Celebrate Senior Living Of Fort Wayne
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Wayne, Indiana.
- Location
- 3420 East State Blvd, Fort Wayne, Indiana 46805
- CMS Provider Number
- 155255
- Inspections on file
- 36
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Celebrate Senior Living Of Fort Wayne during CMS and state inspections, most recent first.
Failure to knock or announce before entering resident rooms. Multiple residents reported that staff entered without knocking, and during observation a CNA entered a resident’s room without knocking, introducing herself, or asking permission. The CNA made a comment about the resident needing a shower after the resident said her legs were hurting, and later observations showed a CNA, an LPN, and transportation staff entering rooms without knocking or announcing themselves.
Failure to Document Bed Hold Notifications: The facility did not provide or document bed hold notices for two residents with repeated hospital transfers. One resident had DM, lung disease, and stroke, and the other had CP, malnutrition, and constipation. Records lacked transfer forms or progress note evidence that bed hold notices were discussed or given, and staff reported keeping copies in a binder without signatures or proof of receipt.
Improper Wound Care Technique During Dressing Change: An LPN failed to use a clean barrier when setting up wound care supplies and handled gauze with bare hands before donning gloves during a resident’s dressing change. The resident had MS, chronic pain, decreased mobility, and a pressure ulcer with a history of wound infection, and the treatment included Santyl, Dakins-soaked gauze, and a foam dressing.
Tube Feeding Not Properly Labeled or Dated: A resident with cerebral palsy and severe protein calorie malnutrition had a tube feeding bag in her room that was not labeled or dated to show when it was hung, and the flush syringe was dated several days earlier. The resident had an enteral feeding order for Vital 1.5 cal at 30 ml/hr with scheduled flushes, and the ADON stated the nurse may have been busy and forgot to make a label for the feeding.
Surveyors observed unsanitary kitchen conditions, including food debris, dust, and improper storage of utensils, with no cleaning schedule or sanitation policy in place. Both the DM and DON confirmed these deficiencies, affecting all residents who received food from the kitchen.
An LPN was overheard loudly discussing a resident's medical condition, specifically a boil, in a public area where other residents could hear. The resident involved had dementia. This breached facility policy requiring dignity, respect, and confidentiality for all residents.
A resident with chronic pulmonary disease and type 2 diabetes mellitus was found on the floor with a nasal fracture and subdural hematoma. The facility failed to report the fall with fracture to the IDOH within the required 24-hour timeframe. The facility's policy did not specify when such incidents should be reported, contributing to the delay.
A facility failed to complete a required elopement risk assessment for a resident with severe cognitive impairment and dementia, who was at high risk for elopement. Despite previous assessments indicating the need for elopement risk protocol, a quarterly assessment was not conducted between August and October. Interviews revealed uncertainty about the missing assessment, contrary to the facility's policy requiring regular evaluations.
Failure to Knock or Announce Before Entering Resident Rooms
Penalty
Summary
The facility failed to ensure dignity for 4 of 5 residents reviewed. Resident 3, who had lung disease, heart disease, and diabetes, told the surveyor on 4/13/26 that staff did not knock before entering the room. Resident 11, who had lung disease and anxiety, also stated on 4/13/26 that staff did not knock before entering her room. Resident 16, who had lung disease, hypertension, and depression, likewise reported on 4/13/26 that staff did not knock before entering the room. During observation, CNA 5 entered Resident 54’s room without knocking, introducing herself, or asking permission to enter. CNA 5 asked if Resident 54 was ready for a shower, and when Resident 54 said her legs were hurting, CNA 5 replied, “it smells like you need a shower. I will be back.” Resident 54 then put a blanket over her head and did not respond. During a later continuous observation, CNA 6, an LPN, and transportation staff were observed entering resident rooms without knocking, announcing themselves, or asking for admittance, and in one instance CNA 6 removed a meal tray from a room without speaking.
Failure to Document Bed Hold Notifications
Penalty
Summary
The facility failed to provide bed hold notification for 2 of 5 residents reviewed. Resident 3 had diagnoses of diabetes, lung disease, and stroke and was sent to the hospital on multiple occasions, including 7/1/25, 7/14/25, 8/14/25, 8/26/25, and 12/29/25. Only one hospital nursing transfer form was available for review, dated 7/14/25, and it included a bed hold notice. No nursing transfer form or bed hold notice was available for the other hospitalizations, and Resident 3's progress notes did not show that a bed hold notice was discussed or given on those dates or within 24 hours afterward. Resident 6 had diagnoses of cerebral palsy, malnutrition, and constipation and was sent to the hospital on 5/18/25, 6/2/25, 7/16/25, and 2/11/26. Her medical record did not contain nursing transfer forms for any of those hospitalizations, and her progress notes did not indicate that a bed hold notice was discussed or given on those dates or within 24 hours. During interview, the Administrator stated the facility could scan in the transfer or discharge notice that included the bed hold policy, but the notices did not require a signature or proof of receipt. Nursing Supervisor 2 stated staff made a copy of the bed hold when sending the resident out and kept the notices in a binder, believing this served as proof of receipt. No other documentation or signed bed hold notices were provided.
Improper Wound Care Technique During Dressing Change
Penalty
Summary
The facility failed to ensure proper technique during wound care treatment for one resident with Multiple Sclerosis, chronic pain, and decreased mobility. During an observation, Employee 2 set up wound care supplies with no clean barrier between the supplies and the bedside table, picked up a stack of 4x4 gauze pads from the treatment cart with bare hands, and placed the pads on the table before donning a protective gown, sanitizing hands, and putting on gloves. During the treatment, the 4x4 gauze was removed from the wound bed, gloves were removed, hands were sanitized, and new gloves were donned. Santyl cream was applied to the wound bed, wet gauze soaked in Dakins solution was packed into the wound, and the wound was covered with an Allevyn foam dressing. The resident’s record showed a care plan for pressure ulcer infections, physician orders for Dakins solution and protein supplements, and progress notes indicating wound infection in January, February, and March 2026. Employee 2 stated they should have used a barrier between the table and supplies and should not have picked up the gauze with an ungloved bare hand.
Tube Feeding Not Properly Labeled or Dated
Penalty
Summary
The facility failed to ensure proper labeling and dating for tube feeding for one resident with a feeding tube. During two observations on April 12, 2026, the resident was seen in her room with a tube feeding bag that was not labeled or dated to show when it had been hung. The tube feed flush syringe was dated 04/10/2026 during both observations. The resident's record showed diagnoses of cerebral palsy and severe protein calorie malnutrition. Physician's orders included a regular, pureed, thin consistency diet and an enteral feeding order for Vital 1.5 cal at 30 ml per hour with a 100 ml fluid flush every 2 hours every shift for nutritional supplement. In interview, the ADON stated she had watched the nurse hang the tube feeding and otherwise would not have known when it was hung, and said the facility labeled and dated tube feedings, though the nurse may have been busy and forgot to make a label. The facility policy stated that the manufacturer's written recommendations regarding hanging time are consulted when determining the schedule for enteral feeding administration, and the Vital 1.5 cal instructions indicated that once opened it should be reclosed, refrigerated, and used within 48 hours.
Failure to Maintain Kitchen Sanitation Standards
Penalty
Summary
The facility failed to follow proper sanitation measures in the kitchen, as evidenced by multiple observations of unsanitary conditions. A metal scoop was found stored inside a tub of brown sugar, and there was visible debris, including grease-like food, dried noodles, raisins, plastic, small pieces of paper, dust, and unidentifiable particles under racks, around and under the sink, and on the floor in the chemical room. Additional observations revealed small cereal particles and dried meat under the stand-up cooler, meal carts, and stove area. The Dietary Manager confirmed there was no cleaning schedule in place and acknowledged that the scoop should not be left in the brown sugar tub and that debris should not be present. The Director of Nursing also confirmed the absence of a kitchen sanitation policy. All 71 residents in the facility received food prepared in this kitchen.
LPN Fails to Maintain Resident Dignity and Privacy
Penalty
Summary
A deficiency occurred when an LPN failed to maintain a resident's dignity and privacy by loudly discussing the resident's medical condition in a public area. During an observation, the LPN was overheard yelling from inside a resident's room to another staff member at the nurses' station, stating that the resident had a boil the doctor wanted to examine and that the resident needed to be laid down. This conversation took place in the presence of three unidentified residents who were in close proximity and could hear the exchange. Later, the LPN was again overheard discussing the resident's condition with a wound nurse practitioner in a manner that was easily audible to others. The resident involved had a diagnosis of unspecified dementia. Facility policy requires that residents be treated with dignity and respect, and that personal and medical information be kept confidential, but these standards were not upheld in this instance.
Failure to Timely Report Fall with Fracture
Penalty
Summary
The facility failed to report a fall with a fracture to the Indiana Department of Health (IDOH) within the required timeframe for a resident. The incident involved a resident who was found on the floor in her room with a pool of blood coming from her nose. The resident was sent to the hospital and diagnosed with a probable subtle acute nondisplaced bilateral nasal bone fracture, a septal fracture, and a subdural hematoma. The facility's administrator reported the incident to the IDOH, but not within the 24-hour window required after being notified of the fracture. The resident involved had a medical history that included chronic pulmonary disease and type 2 diabetes mellitus. The facility's policy on abuse, neglect, and exploitation did not specify when a fall with a fracture should be reported, which contributed to the delay in reporting. An interdisciplinary team meeting was held to determine the root cause and result of the fall, but the deficiency was identified due to the failure to report the incident in a timely manner as required by regulations.
Failure to Complete Elopement Risk Assessment for Resident
Penalty
Summary
The facility failed to ensure that an elopement risk assessment was completed for one of the residents, identified as Resident 53, who was at high risk for elopement due to severe cognitive impairment and dementia. The resident's care plan, dated April 8, 2024, indicated a high risk for elopement and included interventions such as regular assessments and participation in activities to divert attention. However, a quarterly elopement risk assessment was not completed between August and October 2023, despite previous assessments indicating the resident was at risk and should be on the elopement risk protocol. Interviews with the Memory Care Coordinator and Social Worker revealed that the elopement risk assessment for Resident 53 was missing, and they were unsure why it had not been completed. The facility's policy, dated October 2018, required elopement risk assessments upon admission, re-admissions, quarterly, annually, and with significant changes in condition. The failure to conduct the required assessment was identified during a record review and interviews, highlighting a lapse in following the facility's elopement management policy.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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