Good Samaritan Society - Liberal
Inspection history, citations, penalties and survey trends for this long-term care facility in Liberal, Kansas.
- Location
- 2160 Zinnia Lane, Liberal, Kansas 67901
- CMS Provider Number
- 175334
- Inspections on file
- 19
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Good Samaritan Society - Liberal during CMS and state inspections, most recent first.
A resident with DM2, prior stroke with hemiparesis/hemiplegia, malignant brain neoplasm, impaired cognition, and total dependence for transfers was being moved from bed to wheelchair using a full-body mechanical lift with two staff. After the resident was lifted off the bed and the lift was pulled away to position the wheelchair, one staff briefly released physical contact to retrieve the wheelchair, during which the resident rolled to the side, sling loops became partially detached from the lift hooks, and the resident fell, striking the back of the head and developing two hematomas. Facility lifts had hook assemblies without mechanisms to prevent sling loops from unintentionally coming loose, and although facility policy required a "TIME OUT" safety stop to verify secure straps before moving away from the surface, the incident occurred after the lift was moved from the bed. The fall documentation lacked evidence of a completed investigation or identified root cause for the sling detachment.
A resident with dementia and behavioral disturbances was able to access multiple lighters and started a fire in her room, leading to the evacuation of all residents. Staff discovered the fire and extinguished it, but inspection revealed the resident had accumulated hazardous items, including lighters and medical equipment belonging to others, due to inadequate supervision and lack of effective monitoring of personal belongings.
The facility failed to ensure the proper functioning of the call light system, leading to significant delays in response times to residents' needs. Additionally, the facility did not appropriately respond to allegations of abuse, including a large bruise on a resident and a reported sexual assault. These failures placed residents at risk for neglect and abuse, impacting their well-being.
A resident reported a sexual assault by two male perpetrators within the facility, but the staff failed to assess her for injuries or report the incident to authorities. Despite the resident's report to hospital staff and subsequent notifications to the facility, no investigation was initiated, and law enforcement was not contacted until much later. This failure placed the resident in immediate jeopardy and at risk for further harm.
A resident reported being sexually assaulted by two male perpetrators, but the facility failed to investigate or notify law enforcement until a surveyor intervened. Despite the resident's cognitive intactness and medical vulnerabilities, the facility did not act on the allegations, leading to a significant oversight in resident safety and well-being.
A resident with a history of trauma and anxiety disorder reported sexual assault multiple times, but the facility failed to investigate or report the allegations to law enforcement. Despite the resident's symptoms of fear and aggression, consistent with a trauma response, the facility did not document the allegations or initiate an investigation until months later, placing the resident in immediate jeopardy.
The facility failed to maintain sanitary conditions in food storage and preparation, risking food-borne illness. Observations revealed undated and improperly stored food items, scratched kitchenware, and burnt substances in ovens. Dietary staff confirmed these issues, which violated the facility's policy requiring proper labeling and storage of opened food.
The facility failed to submit accurate staffing data to CMS, with discrepancies in the Payroll Base Journal (PBJ) showing a lack of 24/7 licensed nurse coverage and low weekend staffing. Despite daily staffing sheets indicating equal staffing levels, the facility lacked a policy to ensure PBJ accuracy, affecting the reported care for 37 residents.
The facility was cited for multiple deficiencies, including four Immediate Jeopardy citations, indicating substandard quality of care. Issues included unreported and uninvestigated abuse allegations, failure to recognize changes in residents' conditions, and lack of comprehensive care plans. The facility also failed to provide necessary care, maintain a safe environment, and serve food under sanitary conditions. Additionally, the administration was ineffective in addressing quality deficiencies, leading to continued substandard care for all residents.
The facility failed to manage its resources effectively, leading to multiple deficiencies in care and administration. Key issues included inadequate response to abuse allegations, failure to perform timely assessments, and inaccurate staffing reports. These deficiencies compromised residents' well-being and quality of care.
A resident with a history of hemiplegia, hemiparesis, and traumatic brain injury experienced a decline in ADLs and increased behavioral issues, which the facility failed to document as a significant change in condition. The resident's functional abilities deteriorated, requiring total dependence on staff for most ADLs, and exhibited increased behaviors such as yelling and hitting. The facility lacked a policy for MDS completion, relying instead on the RAI manual, leading to the oversight.
The facility failed to accurately complete the MDS for several residents, leading to uncommunicated care needs. One resident's MDS did not reflect the use of a chair alarm despite its documented necessity due to frequent falls. Another resident's MDS inaccurately documented the absence of a personal alarm, despite its confirmed use. Additional inaccuracies included incorrect documentation of urinary catheter use, restraint use, and medication classification, highlighting a pattern of incomplete MDS documentation.
The facility failed to provide restorative nursing programs for several residents, including those with severe cognitive impairment, contractures, and functional limitations. Observations revealed that residents did not receive necessary range of motion exercises or splints, despite recommendations from the therapy department. Staff were unaware of any restorative programs, and the facility lacked a system for routine screening to identify residents who would benefit from such programs.
A resident with a history of falls and intact cognition experienced multiple falls without the care plan being updated for specific incidents. Despite having interventions like a chair alarm and physical therapy consults, the care plan lacked updates for falls on two occasions. Staff interviews confirmed that fall investigations and care plan updates were required but not completed, leading to a deficiency in care planning.
The facility failed to ensure resident safety by not placing a fall mat as required for a resident with severe cognitive impairment and by allowing a single staff member to transfer another resident with a mechanical lift, contrary to policy. These actions led to deficiencies in care and potential safety risks.
A facility failed to follow a Consultant Pharmacist's recommendation to conduct an AIMS assessment for a resident on Risperidone, an antipsychotic medication. Despite the resident's history of traumatic brain injury and behaviors like yelling and hitting, the required assessment was not completed in a timely manner, contrary to facility policy. This oversight was confirmed by the Administrative Nurse, highlighting a lapse in adherence to established procedures.
The facility failed to administer medications as ordered for two residents. One resident did not receive Tramadol for seven days due to unavailability, and the facility did not notify the physician or use the emergency kit. Another resident missed a dose of Aspart insulin because it was not available, and the facility did not follow its policy to notify the physician. These failures placed residents at risk for additional medical problems.
A cognitively impaired resident with a history of elopement risk was able to leave the facility unsupervised due to malfunctioning door locks and a failed WanderGuard system. The resident, who was upset and voicing a desire to go home, was found and returned by a neighbor 14 minutes later. Staff were unaware of the elopement until the resident's return.
Resident Fall From Mechanical Lift Due to Inadequate Sling Security and Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident remained free from accident hazards and received adequate supervision during a mechanical lift transfer, resulting in a fall and head injury. The resident had significant medical conditions including DM2, prior stroke with hemiparesis and hemiplegia affecting the right dominant side, and a malignant brain neoplasm. The resident’s MDS documented moderately impaired cognition, dependence on staff for all care and transfers, and use of a wheelchair for locomotion. The care plan identified the resident as at risk for falls due to stroke-related deficits and required staff assistance with all transfers, specifying use of a total mechanical lift with two staff and a large sling, with staff ensuring proper positioning in the sling before bearing weight. On the morning of the incident, two staff (a CNA and a CMA) were transferring the resident from bed to wheelchair using a full-body mechanical lift. The CNA reported standing close to the resident while the CMA operated the lift controls. After the resident was lifted off the bed, the lift was pulled away from the bed to make room for the wheelchair. The CNA turned away to get the wheelchair and then heard the CMA scream; when she turned back, the resident was partially hanging from the lift with feet in the air and head on the ground, with only two sling loops still attached. The CMA reported that when the CNA let go of the resident and turned to get the wheelchair, the resident rolled to the side in the sling, the sling became partially undone, and the resident fell, striking the back of the head on a leg of the lift. The CMA recalled that three of the four sling loops remained connected after the fall. The nurse who responded found the resident on the floor between the legs of the lift and documented two hematomas on the back of the resident’s head. The facility’s equipment and documentation further contributed to the deficiency. Observation of the full-body lifts in service showed that the hook assemblies used to attach sling loops lacked any mechanism to prevent sling loops from unintentionally coming loose during transfers. The facility’s Safe Resident Handling Program policy required caregivers to perform a “TIME OUT” safety stop while the resident was still over the bed or chair surface, with straps taut, to ensure the straps were secure before moving away from the surface. Administrative staff stated that staff were expected to pause for approximately 30 seconds after lifting the resident free of the surface to double-check that sling loops had not come undone before proceeding with the transfer. The fall report and Fall Scene Huddle Worksheet for this incident did not contain evidence that an investigation was performed or that a root cause of the fall was identified, and there was no documented determination of why the sling loops became detached during the transfer.
Failure to Prevent Resident Access to Hazardous Items Resulting in Fire
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment free from accident hazards, resulting in a cognitively impaired resident starting a fire in her room using a cigarette lighter. The resident, who had a history of dementia with behavioral disturbances, confusion, and impaired cognitive function, was able to access and retain multiple lighters in her room. Despite care plans indicating the need for supervision and the use of a WanderGuard due to elopement risk, the resident was left unsupervised in her room, where she ignited her recliner, triggering the facility's smoke alarm. Staff discovered the fire after noticing a glare from the resident's room. Upon entering, they found the resident in her wheelchair next to the burning recliner. The fire was extinguished by CNAs with the assistance of a resident's representative, and all residents were evacuated from the building. Subsequent inspection of the resident's room revealed not only multiple lighters but also various items belonging to other residents, including medical equipment and scissors, indicating a lack of effective monitoring of potentially hazardous items. Interviews and documentation confirmed that the resident had a history of confusion, hallucinations, and delusions, and her cognitive assessments fluctuated from intact to severely impaired. Staff and administrative interviews indicated that the facility was unaware of how the resident obtained the lighters and that there was no effective system in place to prevent unsafe items from entering resident rooms. The failure to supervise the resident and control access to hazardous items directly led to the fire and placed all residents in immediate jeopardy.
Deficiencies in Call Light Response and Abuse Allegation Handling
Penalty
Summary
The facility failed to ensure the proper functioning of the call light system, which resulted in significant delays in response times to residents' needs. Multiple residents reported issues with call light response times, and observations confirmed extended delays, such as a 42-minute response time for one resident. The facility had been aware of the call light system issues for months but did not have adequate measures in place to monitor and address the problem, as evidenced by the absence of staff at the nurses' station to watch the call light system. Additionally, the facility did not appropriately respond to allegations of abuse. One resident had a large bruise across her chest, which was reported to be caused by improper use of a gait belt. However, there was no investigation or documentation of the incident, and the facility failed to educate staff on proper handling to prevent such occurrences. Another resident reported a sexual assault by two men in the facility, but the facility did not investigate the allegation, notify law enforcement, or take steps to protect the resident from further abuse. The facility's failure to address these issues placed residents at risk for neglect and abuse, impacting their physical, mental, and psychosocial well-being. The lack of timely response to call lights and inadequate handling of abuse allegations demonstrated a significant deficiency in the facility's ability to provide a safe and responsive environment for its residents.
Failure to Report and Investigate Sexual Assault Allegation
Penalty
Summary
The facility failed to report and investigate an allegation of sexual assault made by a resident, identified as R17, who was cognitively intact but dependent on care. R17 reported being sexually assaulted by two male perpetrators within the facility on a specific date. Despite the resident's report of bruises and bite marks, the nursing staff did not respond appropriately, failing to assess her for injuries or report the incident to the necessary authorities. The resident later reported the assault to hospital staff during a visit for chest pain, and the hospital notified the facility of the allegation, but the facility still did not take action. The facility's records, including the Electronic Medical Record (EMR) Progress Notes, indicated that R17 had reported the assault to the facility staff, but no investigation was initiated, and law enforcement was not notified until much later when the resident reported the incident to a surveyor. The facility's grievance log did not document any allegations of abuse or neglect regarding R17, and interviews with staff revealed a lack of awareness and education on handling such allegations. The facility's policy required immediate reporting and investigation of abuse allegations, but this was not followed. The failure to act on R17's allegations of sexual assault placed her in immediate jeopardy and at risk for further harm. The facility did not protect the resident or ensure her safety, as required by their policy. The lack of response and investigation into the allegations of abuse was a significant deficiency, as it compromised the resident's physical, mental, and psychosocial well-being.
Failure to Investigate and Report Sexual Assault Allegations
Penalty
Summary
The facility failed to thoroughly investigate and respond to allegations of sexual assault made by a resident, identified as R17. R17, who was cognitively intact but dependent, reported being sexually assaulted by two male perpetrators on multiple occasions. Despite the resident's report of bruises and bite marks, the facility did not conduct a proper investigation or notify law enforcement until the issue was brought to light by a surveyor. The resident's allegations were initially reported to the facility on 05/16/24, and again during a hospital visit on 05/24/24, but the facility did not take appropriate action. R17's medical records indicated a history of traumatic subdural hemorrhage, anxiety disorder, and other conditions requiring assistance with personal care. The resident had a BIMS score indicating intact cognition and had reported feelings of depression and social isolation. Despite these vulnerabilities, the facility did not adequately protect R17 from potential further abuse or investigate the claims. The facility's failure to act on the resident's allegations was compounded by a lack of documentation in the grievance log and a breakdown in communication among staff members. Interviews with facility staff revealed a lack of awareness and education regarding the handling of abuse allegations. The facility's policy required immediate reporting and investigation of such allegations, but this was not followed. The Director of Nursing, Social Services Designee, and other staff members failed to take necessary steps to ensure the resident's safety and well-being, resulting in a significant oversight that placed the resident in immediate jeopardy.
Failure to Respond to Resident's Allegations of Sexual Assault
Penalty
Summary
The facility failed to appropriately respond to a resident's allegations of sexual assault, which were reported on multiple occasions. The resident, who had a history of traumatic subdural hemorrhage and anxiety disorder, reported feeling down, depressed, and isolated. She also experienced hallucinations and delusions. Despite these symptoms and her report of sexual assault, the facility did not take immediate action to investigate or report the allegations to law enforcement. The resident expressed feelings of fear, anger, and aggressiveness, which were consistent with a trauma response. The resident first reported the assault to facility staff on May 16, 2024, stating that two men had sexually assaulted her in the facility. She described having bruises and bite marks, but the facility's nurse did not find any injuries during a skin assessment. The facility's records show that the resident reported the assault again during a hospital visit on May 24, 2024, and upon her return to the facility on May 29, 2024. Despite these reports, the facility did not document the allegations in their grievance log, nor did they initiate an investigation or notify law enforcement until July 16, 2024, when the resident reported the incident to a state agency surveyor. Interviews with facility staff revealed a lack of awareness and action regarding the resident's allegations. The new administrator, who started on June 10, 2024, was not informed of the allegations until July 17, 2024. The facility's policy required immediate reporting and investigation of abuse allegations, but this was not followed. The facility's failure to respond to the resident's allegations of abuse on three different occasions placed the resident in immediate jeopardy and at risk for untreated trauma.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner, which could potentially lead to food-borne illness among residents. During observations of the kitchen and food storage areas, several issues were identified. A sealed 5-pound bag of cake mix was found without an open date, and a bag of corn bread mix was unsealed. The refrigerator outside the kitchen contained opened containers of orange juice, milk, and chocolate milk, all lacking open dates. Additionally, three frying pans and six cutting boards were found with scratches, and both kitchen ovens had burnt substances on the bottom. The chest freezer contained ice cream with removed lids and freezer-burned cups, as well as an open, undated bag of barbecued pork and a ten-pound bag of frozen vegetables. Dietary Staff BB confirmed these concerns and acknowledged that the undated items were unacceptable. The facility's policy required opened or prepared food to be placed in enclosed containers, dated, labeled, and stored properly, which was not adhered to in this instance.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, the facility's Payroll Base Journal (PBJ) Staffing Data Report for fiscal year Quarter 3, 2023, showed a lack of licensed nurse coverage for 24 hours a day, seven days a week on several specific dates. Additionally, the PBJ reports for subsequent quarters indicated excessively low weekend staffing, despite daily staffing sheets showing equal staffing levels on weekends and weekdays. This discrepancy was confirmed by Administrative Nurse D, who reported that the Administrator compiles and transmits the staff hours to CMS. The facility did not have a policy in place to ensure the accuracy of the PBJ submissions. The report highlights that the facility's failure to provide accurate staffing data included information for agency and contract staff, which should be based on payroll and other verifiable and auditable data in a uniform format as specified by CMS. The facility reported a census of 37 residents at the time of the survey, but the inaccurate staffing data submission could potentially impact the quality of care provided to these residents.
Multiple Deficiencies and Immediate Jeopardy in Facility Care
Penalty
Summary
The facility was found to have multiple deficiencies during the recertification survey, including four Immediate Jeopardy (IJ) citations, which indicated substandard quality of care. These deficiencies were not identified by the facility's Quality Assurance and Performance Improvement (QAPI) program, affecting all 37 residents. The surveyors discovered issues such as abuse, lack of reporting and investigating abuse allegations, and failure to protect residents from further abuse. Additionally, the facility did not recognize significant changes in residents' conditions, failed to complete required assessments, and did not develop comprehensive care plans. The survey revealed that the facility failed to provide necessary care and services to maintain residents' well-being. Specific incidents included the failure to revise fall care plans, provide scheduled pain medication, and respond to pharmacist recommendations. The facility also did not ensure a safe environment, as evidenced by improper use of mechanical lifts and failure to document fall prevention measures. Furthermore, the facility did not serve food under sanitary conditions, potentially leading to foodborne illnesses. The facility's administration was ineffective in identifying and addressing quality deficiencies, as evidenced by inaccurate reporting of staffing information and failure to maintain corrective measures from previous surveys. The lack of an effective QAPI program resulted in continued substandard care, placing all residents at risk for decreased quality of life and well-being.
Ineffective Administration and Resource Management
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, compromising the quality of care and well-being of its residents. Key deficiencies included the lack of an effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by multiple deficient practices and substandard quality of care. The facility did not ensure staff appropriately identified and responded to allegations of abuse, including a resident's report of sexual assault, and failed to report these allegations to the State Agency or local law enforcement as required. Additionally, the facility did not investigate all allegations of resident-to-resident abuse or protect residents from further incidents. There was also a failure to recognize significant changes in residents' conditions and perform timely assessments, which could lead to uncommunicated needs and further deterioration of residents' well-being. The facility's administration was ineffective in developing comprehensive, person-centered care plans and revising fall care plans with necessary interventions. It failed to provide necessary care and services to maintain residents' highest practicable well-being, including issues related to the Restorative Nursing Program and safe transfer procedures. The facility did not provide scheduled pain medication as ordered, respond to pharmacist recommendations, or serve food under sanitary conditions. Furthermore, the facility failed to accurately report staffing information to CMS, which included incorrect reporting of RN coverage. These deficiencies placed residents at risk for decreased quality of care, treatment, and overall well-being.
Failure to Capture Significant Change in Resident's Condition
Penalty
Summary
The facility failed to identify and document a significant change in condition for a resident, who experienced a decline in activities of daily living (ADLs) and an increase in behavioral issues. The resident, who had a history of hemiplegia, hemiparesis, traumatic brain injury, and severely impaired cognition, showed a marked decline in functional abilities between assessments. Initially, the resident required supervision for eating and oral care, moderate assistance with ADLs, and maximal assistance with transfers and personal hygiene. However, by the next assessment, the resident required total dependence on staff for most ADLs and exhibited increased behaviors such as yelling and hitting. Despite these changes, the facility did not capture this significant change in the resident's condition, as evidenced by the lack of a policy for Minimum Data Set (MDS) completion and reliance on the Resident Assessment Instrument (RAI) manual. The resident's behaviors were documented in progress notes, indicating frequent mood behaviors and difficulty in redirection by staff. The failure to recognize and document these changes had the potential to negatively impact the resident's physical, mental, and psychosocial well-being.
Inaccurate MDS Documentation Leads to Uncommunicated Care Needs
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for several residents, leading to uncommunicated care needs. For one resident, the MDS did not reflect the use of a chair alarm, despite documentation in the care plan and physician orders indicating its necessity due to frequent falls. The resident had a history of falls and was found on the floor on multiple occasions, yet the MDS section for alarms was not completed correctly. Interviews with staff confirmed the presence of the alarm, but the facility lacked a specific policy for MDS completion, relying instead on the Resident Assessment Instrument (RAI) manual. Another resident's MDS inaccurately documented the absence of a personal alarm, despite observations and staff interviews confirming its use for several months. The resident had severe cognitive impairment and required significant assistance with activities of daily living. The care plan, physician orders, and progress notes did not mention the alarm, and the MDS was not updated to reflect its use. This oversight was acknowledged by administrative staff, who again cited reliance on the RAI manual for MDS completion. Additional inaccuracies were found in the MDS for other residents, including incorrect documentation of urinary catheter use and restraint use. One resident's MDS inaccurately indicated the use of multiple types of catheters, while another resident's MDS incorrectly noted the use of physical restraints, which the resident denied. Furthermore, a resident receiving antipsychotic medication was not accurately documented in the MDS, with the medication being misclassified. These errors highlight a pattern of incomplete and inaccurate MDS documentation, which could lead to unmet care needs for the residents.
Failure to Provide Restorative Nursing Programs
Penalty
Summary
The facility failed to provide appropriate restorative nursing programs for several residents, leading to deficiencies in maintaining or improving their range of motion and mobility. Resident 4, who had severe cognitive impairment and functional limitations due to hemiplegia and osteoporosis, did not receive therapy or restorative nursing programs. Observations revealed that the resident was not provided with passive range of motion exercises or the necessary splints to prevent contractures, despite recommendations from the therapy department. The restorative aide confirmed that no routine restorative nursing programs were being provided due to time constraints and lack of assessments. Similarly, Resident 11, who had severe cognitive impairment and a stage four pressure ulcer, did not receive the necessary restorative nursing care to prevent worsening contractures. The resident's care plan included interventions for contractures, but observations showed that no range of motion exercises or splints were applied during care. Staff members were unaware of any restorative nursing programs, and the facility lacked a system for routine screening to identify residents who would benefit from such programs. Resident 29, with a history of cerebral infarction and traumatic brain injury, also did not receive restorative nursing programs despite having functional limitations in range of motion. Observations indicated that the resident did not receive exercises or assistance with range of motion during meals. The facility's policy on restorative nursing care was not implemented, and the therapy department's recommendations for continued restorative services were not followed. Additionally, Resident 8, who had dementia and contractures in both lower extremities, did not receive a restorative nursing program to prevent further decline, as recommended by the therapy department. The facility's failure to provide these services placed residents at risk for further decline and discomfort.
Failure to Update Care Plan After Resident Falls
Penalty
Summary
The facility failed to accurately update the care plan for a resident, identified as R7, following multiple falls. R7's electronic health record indicated a history of falls, along with diagnoses of metabolic encephalopathy, muscle weakness, anxiety disorder, and intact cognition. Despite these conditions, the care plan lacked interventions for falls that occurred on January 26, 2024, and April 15, 2024. The care plan did include some interventions, such as the use of a chair alarm and physical therapy consults, but these were not updated following the aforementioned falls. The facility's policy required documentation for any necessary updates to the care plan, which was not adhered to in this case. The report detailed several incidents where R7 was found on the floor, including falls in the bathroom, room, and whirlpool room, with varying degrees of injury. Interviews with staff revealed that a fall investigation should be conducted after each incident, and the care plan should be updated accordingly. However, it was confirmed that the care plan lacked interventions for specific falls, placing the resident at risk for uncommunicated care needs. The facility's failure to update the care plan as required by their policy and state regulations led to this deficiency.
Deficiencies in Resident Safety and Transfer Protocols
Penalty
Summary
The facility failed to maintain an environment free from accident hazards for two residents, leading to deficiencies in care. For one resident, who had severe cognitive impairment and required maximal assistance with activities of daily living, the facility did not consistently place a fall mat next to the resident's bed as per the care plan. On one occasion, the resident was found on the floor next to the bed, with the fall mat improperly placed by the window. A Certified Nurse Aide admitted to forgetting to place the mat, which was a required safety intervention documented in the care plan. Another deficiency involved the unsafe transfer of a resident with severe cognitive impairment and a cerebral aneurysm. The resident's care plan required a total lift transfer with two-person assistance. However, a Certified Nurse Aide transferred the resident alone using a full body mechanical lift, contrary to the facility's policy that mandates two staff members for such transfers. The aide acknowledged the breach, citing the unavailability of other aides at the time. These incidents highlight the facility's failure to adhere to established care plans and policies, potentially compromising resident safety. The lack of proper execution of safety interventions and adherence to transfer protocols were directly observed and reported by staff, indicating lapses in following prescribed procedures for resident care.
Failure to Conduct Timely AIMS Assessment for Resident on Antipsychotic
Penalty
Summary
The facility failed to adhere to the Consultant Pharmacist's recommendations regarding the completion of an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident receiving Risperidone, an antipsychotic medication. The resident, who had a history of traumatic brain injury and exhibited behaviors such as yelling and hitting, was prescribed Risperidone to manage these behaviors. Despite the Consultant Pharmacist's recommendations on multiple occasions to conduct an AIMS assessment to monitor for tardive dyskinesia, a potential side effect of Risperidone, the facility did not complete the assessment in a timely manner. The resident's medical records indicated severely impaired cognition and a history of behaviors that warranted the use of antipsychotic medication. The facility's policy required an AIMS assessment to be conducted every six months, but the assessments were overlooked, as confirmed by the Administrative Nurse. This oversight was contrary to the facility's policy and the Consultant Pharmacist's recommendations, potentially impacting the resident's well-being.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure that two residents received their medications as ordered by their physicians. Resident 8, who has diagnoses including dementia and osteoarthritis, did not receive their prescribed Tramadol for seven days. The medication was not available, and the facility staff failed to notify the physician or obtain the medication from the emergency kit. The resident's electronic health record and medication administration record indicated that the medication was unavailable on multiple occasions, and the facility was unable to locate the narcotic sign-off record for the missing dates. Resident 16, diagnosed with diabetes mellitus and altered mental status, did not receive their prescribed Aspart insulin on one occasion. The facility staff documented that the medication was not available, and the insulin was not administered as per the sliding scale orders. The facility's policy required that if a medication is not available for 24 hours, the physician must be notified, but this was not done in a timely manner. The facility's failure to administer medications as ordered placed both residents at risk for additional medical problems. The facility's policies on medication administration and ordering from the pharmacy were not followed, leading to these deficiencies. The lack of communication and failure to utilize the emergency kit contributed to the residents not receiving their necessary medications.
Failure to Prevent Elopement of Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide adequate supervision and a safe environment for a cognitively impaired resident identified as an elopement risk. The resident, who had diagnoses of Alzheimer's disease, altered mental status, restlessness, agitation, and dementia, was left unsupervised near the front entrance despite being upset and voicing a desire to go home. The front doors, which were known to be malfunctioning and did not require a code to open, allowed the resident to exit the facility without staff awareness. Additionally, the WanderGuard system, which was supposed to alert staff when the resident approached the exit, failed to alarm. The resident was found and returned to the facility by a neighbor 14 minutes later, uninjured but without staff knowledge of her elopement until her return. The resident's medical records and care plan indicated that she had severe cognitive impairment, used a wheelchair for mobility, and was at risk for elopement. The care plan included the use of a WanderGuard bracelet to alert staff to her movements near exit doors and required staff to check the WanderGuard daily. Despite these measures, the resident was able to leave the facility due to the malfunctioning door lock and the failure of the WanderGuard system. Staff interviews revealed that the resident had been upset and crying throughout the day, asking to go home, and was last seen by staff shortly before her elopement. Maintenance staff confirmed that the WanderGuard system and door locks had been checked and were reported to be functioning properly prior to the incident. Observations and interviews with staff indicated that the resident had been left unsupervised near the front entrance, and staff were unaware of her elopement until she was brought back by a neighbor. The facility's policy on elopement required measures to minimize the risk of elopement, but these measures were not effectively implemented in this case. The failure to provide adequate supervision and a safe environment for the resident, who was known to be an elopement risk, resulted in her leaving the facility without staff knowledge and placed her in immediate jeopardy.
Latest citations in Kansas
Surveyors identified unsanitary food storage and preparation conditions, including food debris in a reach-in freezer, an unknown spilled liquid in a reach-in refrigerator, missing two-inch air gap on an ice machine drain, dirty carts used for clean dishes, and a steamtable shelf with built-up food debris. A dietary staff member acknowledged these areas needed cleaning, and it was determined the facility lacked a cleaning schedule or policy for kitchen cleanliness.
The facility failed to complete and analyze Care Area Assessments (CAAs) for multiple residents after Admission, Annual, and Significant Change MDS assessments triggered areas such as cognition, mood/behavior, functional status, urinary incontinence/indwelling catheter, nutrition, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, and visual function. Instead of documenting individualized analysis of underlying causes and contributing factors, an LPN reported she had stopped writing CAA notes and relied mainly on check-off worksheets and the fact that triggers appeared in the MDS CAA section. No facility policy on CAAs was provided to surveyors, and the CAAs consistently lacked required analytical documentation for residents with diverse and significant clinical needs.
A resident with dementia, severe cognitive impairment, and an indwelling urinary catheter was repeatedly observed sitting in common areas with his catheter drainage bag resting on his lower leg, visibly filled with dark amber urine and lacking a privacy cover, despite a care plan directing staff to cover the drainage bag. CNAs reported that the bag often slid down from the resident’s thigh, that they did not use catheter dignity bags on their hall, and that they simply moved the bag back up when it slid down. An administrative nurse stated she had not considered the use of dignity bags on the memory care unit, even though the facility’s resident rights policy affirms each resident’s right to a dignified existence, privacy, and confidentiality.
Two residents with documented cognitive ability to participate in care planning were not invited to any care plan meetings, and their EMRs lacked evidence of care plan conferences, invitations, or Interdisciplinary Care Conference assessments. Administrative staff stated that invitations should be mailed or hand-delivered and uploaded to the EMR, and that an Interdisciplinary Care Conference note should be completed, but none of this documentation existed for these residents, contrary to facility policy and federal requirements for resident and/or representative participation in care planning.
A resident with C-diff and CHF, newly admitted and with a baseline care plan that did not address call light use, was repeatedly found without access to a call light. Surveyors observed the resident yelling for help with her room door closed and later noted the call light on the floor under the bed and again on the floor while the resident sat in a recliner and stated she wanted to return to bed but could not do so independently. Staff reported using a binder clip to attach the call light to the resident’s clothing because the cord lacked a clip, acknowledged the resident sometimes threw the call light to the floor, and stated that call lights should be kept within residents’ reach. An administrative nurse confirmed the expectation that call lights be accessible at all times and was unsure about the use of a binder clip, and no facility policy on call lights was provided.
Surveyors found that a resident’s bathroom and handwashing area were not maintained in a safe, sanitary, and comfortable condition, including a loose baseboard with black substance behind it, a cracked toilet seat, and an empty, improperly mounted hand soap dispenser. Maintenance staff confirmed these conditions, noted that the soap dispenser was nonfunctional, and reported that although a QR code system existed for reporting maintenance issues, these problems had not been reported. Maintenance staff also stated there were no facility policies for maintenance repair in resident rooms and no policy provided for ensuring a safe, homelike environment.
Multiple residents were affected by inaccurate MDS assessments, including a resident with dementia and an indwelling catheter who was miscoded as always incontinent of urine and independent in ADLs despite staff and EMR documentation showing long-term catheter use and total dependence for dressing and wheelchair positioning. Another resident with a history of stroke was incorrectly coded as having a restraint, even though bed grab bars were used as enablers to assist with repositioning and did not limit voluntary movement. A resident with diabetes and unsteadiness experienced two documented falls that were not captured on the MDS, and another resident with diabetes, depression, CAD, and CKD was actively receiving hospice services per EMR, social services, and staff interviews, yet hospice was not coded on the MDS. The consultant MDS nurse confirmed these were significant coding errors not in accordance with the RAI User’s Manual.
A resident with C. diff and CHF was admitted, and while a baseline care plan documenting contact precautions was created, the resident later reported not knowing what a baseline care plan was. The resident was also found yelling for help with her call light on the floor under the bed. Nursing staff stated that baseline care plans are started on the day of admission and reviewed with residents, but also indicated that residents and families are not given written copies. An administrative nurse claimed a 48-hour interdisciplinary care conference had been completed, yet no corresponding documentation existed in the EMR, and explanations about who was responsible and why it was missing were inconsistent. No facility policy for baseline care plans was provided.
A resident with dementia and severe cognitive impairment was inaccurately assessed and care planned as needing only setup or independent assistance with dressing, despite actually requiring total staff assistance. The EMR lacked clear ADL documentation, and the ADL CAA did not trigger, leading to inaccurate MDS entries and a care plan that did not match the resident’s functional status. Surveyors observed the resident sitting in a wheelchair wearing dirty, food-stained pants and being taken to the dining room without a clothing change, with the soiled pants not changed until later when two CNAs provided total assistance. Staff, including CNAs, an LN, and an administrative nurse, acknowledged that the resident needed total help with dressing and should always be in clean clothing, revealing a failure to provide appropriate ADL support and maintain clean attire.
A resident with dementia and severe cognitive impairment was transported multiple times in a wheelchair without staff ensuring that his feet remained safely on the foot pedals. Although assessments inaccurately documented that he was independent with walking using a walker and/or wheelchair, his care plan did not instruct staff on proper use of wheelchair foot pedals. During observed transports by CNAs, the resident’s shoed feet repeatedly fell off the pedals and skimmed the floor between them. Staff acknowledged that his feet did not stay on the pedals and that the pedals were not effectively adjusted, and nursing leadership confirmed expectations that feet should remain on the pedals during transport. No wheelchair safety policy was provided.
Unsanitary Kitchen Conditions and Lack of Cleaning Policy
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions when surveyors observed multiple cleanliness and equipment issues in the kitchen. During an initial kitchen tour on 04/27/26 at 08:57 AM, the three-door reach-in freezer was found with food debris on the bottom shelf, and the three-door reach-in refrigerator had an unknown spilled liquid on the bottom shelf. The drain to the ice machine did not have the required two-inch air gap. Two black two-tiered plastic carts used to store clean dishes had food debris on the bottom tier, and the bottom shelf of the steamtable, which was used to store plate covers, had a buildup of food debris. On 04/28/26 at 01:57 PM, a dietary staff member confirmed these areas required cleaning, and it was identified that the facility did not have a cleaning schedule or a policy regarding kitchen cleanliness. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Complete and Analyze Care Area Assessments for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to complete comprehensive Care Area Assessments (CAAs) with analysis of underlying causes, contributing factors, and risk factors for multiple residents following MDS assessments. Record review showed that numerous residents had Admission, Annual, or Significant Change MDS assessments that triggered CAAs in areas such as mood/behavior, cognitive loss/dementia, functional abilities, communication, urinary incontinence/indwelling catheter, nutritional status, dental care, pressure ulcers, pain, falls, psychotropic drug use, psychosocial well-being, visual function, and psychosocial well-being. For each of these triggered areas, the corresponding CAAs lacked analysis of the findings. This pattern was identified for residents with a wide range of clinical issues, including dementia, incontinence, falls, pressure ulcers, nutritional concerns, psychotropic medication use, pain, and functional decline. During an interview, a licensed nurse reported that she had stopped writing CAA notes the previous year after being told to do so by someone she could not identify. She stated that she did not write anything on the triggered CAAs and that, at times, she would document risk concerns only on a main check-off worksheet, relying on the fact that the triggers were already reflected in the MDS CAA section. The facility did not provide a policy regarding CAAs when requested. These findings demonstrate that the facility did not ensure that comprehensive assessments were fully completed as required when residents were first admitted and periodically thereafter.
Failure to Maintain Dignity and Privacy for Resident with Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to a dignified existence by not maintaining privacy for his urinary catheter drainage bag as directed in his care plan. The resident had diagnoses including bladder calculus and dementia, with a BIMS score of one indicating severe cognitive impairment, and was dependent on staff for toileting hygiene with an indwelling urinary catheter and constant urinary incontinence. His care plan, revised 03/23/26, instructed staff to cover his drainage bag with a privacy cover. However, during observations on 04/27/26, the resident was seen sitting in his wheelchair at his room doorway and later in the dining room with his catheter drainage bag resting on his lower left leg, supported by his shoe, containing dark amber urine and visible to visitors and other residents, without a privacy cover. Staff interviews confirmed that the catheter drainage bag frequently slid from the resident’s left thigh down to his lower leg and that staff did not consistently reposition it or use dignity/privacy bags. One CNA stated he had never placed a dignity bag on the resident’s drainage bag, and another CNA reported that staff on their hall did not utilize catheter dignity bags, instead just moving the bag back up when it slid down. An administrative nurse acknowledged she had not considered staff use of dignity bags for urinary catheters on the memory care unit. The facility’s Resident Rights policy, approved 12/2024, stated that each resident has the right to a dignified existence including privacy and confidentiality, which was not followed in this case.
Failure to Involve Cognitively Able Residents in Care Plan Meetings
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were given the opportunity to participate in the development and implementation of their person-centered plans of care. For one resident with a Brief Interview of Mental Status (BIMS) score of 12, indicating moderately impaired cognition, the electronic medical record showed an admission MDS and a Significant Change MDS, but there was no documentation of any care plan meeting in the prior four months. This resident reported not being invited to any care plan meeting. For a second resident with a BIMS score of 14, indicating intact cognition, the electronic medical record contained an admission MDS and a Quarterly MDS, but there was no documentation of a care plan meeting in the prior two months. This resident also reported not being invited to any care plan meeting. Administrative staff reported that residents and/or family members were supposed to be mailed or hand-delivered invitations to attend care planning meetings and that a copy of the invitation should be uploaded into the EMR. They further stated that an Interdisciplinary Care Conference assessment should be completed in the EMR during the care plan meeting. However, the administrative nurse confirmed that there was no documentation of invitations, Interdisciplinary Care Conference assessments, or completed care plan meetings for the two residents. The facility’s care planning policy stated that social services should attend care plan meetings and that the team presents information to the resident and/or representative about progress toward care plan goals, and referenced federal law requiring resident and/or representative participation in care plan meetings to the extent possible, but this process was not carried out or documented for the two residents identified.
Failure to Keep Call Light Within Reach for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach and to reasonably accommodate the resident’s needs and preferences. The resident had documented diagnoses of C-diff and CHF, and her baseline care plan dated 04/23/26 directed staff to evaluate for changes in level of consciousness but did not include any direction regarding call light use or accessibility. On 04/28/26 at 08:06 AM, surveyors observed the resident’s room door closed while she yelled loudly for help several times. When a licensed nurse entered the room, the resident was lying on her left side in bed, stated she wanted to get up, and reported she could not find her call light. The call light was observed on the floor under her bed. Later that morning, a CNA attached the call light to the resident’s shirt using a black and silver binder clip because the call light cord did not have its own clip. On 04/29/26 at 12:15 PM, the resident was seated in a recliner with the call light again lying on the floor out of her reach; she reported she wanted to go to bed and could not get herself back into bed. Staff interviews revealed that the CNA used the binder clip to keep the call light attached to the resident, and the licensed nurse stated staff should make sure the call light is clipped to the resident’s clothes and reported that the resident would throw her call light on the floor. An administrative nurse stated she expected staff to ensure all residents always have their call lights in reach and was unsure about using a binder clip to hold a call light in place. The facility did not provide a policy regarding call lights.
Failure to Maintain Safe and Sanitary Resident Bathroom Environment
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, functional, sanitary, and comfortable environment in Resident 87’s bathroom and handwashing area. During an environmental tour with Maintenance Staff UU, surveyors observed an approximately four-foot section of loose baseboard to the left of and behind the toilet, with a black substance present on the wall and floor behind the loose baseboard. They also noted an approximately three-inch crack in the toilet seat and an empty hand soap dispenser hanging above the handwashing sink, mounted with exposed lag bolt fasteners. Maintenance Staff UU confirmed these conditions, acknowledged that the soap dispenser did not work, and stated that the toilet seat should be replaced, the bathroom baseboard removed, the black substance tested for mold, and the sheetrock removed and replaced. Further interview with Maintenance Staff UU revealed that the facility had implemented a QR code system for staff and visitors to report maintenance items, but the issues in this resident’s bathroom had not been reported through that system. He also reported that there had been a leak behind the handwashing sink that had flowed into the bathroom area, leading to the sink’s replacement, but he had received no report of the specific deficiencies observed in the bathroom. Additionally, Maintenance Staff UU stated that the facility did not have policies for maintenance repair in residents’ rooms, and the facility did not provide a policy for ensuring a safe, homelike environment.
Inaccurate MDS Coding for ADLs, Restraints, Falls, and Hospice Services
Penalty
Summary
The deficiency involves the facility’s failure to complete accurate Minimum Data Set (MDS) assessments in accordance with the Resident Assessment Instrument (RAI) User’s Manual, resulting in multiple residents’ clinical status not being correctly reflected. For one resident with dementia and severe cognitive impairment, the Significant Change and subsequent Quarterly MDS assessments coded him as always incontinent of bladder and independent with eating and upper body dressing, with use of a walker and wheelchair. However, the electronic medical record showed ongoing indwelling catheter care each shift and no documentation of walker use, wheelchair mobility, or dressing requirements during the review period. Staff interviews revealed that this resident had an indwelling catheter for more than a year, had not walked for several years, and was dependent on staff for all ADLs, including dressing and wheelchair positioning, contradicting the MDS coding. Observations showed the resident slumped in a wheelchair, wearing a hospital gown over clothing, with a visible catheter bag on his lower leg and feet frequently skimming the floor despite foot pedals being present, further indicating dependence and catheter use not accurately captured on the MDS. Another deficiency involved a resident with a history of stroke, hemiplegia, and hemiparesis whose Significant Change MDS coded the use of “other restraint.” During observation, the resident was seen in bed with bilateral grab bars at the head of the bed and her right arm positioned on a pillow. The resident reported using the grab bars to help move and reposition herself in bed. CNAs and administrative nursing staff confirmed that the facility did not use restraints and that the grab bars were used as enablers to assist residents with repositioning and to increase independence. Administrative staff acknowledged that the MDS coding for restraints was inaccurate because the grab bars did not limit the resident’s voluntary movement or access to her body. A further inaccuracy was identified for a resident with diabetes, atrial fibrillation, unsteadiness of feet, and a toe fracture. Both a Significant Change and a Quarterly MDS documented intact cognition, partial/moderate assistance with transfers, no ambulation, and no falls. However, progress notes in the EMR documented two unwitnessed falls during the look-back period, including one where the resident was found on the floor next to the bed with a forehead skin tear and another where the resident was found sitting on a fall mat on the floor with a scratch on the ankle. These documented falls were not reflected on the MDS. In addition, another resident with diabetes, depression, CAD, and chronic kidney disease had a Significant Change MDS that coded no hospice services, while the EMR contained a hospice certification and physician orders initiating hospice services, and social service notes and staff interviews confirmed that hospice services, including bathing by a hospice aide, were being provided during the look-back period. The consultant MDS nurse confirmed that these assessments were inaccurate and not completed in accordance with the RAI User’s Manual, constituting significant errors in coding for urinary status, ADL dependence, restraints, falls, and hospice services. The consultant MDS nurse stated that the resident with the indwelling catheter should have been coded as not rated for urinary continence due to catheter placement rather than as always incontinent, and that his ADL status should not have been coded as independent given his dependence on staff for dressing and wheelchair positioning. For the resident with grab bars, the nurse confirmed that the grab bars were used as enablers and not as restraints, making the restraint coding inaccurate. For the resident with documented falls, the MDS failed to capture falls that occurred within the look-back period, and for the resident receiving hospice services, the MDS did not reflect hospice care that was active during the look-back period. These miscodings met the RAI Manual’s definition of significant error, in which the resident’s overall clinical status is not accurately represented on the assessment and the error has not been corrected by a more recent assessment.
Failure to Provide and Communicate Baseline Care Plan to New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a summary of the baseline care plan to a newly admitted resident and to ensure that the baseline care plan process was completed and documented as required. The resident’s EMR documented diagnoses of C. difficile and CHF. The Entry MDS was completed on the admission date, and the admission MDS was noted as in progress with no information available. A baseline care plan dated the day after admission documented contact precautions, including staff use of gowns and masks when changing contaminated linens and proper handling and bagging of soiled linens. However, during an interview several days after admission, the resident reported she did not know what a baseline care plan was, indicating that the plan had not been explained or summarized to her. Further observations and interviews showed additional failures in implementing and communicating the baseline care plan. On one occasion, the resident was heard yelling for help with her room door closed; when a nurse entered, the resident stated she wanted to get up but could not find her call light, which was observed on the floor under the bed. A nurse reported that the baseline care plan was started on the day of admission and that nurses would review it with the resident, but also stated that the charge nurse would not provide a written copy of the baseline care plan to the resident or family. An administrative nurse reported she would review the baseline care plan with the resident and/or family and claimed to have completed a 48-hour interdisciplinary care conference, but there was no opened or completed conference note in the EMR. She gave inconsistent explanations regarding who was responsible and why the conference note was missing. The facility did not provide a policy for baseline care plans.
Failure to Provide Accurate ADL Assessment and Timely Clothing Changes
Penalty
Summary
The facility failed to provide appropriate assistance with activities of daily living (ADLs), specifically dressing and clothing changes, for a resident with severe cognitive impairment. The resident had a diagnosis of dementia and repeated Brief Interview for Mental Status (BIMS) scores of one, indicating severe cognitive impairment. Despite this, both a Significant Change MDS and a Quarterly MDS inaccurately documented that the resident required only setup assistance with lower body dressing. The ADL Care Area Assessment did not trigger, and the resident’s care plan, revised on 03/23/26, inaccurately instructed staff that the resident was independent with dressing. The electronic medical record lacked staff documentation of the resident’s ADL needs, resulting in care instructions that did not reflect the resident’s actual functional status. On the day of observation, the resident was seen sitting in a wheelchair wearing black pants with food crumbs on them in the morning, and later was transported by a CNA to the dining room still wearing the same dirty pants. The pants were not changed until early afternoon, at which time two CNAs provided total assistance to change the dirty pants, and the resident was unable to participate in dressing or undressing. During interviews, the CNAs, a licensed nurse, and an administrative nurse all stated that residents should always be dressed in clean clothing and confirmed that this resident required total staff assistance with dressing. These observations and interviews showed that the resident’s actual need for total assistance with dressing and clothing changes was not accurately reflected in the MDS, care plan, or ADL documentation, and that the facility did not ensure the resident was kept in clean clothing as expected by facility policy for ADL care.
Failure to Maintain Safe Wheelchair Foot Positioning During Resident Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision during wheelchair transport for a resident with dementia. The resident’s EMR documented a diagnosis of dementia and a BIMS score of one on both a Significant Change MDS and a Quarterly MDS, indicating severe cognitive impairment. These MDS assessments inaccurately documented that the resident was independent with walking using a walker and/or wheelchair, and the ADL CAA did not trigger. The resident’s care plan, revised 03/23/26, identified cognitive impairment due to dementia but did not include instructions for staff on the use of wheelchair foot pedals while propelling the resident. On multiple observed occasions, staff propelled the resident in a wheelchair without maintaining his feet safely on the foot pedals. During transport from his room to the dining room, the resident’s left shoed foot fell from the foot pedal and skimmed the floor between the pedals, and later, during transport from the dining room to the shower room, both shoed feet skimmed the floor between the pedals. CNAs reported that the resident’s feet never stayed on the foot pedals and described the pedals as useless because he could not keep his feet on them. A licensed nurse confirmed the resident’s feet did not always remain on the foot pedals when staff propelled him and stated the pedals should be adjusted to better fit his needs. An administrative nurse stated it was the expectation that staff ensure the resident’s feet remained on the foot pedals during transport and that pedals should be lowered if needed. The facility did not provide a policy regarding wheelchair safety.
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