have a connection with the community. The residents were provided a notice of transfer/discharge on [DATE]. On 07/30/2024, four days after the notice was issued, the facility transferred and discharged the residents to other healthcare facilities, moving them further away from their families and friends. This was completed without providing a 30-day notification period and without obtaining the approval of the residents' State Guardian. On 07/31/2024, the residents' State Guardian was unaware the residents had already been transferred to other healthcare facilities. Review of an email the State Guardian sent to the facility revealed she requested them to hold off on transferring the residents. This resulted in psychosocial harm with R3 experiencing difficulty with adjusting to her new environment, crying, and stating, What did I do wrong? Additionally, the facility transferred R14 to the Emergency Psychiatric Services (EPS) on the evening of 08/15/2024 due to her challenging behaviors. On 08/16/2024, the facility initiated a discharge for R14 and refused to accept the resident upon return from the 08/15/2024 emergency room visit. The Emergency Psychiatric Services (EPS) explained to the facility that the resident's behaviors were related to the progression of the resident's disease process for dementia. Further, the EPS advised that the resident's medications be reviewed for the successful management of the resident's disease. The facility, however, failed to follow the recommendations of the EPS. Instead, on 08/16/2024, the facility left the resident at the hospital, refusing to accept the resident. This complicated the ability of the resident's State Guardian to place the resident within another facility. The resident remained at the hospital until, 09/12/2024, when the resident's State Guardian was finally able to place the resident in a long-term care facility. The facility's failure to have an effective system in place to ensure each resident's State Guardian was notified of the intent to transfer and discharge residents within the required 30 days so that approval would be granted for a safe and orderly discharge to other healthcare facilities has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 09/13/2024 and was determined to exist on 07/30/2024 in the area of 42 CFR 483.15, F623 Transfer and Discharge Requirements at a Scope and Severity (S/S) of a K. The facility was notified of the Immediate Jeopardy on 09/13/2024. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 09/20/2024, alleging removal of the IJ on 09/20/2024. The State Survey Agency (SSA) determined the facility removed the IJ as alleged before exit on 09/20/2024. The facility implemented the following: 1. a. On 07/26/2024, Social Service spoke with Resident #3's appointed State Guardian and discussed the transfer of Resident #3 to a sister facility. On 07/26/2024 Social Services talked to the Ombudsman and informed them of the transfer. On 07/30/2024, four days later, the facility transferred Resident #3 to the sister facility. Resident #3 is no longer a resident of the facility. 1. b. On 07/26/2024, Social Service spoke with Resident #4's appointed State Guardian and discussed the transfer of Resident #4 to a sister facility. On 07/26/2024 Social Services talked to the Ombudsman and informed them of the transfer. On 07/30/2024, four days later, the facility transferred Resident #4 to a sister facility. Resident #4 is no longer a resident of the facility. 1. c. On 07/26/2024, Social Services spoke with R13's appointed State Guardian and discussed the transfer of R13 to a sister facility. On 07/26/2024, Social Services talked to the Ombudsman and informed them of the transfer. On 07/30/2024, four days later, the facility transferred R13 to a sister facility. R13 is no longer a resident of the facility. 2. a. All residents have the potential to be affected. 2. b. On 09/15/2024, the facility Administrator reviewed 98 residents currently in-house for facility-initiated transfer/discharge. No facility-initiated transfer/discharge notices were in effect on the 98 residents. (Facility-initiated transfer or discharge: A transfer or discharge which the resident objects to, did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences). This does not include emergency transfers. 3.a. On 09/19/2024, the Corporate Independent Risk Manager (IRM) spoke with the State Guardian for the current residents. The Guardian educated the Corporate Independent Risk Manager on the process the State Guardian office must complete before approving a Facility-Initiated Transfer/Discharge of a resident. 3.b. On 09/19/2024, the Corporate Independent Risk Manager (IRM) educated in a small group setting the [NAME] President of Clinical Operations (VPCO), Signature Care Consultant (SCC), Regional Social Services, the Administrator, Interim Director of Nursing, Business Office Manager, and Social Services on the process the State Guardian office must complete for a Facility-Initiated Transfer/Discharge of a resident. The Corporate Independent Risk Manager (IRM) created two resource binders to be kept in each Social Service Office. The resource binders would include the steps needed for the state Guardian Office concerning transferring or discharging a resident with an appointed state guardian. If a new Social Service, Business Office Manager, Director of Nursing, or Administrator is hired, they will be trained in orientation by Signature Care Consultant or Corporate Independent Risk Manager on the process the State Guardian office must complete for a Facility Initiated Transfer/Discharge of a resident. 3.c. On 09/19/2024, the Senior [NAME] President of Quality requested the local Ombudsman to be a member of the newly created Facility-Initiated Transfer or Discharge Subcommittee. The local ombudsman agreed to be a team member on the Facility-Initiated Transfer or Discharge Subcommittee on 09/19/2024. This subcommittee was created on 09/15/2024. 3.d. On 09/15/2024, the facility implemented a new procedure concerning Facility initiated transfers or discharges, utilizing a subcommittee of members (Vice President of Operations (VPO), [NAME] President of Clinical Operations (VPCO), Independent Risk Manager, Signature Care Consultant, Social Services, a nurse or C.N.A. familiar with the resident, the Medical Director, and the Ombudsman. As of 09/19/2024, there has not been a meeting scheduled for the subcommittee as there has not been an identified need for a Facility-Initiated Transfer or Discharge in the facility. 4.a. An Ad Hoc Quality Assurance meeting was held on 09/15/2024 with the Medical Director, the Facility Administrator, the Interim Director of Nursing, and the Care Consultant at that time on 09/15/2024. The Facility Administrator presented the plan and information at the QAPI meeting on 09/15/2024. The Medical director attended via phone on 09/15/2024 and was notified of the implementation of the facility's improvement plan. The Medical Director reviewed the entirety of the plan and made no further suggestions. The Medical Director stated the plan was appropriate. Starting on 09/15/2024, the Facility Administrator will hold a Quality Assurance meeting daily until immediacy is removed. Then, it will decrease to monthly for recommendations and further follow-up regarding the above-stated plan. Moving forward, the Facility Administrator will continue to be the person who presents the information and audits at the QAPI Meetings, and the following members are expected to be present unless unable to attend: Facility Administrator, Medical Director, Director of Nursing, Assistant Director of Nursing, Staff Development Coordinator, Plant Ops Director, Social Services· Director, Activity Director, Therapy Director, and MDS Coordinator. The QAPI Committee will determine at what frequency any ongoing audits must continue. The Administrator is responsible for implementing this plan. During a telephone interview with the District Ombudsman on 09/20/2024 at 3:05 PM, she stated the facility requested that the Ombudsman sit on the Facility-Initiated Transfer or Discharge Subcommittee. The Ombudsman joining the committee was to ensure the facility did not transfer/discharge a resident without following the appropriate guidelines and collaborating with the entire team as required. The findings include: Review of the facility's policy titled, Transfer/Discharge Notice, revised 03/25/2024, revealed the appropriate notice will be provided to the resident and/or resident representatives along with other required organizations if it is necessary to transfer or discharge a resident from a facility. Additionally, the facility will issue a notification at least 30 days before the date of transfer/discharge. 1. Review of R3's Face Sheet found in the resident's electronic medical record (EMR) revealed the facility admitted the resident on 10/06/2023 with diagnoses to include unspecified dementia, mood disturbance, and anxiety. Review of R3's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/30/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 13 of 15, which indicated the resident was cognitively intact. Review of R3's Notice of Transfer or Discharge letter, dated 07/26/2024, and addressed to R3's State Guardian, revealed it was delivered in person to the resident and sent by overnight mail to the family member/legal representative with a Return Receipt Requested. According to the letter, the facility stated that the transfer was necessary for the welfare of the resident, as the facility could not meet R3's needs. The effective discharge date was 07/30/2024, four days after the notice was issued to the resident. Review of R3's EMR revealed a Resident Progress Note, dated 07/26/2024 at 4:52 PM, revealed the Social Service Director (SSD) spoke with the resident's State Guardian and informed her the resident would be transferred to a sister facility (the facilities share the same parent company). Review of R3's EMR revealed a Resident Progress Note, dated 07/26/2024 at 5:02 PM, revealed the Social Service Director (SSD) spoke with the State Long Term Care (LTC) Ombudsman and informed her the resident would be transferred to a sister facility. During an interview with Family (F) 3 on 09/11/2024 at 12:59 PM, she stated she learned the facility transferred R3 to another facility by accident from the resident's State Guardian. Family (F) 3 stated the State Guardian called her to inform her of the requested transfer and to discuss any concerns F3 would have regarding having R3 further away from the family. During the conversation on 07/30/2024 with the State Guardian, she stated the facility had requested R3 to be transferred to a sister facility. Family 3 stated she told the State Guardian that it would burden the family significantly and potentially mean they could not visit as frequently as they do. Family 3 stated the State Guardian never stated that R3 had been transferred already, only that she was scheduled to be transferred. Per the interview, F3 stated that within her discussion with the resident's State Guardian, she was informed that placement closer to the resident's family would be requested. F3 stated the facility never asked if transferring the resident would burden the family, and they never told her why the resident was transferred. Furthermore, F3 stated when she hung up the phone after speaking with the resident's State Guardian, she immediately received a call from the sister facility. According to F3, the sister facility's nurse called her to inform her the facility had admitted R3. In a continued interview with F3, on 09/11/2024 at 12:59 PM, she stated the new facility was 80 miles away from the resident's family. Further, she stated this made it difficult and even physically challenging for the family, many in their eighties, to visit R3. Previously, F3 was only 14 miles from the facility, making visiting more accessible for all the family. Additionally, due to R3's dementia, F3 stated visits can only last for 15 to 20 minutes, and sometimes R3 was not receptive to visits at all. She stated it would be an extreme burden for the family to drive 160 miles round trip to be denied a visit by R3. Additionally, F3 was upset about R3's transfer, primarily due to the facility needing approval from the State Guardian. Family 3 stated the State Guardian was still looking for a facility closer to the family. She stated she was concerned about how the facility handled the entire process and said it was all done in a cloak and dagger manner. During a telephone interview with Social Service Director (SSD), at the accepting facility, on 09/11/2024 at 3:49 PM, she stated R3 had difficulty adjusting to the transfer to her new home. Upon arrival, R3 was crying and expressed confusion as to why she was sent away from her home and would often ask, What did I do wrong? She stated R3 repeatedly requested to speak with her State Guardian about her transfer. The SSD stated R3 was slowly adjusting to her new environment over the past several weeks and was getting along well with her roommate. The State Survey Agency (SSA) surveyor requested to speak with the resident; however, the SSD stated the resident was engaged in an outside activity and was having a good day. Per the interview, the SSD stated that discussing the resident's transfer with her might upset her. 2. Review of R4's Face Sheet found in the resident's EMR revealed the facility admitted the resident on 10/29/2022 with diagnoses to include cerebral infarction, generalized anxiety disorder, and mild cognitive impairment. Review of the R4's quarterly MDS, with an ARD of 07/30/2024, revealed the facility assessed the resident to have a BIMS score of 10 of 15, which indicated the resident was moderately impaired. Review of R4's Notice of Transfer or Discharge letter, dated 07/26/2024, and addressed to R3's State Guardian, revealed it was delivered in person to the resident and the State Guardian, and sent by overnight mail to the family member/legal representative with a Return Receipt Requested. According to the letter, the facility stated the transfer was necessary for the welfare of the resident, as the facility could not meet R3's needs. The effective date of discharge was 07/30/2024, four days after the notice of transfer or discharge was issued to the resident. Review of R4's EMR revealed a Resident Progress Note, dated 07/26/2024 at 4:57 PM, revealed the Social Service Director (SSD) spoke with the resident's State Guardian and informed her the resident would be transferred to a sister facility. Per the note, the Ombudsman was also made aware of the transfer. During a telephone interview with the SSD at the accepting facility on 09/11/2024 at 3:49 PM, she stated R4 was adjusting well to his transfer and has had no complaints. The SSD stated the facility accepted the resident on 07/30/2024. According to the interview, the SSD stated R4 has not exhibited any behaviors since his arrival. Per the SSD, R4 was unavailable for an interview. During an interview with the SSD on 09/05/2024 at 4:15 PM, she stated she spoke with R3 and R4's State Guardian on 07/26/2024 regarding both of their discharges. She stated the State Guardian agreed with the transfer/discharge. During a telephone interview with R3 and R4's State Guardian on 09/05/2024 at 11:15 AM, she stated the facility failed to provide a 30-day notice before the resident's discharge on [DATE]. The State Guardian stated she made the SSD aware through e-mails and telephone conversations discussing the possible transfer/discharge that the State Guardian's office has a process that she must follow to ensure the residents were not inappropriately discharged . The State Guardian stated she needed to obtain supervisory approval for the transfer/discharges. She also stated she informed the SSD that she would need to make a site visit to each facility before approving the transfer/discharge. She stated the facility knew the process because she had informed the administration, more than once, of the need to notify her before any transfer or discharge. 3. Review of R13's Face Sheet found in the resident's EMR revealed the facility admitted the resident on 11/29/2023 with a primary diagnosis of hemiplegia related to cerebral vascular accident (CVA), reduced mobility, psychiatric disorder, cognitive communication deficit, anxiety, unspecified psychosis, dementia, and failure to thrive. Review of R13's Notice of Transfer or Discharge letter, dated 07/26/2024, and addressed to R13's State Guardian, revealed it was delivered in person to the resident and the State Guardian. According to the letter, the facility stated the transfer was necessary for the welfare of the resident, as the facility could not meet the resident's needs. The effective date of discharge was 07/30/2024 with the resident's transfer being more than 150 miles away to the sister facility. Review of R13's EMR revealed a Resident Progress Note, dated 07/26/2024 at 4:56 PM, revealed the SSD spoke with the resident's State Guardian and informed her the resident would be transferred to a sister facility. Per the note, the Ombudsman was also made aware of the transfer. Record review of R13's MDS, dated [DATE], revealed the facility assessed the resident at discharge to have a BIMS score of 9 out of 15, which indicated the resident had moderate cognitive impairment. Review of the SSD email, dated 07/30/2024, revealed she emailed R13's State Guardian and requested a reply to her email, informing her the resident would be transferred/discharged . The resident's State Guardian replied by requesting the facility to hold off on discharging the resident. She replied, I am waiting for my supervisor's approval on this. Further review of the SSD's email, dated 07/31/2024 at 8:30 AM, revealed the resident's State Guardian emailed, Please, do not send the residents to other facilities until I get approval. This email was sent after the resident had been admitted to the sister facility. During an interview on 09/06/2024 at 10:15 AM with the Regional Nurse Consultant, she stated the residents with the least connection to the community were chosen to transfer to sister facilities. She stated the purpose of the residents' transfers was to open their rooms up for a different type of skilled services. During an interview on 09/09/2024 at 10:48 AM, the SSD stated that she and the Chief Nursing Officer (CNO) called the residents' State Guardian, and she was 100% (percent) in agreement with transferring the residents to sister facilities. Per the interview, she stated she had emails to validate the State Guardian's agreement. However, a review of the emails between the SSD and the State Guardian revealed the State Guardian requested for the transfer/discharge to be held until she could obtain approval from her supervisor. 4. Review of R14's Face Sheet, found in the electronic medical record (EMR), revealed the facility admitted the resident on 02/21/2024 with diagnoses to include unspecified dementia with behavioral disturbance and major depressive disorder. Review of R14's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/21/2024 revealed the resident was assessed to have a Brief Interview for Mental Status (BIMS), score of three out of 15, which indicated severe cognitive impairment. Review of the Psychiatry Progress Note dated 04/12/2024, at 11:46 AM, revealed the resident was referred to psych services due to her history of depression, dementia, and sleep problems. Further review of the note revealed nursing staff had reported no changes in R14's mood or cognition. Further review of the progress note revealed the resident's chart was reviewed for any medication changes, labs, behaviors, with no significant findings. Review of R14's emergency room Discharge Orders, found in the resident's EMR, dated 07/11/2024, revealed R14 was transferred from the facility to the local hospital's Emergency Psychiatric Services (EPS) for a psychiatric evaluation relating to endorsing actual harm. The resident denies this and no sign of agitation or other symptoms was noted. Continued review revealed R14 did not meet the criteria for admission. Further review revealed the resident had progressed dementia. Review of R14's Discharge MDS, dated 07/24/2024 revealed the resident was discharged to an independent psychiatric facility. There was no BIMS score listed in this MDS. Further review of the MDS revealed the resident had a change in her baseline cognition. Further review of the MDS, under Section E, revealed the resident had no behaviors noted, at discharge. A review of a local hospital's Psychiatry Transfer Form, found in R14's EMR, revealed that R14 was admitted to the local hospital on [DATE] with diagnoses to include recurrent, severe major depressive disorder with psychotic features, suicidal ideation, moderate, unspecified dementia with other behavioral disturbances. Review of R14's Psychiatry Notes found in the resident's EMR, dated 08/15/2024 at 6:48 PM, indicated the resident was transferred from the facility to the local hospital's Emergency Psychiatry Service (EPS) for a psychiatric evaluation due to the resident experiencing combative behavior with staff at the facility. Further review of the note revealed the resident had a diagnosis of dementia, and this was a normal progression of her disease. The note revealed the resident did not meet the criteria for admission to a psychiatric facility. Additionally, an addendum was added which listed a diagnosis of dementia with behavioral disturbances and the resident's medications should be considered and other recommendations for a more successful management of her disease. Continued review of the note revealed the facility was working on locating new placement for the resident, a locked facility. The note revealed the hospital would keep the resident overnight to allow the facility time to plan for the resident. The Director of Nursing (DON) had promised to call the physician by 9:00 AM with a plan and R14 would be discharged at that time. That call never happened and the resident was subsequently returned to the facility on the evening of 08/16/2024. The facility declined to accept this resident and she was returned to the hospital EPS and was admitted to the Behavioral Health Unit until her discharge to a Long Term Care facilty on 09/12/2024. Review of a Social Service Progress Note, found in R14's EMR, dated 08/15/2024 at 11:07 PM revealed the SSD spoke with the EPS attending physician to advise him that the facility was not the appropriate place for R14 due to her escalating behaviors, being a danger to herself and others. She documented in the progress note that R14 had recent mental decompensation, resulting in three visits to the hospital. The progress note documented that the attending physician at EPS explained that R14 was not appropriate for an acute psychiatric stay and revealed that R14 was not exhibiting the same behaviors at the hospital. Further review of the note revealed the physician explained to the SSD he assessed R14 as having a progression of dementia, which an acute psychiatric stay would not fix, nor was it appropriate at this time. According to the note, the EPS physician recommended a dementia unit due to the progression of the resident's diagnosis. During an interview on 09/09/2024 at 3:15 PM, with an Emergency Psychiatry Services (EPS), MD he stated on 08/15/2024 he spoke with the (former) Director of Nursing, and she stated if he could keep the resident overnight, she would call EPS first thing in the morning with a plan for placement. He stated the former DON never returned his call. On 08/16/2024, he stated the resident was discharged and transferred to the facility, but was turned away by staff. The EPS MD stated he could not recall the nurse's name, but when he spoke with the facility's nurse, on the night of 08/16/2024, she stated she was not going to accept the resident and would be sending her back to the hospital. With no placement, he stated the resident was subsequently admitted to the medical floor until placement could be found. During a telephone interview with Registered Nurse,(RN)2, on 09/04/2024 at 3:16 PM, she stated that when R14 returned to the facility from the hospital on [DATE], she declined to accept the resident at the door. She stated the (former) DON instructed her not to accept the resident. During an interview on 09/09/2024 at 3:56 PM with the Chief Nursing Officer (CNO) for the facility, regarding R14 who was sent to EPS and not allowed to return to the facility, she stated she had been on the phone with the resident's guardian six (6) or seven (7) times about various things. She stated R14 had been in and out of the facility for behaviors. Further, she stated the facility did not have, in writing, the reason for the resident's discharge, a notice that was sent to the Ombudsman, or notification to the resident's State Guardian, that was at least 30 days before the resident was discharged from the facility. During an interview with the Nurse Practitioner, on 09/09/2024 at 3:20 PM, she stated she was unaware of any recommendations from the EPS, which suggested the resident's medications would be reviewed with other recommendations for the management of the resident's disease. During an interview with the Medical Director, on 09/10/2024 at 4:05 PM, he stated he was not familiar with any recommendations from the Hospitalist regarding medication adjustments for the resident. Further, he stated the resident should have been referred to Psychiatric Services for any changes. During an interview on 09/09/2024 at 1:10 PM with the State Guardian, she stated that the old team seemed to understand the process but since the change in management, she has repeatedly tried to educate the facility on the process, but assistance was declined. She stated the standard process was to schedule a meeting with the resident and staff to discuss with the guardian what the need might be. Then the guardian would go to his or her next-line supervisor and provide information on the intended facility. At that time, she stated the intended or selected facility would be reviewed and approved by her team. She stated the approval would be relayed to the Interdisciplinary team (IDT) for further action. The State Guardian stated she asked the facility to look for a facility for R14 before discharging her. Per the interview, she stated she was unable to secure placement for the resident until September. During an interview on 09/10/2024 at 2:10 PM with the Medical Director, he stated he was aware of the plan to change some of the long-term beds to skilled beds and that there were residents who would be transferred to sister facilities. Further, he stated he was not responsible for the residents' transfer/discharge. During an interview on 09/09/2024 at 3:56 PM with the CNO, she stated that she was on the call with the SSD and the State Guardian during a conversation regarding the transfer of residents to sister facilities. She stated the reason she was on this call was to make sure things went smoothly. She stated there were emails to prove that the State Guardian was aware of the plan for transfer/discharge of the residents to sister facilities, to open rooms for a new type of service. The CNO revealed the facility had not provided the residents with a 30-day notice before transfer/discharge. She stated this was a learning experience for the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility's fact sheet Preventing the Spread of Bloodborne Pathogens, review of the facility's online education course outline, Bloodborne Pathogens and the Use of Standard Precautions, review of Assure Platinum Blood Glucose Monitoring System Cleaning and Disinfecting QA/QC Reference Manual, Microdot (brand) bleach wipes manufacturer's instructions, Cleaning and Disinfecting Recommendations,'; review of the facility's internal resource Common Infections, PPE & Isolation Guidelines,; review of the CDC's Enhanced Barrier Precaution (EBP) door signage, and review of the facility's policies, it was determined the facility failed to implement recommended interventions for the cleaning and disinfecting of a shared glucometer (glucose monitoring device), according to manufacturer's instructions. This affected two (2) of seventy-one (71) sampled residents (Residents #325 and #327). The facility had twenty-six (26) residents that required glucose monitoring. Observation on 01/22/2024 of Licensed Practical Nurse (LPN) #1, performing a blood glucose fingerstick using a shared glucometer between Residents #325 and #327 revealed the LPN failed to clean and disinfect the glucometer per the manufacturers' instructions between resident use. In addition, LPN #1 failed to perform hand hygiene between the residents. Further observation on 01/25/2024 of LPN #4 cleaning and disinfecting the glucometer after use on Resident #332 revealed LPN #4 did not use barriers for the machine, failed to disinfect it correctly, and failed to place it in its disinfection case for storage. The facility's failure to have an effective system in place to ensure residents had blood glucose fingersticks performed using a clean and disinfected glucometer has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 01/24/2024 and was determined to exist on 01/22/2024 in the area of 42 CFR 483.80 Infection Control at a Scope and Severity (S/S) of a J. The facility was notified of the Immediate Jeopardy (IJ) on 01/24/2024. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 01/26/2024 alleging removal of the IJ on 01/27/2024. The State Survey Agency (SSA) determined the removal of the IJ as alleged before exit on 01/28/2024, which lowered the S/S to an E while the facility develops and implements a Plan of Correction (PoC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. Furthermore, the facility failed to follow its infection prevention and control policies and procedures regarding the handling of linens to prevent the spread of infection, and failed to disinfect a shared lift. The findings include: Review of the facility's policy titled, Infection Control, revised 10/2018, revealed the facility established guidelines for implementing isolation precautions, including standard and transmission-based precautions, and to provide guidelines for the safe cleaning and reprocessing of reusable resident care equipment. Continued review of the policy revealed that all personnel would be trained on infection control policies and practices upon hire and periodically thereafter. Per the policy, the quality assurance and performance improvement (QAPI) committee and the infection control committee were responsible to review and revise the facility's Infection Prevention and Control Program (IPCP) and to assist department heads and managers to ensure that infection control policies and practices were implemented and followed. Review of the facility's policy titled, Glucometer Cleaning and Disinfecting, revised 01/24/2024, revealed the purpose of cleaning glucometers was to minimize the risk of transmitting bloodborne pathogens. The review revealed cleaning and disinfection procedures should be performed to clean dirt, blood, and other bodily fluids off the exterior of the glucometer before performing the disinfectant procedure. Furthermore, the policy stated all licensed staff would follow the manufacturer's guidelines and recommendations for cleaning and disinfecting of the glucometer. Review of the Assure Platinum Blood Glucose Monitoring System Cleaning and Disinfecting QA/QC Reference Manual, revised 12/2014, revealed the blood glucose meters needed to be cleaned and disinfected after each use. The manual stated cleaning and disinfecting was accomplished according to the manufacturer's guidelines with an Environmental Protection Agency (EPA) registered disinfectant or germicide that was approved for a health care setting. Per the manual, Microdot (brand) bleach wipes were approved for use with the Assure Platinum (brand) glucometer. Review of the Microdot bleach wipes instructions, Cleaning and Disinfecting Recommendations, no date, revealed to thoroughly clean the glucometer surface; wrap the glucometer with a bleach wipe, covering all surfaces of the glucometer; and place the wrapped glucometer face down inside the disinfection case. The instructions continued, with the lid closed, activate a timer for three (3) minutes to allow the glucometer to remain in contact with the bleach wipes. Review of the facility's policy titled, Transmission Based Precautions, dated 09/15/2023, revealed transmission-based precautions (TBP) included contact precautions, droplet precautions, and airborne precautions. The policy stated TBP were initiated when a resident developed signs and symptoms of a transmissible infection or had a laboratory confirmed infection and was at risk for transmitting the infection to other residents. 1. Review of the facility's Glucose Monitoring list, dated 01/23/2024, revealed the list contained twenty-four (24) residents, including Residents #325 and #327. Review of the facility's Glucose Monitoring list, dated 01/24/2024, revealed the list contained twenty-six (26) residents, including Resident #325 and #327. Continuous observation, on 01/22/2024 at 6:22 PM, of Licensed Practical Nurse (LPN) #1, while performing a pre-meal blood glucose test revealed LPN #1 entered Resident #325's room holding a blue plastic basket with Resident #325's insulin pen, a bottle of glucose testing strips, unwrapped gauze, unused lancets, alcohol wipes, and band aids. The LPN performed a blood sugar finger stick on Resident #325. LPN #1 exited the room without performing hand hygiene (HH). She was carrying the shared glucometer inside the basket on top of the other supplies. LPN #1 failed to clean the glucometer used on Resident #325. LPN #1 then walked into Resident #327's room with the basket of supplies and the contaminated glucometer and performed a blood sugar finger stick on the resident. She did not perform HH prior to entering the room. LPN #1 then exited the room with the glucometer inside the basket. She did not clean the glucometer prior to exiting Resident #327's room nor did she perform HH upon exit. In an interview with LPN #1 on 01/22/2024 at 6:30 PM, she stated she cleaned the glucometer after each use. She stated she had just used a bleach wipe which was located on her medication cart. The State Survey Agency (SSA) Surveyor asked LPN #1 to demonstrate how she cleaned the glucometer. LPN #1 placed the contaminated glucometer in the top drawer of the medication cart without a barrier. LPN #1 stated, I used these. She then opened the bottom drawer of the medication cart and took out a container of Microdot bleach wipes. LPN #1 stated she tried to pull a wipe out of the container but realized the container had never been opened and was still factory sealed. The LPN then stated, I didn't clean it [the glucometer] between sticks. I'm not going to lie to you. When asked about the cleaning process of the glucometer, LPN #1 stated it should be cleaned after every use and left wet for five (5) minutes. In continued interview with LPN #1 on 01/22/2024 at 6:30 PM, she stated the shared glucometer should be stored in a plastic container after cleaning. Although she pointed to a blue plastic lid, she was unable to find the bottom part of the container. Observation, at the time of the interview, revealed there was a blue lid on the medication cart, but no disinfection container was available. Furthermore, when interviewed about placing the contaminated glucometer and Resident #325's insulin pen on top of unused clean lancets and the blood glucose monitoring strips, she stated that was how she carried her supplies from room to room. LPN #1 stated she did not consider placing contaminated equipment on clean supplies was an infection control breach. The LPN stated, Nothing touched a resident. She stated she received IPCP training upon hire and annually. When interviewed related to the significance of cleaning and disinfecting multi-use equipment and performing HH before and after direct resident care, LPN #1 explained that those actions helped to prevent the spread of infection. In an interview with Registered Nurse (RN) #1 on 01/23/2024 at 10:02 AM, she stated her practice for cleaning shared glucometers was to wipe them down with an alcohol wipe after each use. She further stated she cleaned the glucometer at the beginning of her shift with a bleach wipe. Per the interview, the facility trained her to clean the glucometers but did not specify which wipe to use. In an interview with the Director of Nursing/Infection Preventionist (DON/IP) and the Minimum Data Set/Infection Preventionist (MDS/IP) Nurse on 01/23/2024 at 1:27 PM, they stated all staff members were trained on IPCP. The DON/IP stated the facility followed state and federal guidelines to prevent the spread of infection. The DON/IP stated the facility did not have a specific policy addressing shared equipment, and clinical staff members were trained to clean multiuse or shared equipment, including vital sign equipment, glucometers, and Hoyer lifts (brand of mechanical lift) after each use. The DON/IP stated, Everyone who is clinical receives this on hire. She stated it was her expectation for staff using shared and multi-use equipment to clean and disinfect the equipment after each use with a bleach wipe and to wait for the appropriate time. The DON/IP further stated clinical staff members were aware of kill times, and they were posted on the bleach wipe container. During the interview the DON/IP stated, We use an alcohol swab to clean bleach residue off the glucometer and use a bleach wipe first for proper kill time. I'd have to refer to the container for kill time, but I believe it's two (2) or three (3) minutes. The DON/IP stated that she and the unit managers continually perform visual audits and on the spot education. However, she stated, We don't keep paper records of those audits. Both the DON/IP and the MDS/IP Nurse stated following IPCP guidelines were important to prevent the spread of infectious material. Observation with the DON, on 01/24/2024 at 8:55 AM, revealed there were currently twelve (12) shared glucometers being used throughout the facility, and all should be kept on the medication carts. Further observation revealed seven (7) of the eight (8) medication carts had glucometers, with two (2) on the 100 Hall; one (1) on the 200 Hall; one (1) on the 400 Hall; one (1) on the 500 Hall; two (2) on the 600 Hall; two (2) on the 700 Hall; and one (2) on the 800 Hall. One (1) glucometer was found on the 300 Hall treatment cart. The 300 Hall glucometer was stored in a blue plastic tray with unwrapped gauze, band aids, lancets, alcohol wipes, and packaged needles. In additional interview with the DON/IP on 01/24/2024 at 9:15 AM, she stated to prevent cross contamination, shared glucometers should not be stored inside the plastic basket along with other supplies on the medication cart. She stated they should be placed in a container with a lid after cleaning and disinfecting per manufacturer's instructions. When asked who was responsible for ensuring IPCP compliance and addressing breakdowns related to infection control, the DON stated that unit managers and nurse leadership perform weekly audits of the medication carts and daily visual rounds of clinical staff performing direct care to ensure compliance with IPCP. The DON/IP stated of the residents who received glucose monitoring, one (1) resident had a bloodborne pathogen. She stated Resident #329 had a diagnosis of HIV. Additionally, she stated Resident #329 had a diagnosis of diabetes and received insulin and blood glucose monitoring before meals. Review of Resident #329's Face Sheet revealed the facility admitted the resident on 01/17/2024 with diagnoses to include human immunodeficiency virus (HIV) disease, type 2 diabetes mellitus, and history of urinary tract infections. Resident #329 was on the Glucose Monitoring list. Review of Resident #331's Face Sheet revealed the facility admitted the resident on 01/12/2024 with diagnoses to include type 2 diabetes mellitus and acute and chronic hepatitis B (HBV). Resident #331 was on the Glucose Monitoring list. Observation on 01/25/2024 at 3:45 PM during quality monitoring, by a Regional Care Consultant Nurse, of Licensed Practical Nurse (LPN) #4 performing a blood glucose fingerstick on Resident #332, revealed LPN #4 retrieved the glucometer from the top drawer of the medication cart. The glucometer was resting on top of an open roll of bandage tape along with a pair of bandage scissors. It was in close contact with various items in the drawer. LPN #4 placed the glucometer on the medication cart without using a barrier sheet, and then collected the necessary supplies in a plastic cup. LPN #4 proceeded to the resident's bedside and put the supplies on the bedside table. The blood glucose fingerstick was performed, and immediately after the procedure, the LPN placed the contaminated glucometer, with the test strip still engaged on top of the resident's bedside table without using a barrier. LPN #4 then moved to the resident's sink and placed the glucometer on a barrier. The LPN removed the Microdot bleach wipe container from the cart and placed it on the resident's sink without using a barrier. The LPN gloved and cleaned the glucometer. The glucometer was then wrapped with bleach wipes; however, LPN #4 did not cover all four (4) sides, and it was placed on top of the medication cart using a barrier instead of being put in the disinfectant case as per manufacturer's instructions. In an interview with LPN #4 on 01/25/2024 at 3:45 PM, he stated that all clinical staff had received training to include written instruction and a test regarding how to clean and disinfect glucometers. However, he stated he did not receive a live demonstration and was not asked to demonstrate proper technique back. 2. Observation on 01/23/2024 at 3:10 PM, revealed a dirty towel on the floor in the 400 Hall outside of room [ROOM NUMBER]. The towel remained on the floor for five (5) minutes while multiple staff members walked past it. When the DON noticed the towel, she picked up the towel and placed it in a plastic bag, which she then put in the soiled utility room. Observation, on 01/23/2024 at 5:30 PM, revealed a dirty sheet lying in the entrance of room [ROOM NUMBER], which extended to the hallway of the 700 Hall. In an interview with the Director of Housekeeping on 01/24/2024 at 5:00 PM, the Director stated linen should never be thrown on the floor or other surfaces in the room or in the hallway. The Director stated linen should be bagged and taken to the dirty utility promptly. Observation on 01/25/2024 at 8:30 AM, revealed Certified Nursing Assistant (CNA) #14 walking down the 800 Hall holding clean linens against her uniform. In an interview with CNA #14 she stated she had been trained on IPCP policies. She stated linen should be held away from the body to prevent the spread of germs. In an interview with the MDS/IP Nurse on 01/24/2024 at 8:35 AM, she stated staff should not hold linen up against their clothing. She stated linen should be held away from the body to prevent cross contamination. She stated when she saw staff members failing to follow IPCP policies she would stop and educate them on the spot. 3. Observations on 01/22/2024 at 3:38 PM and on 01/23/2024 at 3:27 PM revealed the sit-to-stand lift in the 400 Hall was visibly soiled with a brown substance streaked on the foot pad and bottom bar of the lift. In an interview on 01/23/2024 at 3:27 PM, the Director of Nursing (DON) stated the lifts should be cleaned after every use and when visibly soiled. She further stated she would clean the lift and re-educate staff. In an interview with the Regional Care Consultant (RCC) Nurse on 01/28/2024 at 5:32 PM, she stated that all staff should follow IPCP to prevent the spread of infection in the facility. In an interview with the Director of Regulatory on 01/28/2024 at 2:45 PM, she stated the role of the Director of Regulatory was to assist the facility and train the nursing leadership and staff. Additionally, she stated regional nurses were assigned to help the DON by providing resources. The Director of Regulatory emphasized that all staff members should follow the facility's IPCP. She also mentioned that the facility followed state and federal guidelines, and if CMS required something to be followed, the facility should comply with the requirements. She stated it was important to prevent the spread of infection. During an interview with the Administrator on 01/28/2024 at 5:05 PM, the Administrator stated it was her expectation for the staff to follow the facility's IPCP, which included current standards, policies, and procedures based on state and federal regulations. She stated the QAPI committee reviewed policies annually. When asked if following current guidelines was important to provide a safe environment and to help prevent the spread of infections, she stated, Yes. She reported nurse leadership ensured quality assurance and compliance with IPCP through a triple check system that included daily visual rounds at the bedside and of clinical staff performing direct care. She added that although daily rounding by nurse leadership was not documented, issues were resolved through a root cause analysis of the failure. According to the Administrator, the root cause of the staff's failure to clean the glucometers was that staff did not understand the education. She further emphasized that the facility followed state and federal regulations, including the state health department recommendation. She stated all staff should follow IPCP to prevent the spread of infection in the facility. The facility provided an acceptable Immediate Jeopardy (IJ) Removal Plan on 01/26/2024, alleging removal of the IJ on 01/27/2024. Review of the IJ Removal Plan revealed the facility implemented the following: 1. Residents #325 and #327 were assessed by a licensed nurse on 01/24/2024 using a Risk for Infection Assessment, in which each resident was assessed for any signs and symptoms of infections. A full set of vital signs was included in the assessment. Residents #325 and #327's physician and responsible parties were notified of the potential for bloodborne pathogen exposure on 01/24/2024 by a licensed nurse. Glucometer Cleaning and Disinfecting Policy was revised on 01/24/2024 by the Governing Body, which included the [NAME] President (VP) of Regulatory, VP of Clinical Operations, VP of Operations, and the VP of Clinical Reimbursement. LPN #1 was educated by the Chief Nursing Officer (CNO) on 01/24/2024 on Preventing the Spread of Bloodborne Pathogens. 2. On 01/24/2024 all twenty-six (26) residents receiving accu-checks (blood glucose monitoring) were assessed by a licensed nurse to ensure there were no signs and symptoms related to bloodborne pathogen exposure. In addition, on 01/24/2024, all residents receiving accu-checks and/or the residents' representatives and physicians were notified of the potential bloodborne pathogen exposure. Each was offered lab testing related to the potential bloodborne pathogen exposure. This was completed by licensed nurses. On 01/24/2024, physician's orders were obtained for twenty-five (25) of the twenty-six (26) residents and/or resident representatives who requested lab testing completed. A hepatitis (HEP) and human immunodeficiency virus (HIV) exposure panel was obtained on 01/26/2024 for twenty-three (23) of the twenty-six (26) residents. One (1) resident refused labs, one (1) resident was transferred to the hospital on [DATE], and one (1) resident was discharged home on [DATE] prior to the lab being drawn. An at Risk for Infection care plan was implemented and completed on 01/24/2024 for each of the twenty-six (26) residents. Testing was offered and he/she is expected to return to the facility. Resident #325 refused and then was admitted to the hospital. Resident #325 was offered and refused, wishing to have it done at his/her PCP. 3. Education by the Regional Care Consultant (RCC) Nurse, Director of Regulatory, and the Vice-President (VP) of Clinical Operations on the Glucometer Cleaning and Disinfecting process per the manufacturers' guidelines and on bloodborne pathogens was provided to the Director of Nursing (DON), Minimum Data Set (MDS) Nurses, and licensed nurses on 01/24/2024. A posttest was given requiring a minimum score of one hundred percent (100%). Those who did not receive a score of one hundred percent (100%) were reeducated and tested again, until a score of one hundred percent (100%) was achieved. Any nurse not receiving education by 01/24/2024 would be provided with the education prior to working their next shift. Due to a breach in infection control practices observed on 01/24/2024 during observation of an accu-check being performed, all licensed nursing staff were immediately reeducated. The RCC Nurse, Director of Regulatory, and the VP of Clinical Operations revised the education to include the required steps of completing an accu-check per the manufacturers' guidelines and on the cleaning and disinfection process of the glucometer per manufacturers' guidelines. The revised reeducation was done on 01/25/2024 and required a competency review with a return demonstration. This was repeated until each licensed nurse on the day and evening shifts passed the competency return demonstration with one hundred percent (100%) accuracy. The RCC Nurse arrived at the facility prior to the day shift on 01/26/2024 so that any licensed nurses that had not been educated and were scheduled to work were reeducated prior to working their shift. Any licensed nurse not receiving reeducation by 01/26/2024 would not work until they had completed reeducation and passed the competency return demonstration. All new licensed nurses or agency nurses would be educated by a member of nursing management during orientation prior to providing resident care. Starting 01/25/2024, the DON, Assistant DON, Unit Managers, MDS Nurse, or Regional Nurses would observe ten (10) accu-checks weekly for four (4) weeks, being performed with the cleaning and disinfecting process after the accu-check had been performed. 4. An ad hoc Quality Assurance Performance Improvement (QAPI) meeting was held on 01/24/2024 with the Medical Director and the QAPI Team Members, which included the DON, Administrator, and the Administrator in Training. The QAPI Committee would meet daily for seven (7) consecutive days, starting on 01/25/2024, then weekly for four (4) weeks, then monthly thereafter for recommendations and further follow up regarding the plan of correction. Audit documentation would be submitted to the QAPI Committee for review and to ensure compliance. The Administrator was responsible for the oversight of the removal plan to ensure ongoing compliance. The State Survey Agency validated implementation of the facility's IJ Removal Plan as follows: 1. Review of the Risk for Infection Assessments dated 01/24/2024 confirmed Residents #325 and #327 were assessed by the DON and each resident was assessed for any signs and symptoms of infections. A full set of vital signs was included in the assessment. Review of the Risk for Infection Assessments dated 01/24/2024 confirmed Residents #325 and #327's physician and responsible parties were notified by the Director of Nursing (DON) of the potential for bloodborne pathogen exposure on 01/24/2024. Review of the revised Glucometer Cleaning and Disinfecting Policy, dated 01/24/2024, revealed it included the addition of 1) licensed staff would follow the manufacturer's guidelines and recommendations for the cleaning and disinfecting of the glucose monitors; and 2) the staff would receive education on cleaning and disinfecting the glucose monitors per the manufacturer's guidelines upon hire and as needed. Review of signed documentation related to LPN #1's reeducation by the Chief Nursing Officer (CNO), dated 01/24/2024, indicated LPN #1 was educated on the Glucometer Cleaning and Disinfecting Policy, the Infection Control Policy, and Preventing the Spread of Bloodborne Pathogens education module by the American Red Cross. 2. Review of the Risk for Infection Assessment sheets, dated 01/24/2024, revealed the DON, the RCC Nurse, and the Director of Regulatory (also a nurse) performed a risk assessment on all twenty-six (26) residents receiving accu-checks (glucose monitoring). Review of the Risk for Infection Assessment sheets, dated 01/24/2024, revealed the DON, the RCC Nurse, and the Director of Regulatory notified all residents and/or the residents' representatives and physician of the potential bloodborne pathogen exposure. Review of lab orders dated 01/24/2024 for twenty-five (25) of the twenty-six (26) residents receiving accu-checks, revealed a HEP and HIV Exposure Panel was ordered by the physician for residents and/or resident representatives who requested lab testing. One (1) resident was discharged on 01/25/2024. Review of the completed lab orders revealed a HEP and HIV Exposure Panel lab draw was completed on 01/26/2024 for twenty-three (23) of the twenty-six (26) residents. One (1) resident refused labs, one (1) resident was transferred to the hospital on [DATE], and one (1) resident was discharged home on [DATE] prior to the lab being drawn. Review of Care Plans revealed a Risk for Infection care plan was implemented on 01/24/2024 for each of the twenty-six (26) residents to include the resident was at risk for potential adverse effects related to potential bloodborne pathogen exposure. Interventions included to notify the provider of the potential exposure, perform a nurse assessment for signs and symptoms of adverse effects, obtain labs as ordered by the provider, and notify the resident and/or responsible party of the potential exposure. 3. Review of education, posttests with a score of one hundred percent (100%) achieved, and sign-in sheets, dated 01/24/2024, revealed thirty-one (31) nursing staff members were educated on the Glucometer Cleaning and Disinfecting process per the manufacturers' guidelines and on bloodborne pathogens, and it was provided by Nursing Leadership. Review of the revised reeducation, completed on 01/25/2024 to 01/26/2024, revealed training and education to include Glucometer Cleaning and Disinfecting and Blood Glucose Testing, with return demonstration competency tests, signed by the staff and educator, showing one hundred percent (100%) accuracy achieved for thirty (30) nursing staff. Review of the quality assurance (QA) audits revealed the Regional Nurses observed three (3) accu-checks being performed with the cleaning and disinfecting process after the accu-check had been performed on 01/26/2024 and 01/27/2024. Observation on 01/28/2024 at 11:30 AM of Licensed Practical Nurse (LPN) #4 performing a blood glucose fingerstick on Resident #330, revealed LPN #4 performed the procedure and cleaned and disinfected the glucometer correctly, per manufacturers' instructions. Observation on 01/28/2024 at 11:45 AM of RN #7 (Agency) performing a blood glucose fingerstick on Resident #90, revealed RN #7 performed the procedure and cleaned and disinfected the glucometer correctly, per manufacturers' instructions. Observation on 01/28/2024 at 12:01 PM of LPN #10 performing a blood glucose fingerstick on Resident #97, revealed LPN #10 performed the procedure and cleaned and disinfected the glucometer correctly, per manufacturers' instructions. Observation on 01/28/2024 at 12:15 PM of RN #2 performing a blood glucose fingerstick on Resident #20, revealed RN #2 performed the procedure and cleaned and disinfected the glucometer correctly, per manufacturers' instructions. In interviews with Licensed Practical Nurse (LPN) #4 on 01/28/2024 at 11:30 AM; RN #7 on 01/28/2024 at 11:45 AM; LPN #10 on 01/28/2024 at 12:01 PM; and RN #2 on 01/28/2024 at 12:15 PM, all stated the RCC Nurse conducted one-on-one (1:1) training for all nurses on how to properly clean and disinfect glucometers. All stated the nurse trainer provided live demonstrations and had the nurses perform a return demonstration to ensure proper understanding. All stated infection control training was important in preventing the spread of disease. All stated they had received a live demonstration and education to include written instruction and a test regarding how to perform blood glucose monitoring and how to clean and disinfect glucometers per the manufacturer's instructions. They further stated they had to pass the written test with one hundred (100%) accuracy, and they were required to perform a return demonstration. In an interview with the RCC Nurse on 01/28/2024 at 5:32 PM, she stated she was responsible for providing education to all nurses working in the facility on how to clean and disinfect glucometers. She stated that she had provided training to all nurses before the start of their shift, which involved both instruction and live demonstration. After that, she stated each nurse was required to provide a return demonstration to ensure compliance. She stated the education was based on the manufacturer's instructions for the glucometer and Microdot bleach wipes. In an interview with the Director of Regulatory on 01/28/2024 at 2:45 PM, she stated nursing staff received education on cleaning and disinfecting glucometers from the RCC Nurse. She stated the training was followed by a return demonstration to ensure the staff understood it. The Director of Regulatory reported the education was based on manufacturers' instructions for the glucometer and Microdot bleach wipes. 4. Review of the QAPI sign-in sheet dated 01/24/2024 revealed the QAPI Committee, which included the Medical Director, Administrator, DON, Risk Manager, VP of Clinical Operations, VP Regulatory, VP Operations, and Administrator in Training, had a meeting. Review of the QAPI sign-in sheet dated 01/25/2024 revealed the QAPI Committee, which included the Medical Director, Administrator, DON, MDS Nurse, and the Social Services Director, had a meeting. Review of the QAPI sign-in sheet dated 01/26/2024 revealed that the QAPI Committee, consisting of the Medical Director, Administrator, DON, MDS Nurse, and Social Services Director, had a meeting. During an interview with the VP of Clinical Operations on 01/26/2024 at 3:43 PM, he stated the QAPI Committee had convened to address the IJ findings. He stated the committee discussed the education and re-education of staff, as well as the progress of staff education and competency training. He stated the Medical Director, Administrator, DON, and other nursing leadership members met daily on 01/24/2024, 01/25/2024, and 01/26/2024 as part of the IJ removal plan.