Eastport Memorial Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Eastport, Maine.
- Location
- 23 Boynton Street, Eastport, Maine 04631
- CMS Provider Number
- 205146
- Inspections on file
- 20
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Eastport Memorial Nursing Home during CMS and state inspections, most recent first.
Poor housekeeping and maintenance were observed during environmental tours when flooring was peeled up in multiple areas near a room and the nurse's station, creating potential tripping hazards. In the laundry room, a dryer and connected tubing were heavily covered with dust, and in the kitchen, yellow and black tape was seen around the stove and other fixtures, which the FSD identified as an uncleanable surface.
A facility failed to incorporate PASRR Level II recommendations into one resident’s assessment and care plan and did not provide the required psychiatric, behavioral health, and supportive services identified in the PASRR. In a separate case, a resident with a new MH diagnosis did not have an updated PASRR referral submitted to the State mental health authority for a new Level II determination, and the MDS nurse confirmed the omission.
Failure to complete baseline care plans within 48 hours for two residents. One resident’s record showed no baseline care plan was developed after admission, and the DON confirmed it was not done. For another resident, the paper form labeled as the interim plan of care was incomplete, did not include the minimum care instructions needed, and there was no evidence the resident or resident representative was informed of or given a copy within 48 hours.
The facility failed to maintain its infection prevention and control program when a surveyor observed a soiled bed pan stored on the floor under a resident's bed. An LPN stated that bed pans are reused, washed, bagged, and should not be stored under a resident's bed, and the used bed pan was later observed and confirmed under the bed.
Failure to Monitor Antibiotic Use: The facility failed to implement its ASP, including antibiotic use protocols and a system to monitor antibiotic use for 2 reviewed months. The IP stated she could not provide evidence that antibiotic stewardship was completed because the pharmacist had the only copy, and she tracked only which residents were on antibiotics rather than culture and sensitivity results. She later confirmed she could not find evidence of antibiotic stewardship monitoring after checking multiple locations.
Failure to document influenza and pneumococcal vaccine offers. Record review and an interview with the IP showed that 4 of 5 residents reviewed had no evidence in the clinical record that they received, were offered, or refused the indicated flu or pneumococcal vaccines. The missing documentation included residents with CDC-recommended PCV series completion and one resident with no evidence of an influenza vaccine offer.
Incomplete CNA Training Records: An effective training program was not maintained because 5 of 5 CNAs reviewed lacked documentation of required in-service training, including topics such as abuse, neglect and exploitation, dementia, communication, IC, behavioral training, Resident Rights, and QAPI. During an interview, the Administrator stated she had not assigned all required trainings and was relying on the Health Care Academy list, which did not include several required topics.
Failure to maintain resident dignity and privacy during care. A resident was left without being boosted up in bed or having the HOB raised before beverages were offered, and the resident stated they had not been washed up and could not eat or drink without sitting up. For another resident, the curtain at the foot of the bed was not pulled during morning care, the resident was exposed from the waist down, and the door was repeatedly left open while staff entered and exited the room.
Failure to Complete Ordered PT Evaluation: A resident with a right-sided deficit reported staff did not assist with ROM exercises and said therapy was not allowed. The chart showed a physician order for in-house OT and PT, OT had been evaluated and was receiving services, but PT had not completed an eval or provided tx. The Charge Nurse and Administrator confirmed PT had not occurred, and the PT later said he thought the order was for OT only.
Failure to Offer Updated COVID-19 Vaccine: A resident's record showed admission to the facility, but there was no evidence that the updated COVID-19 vaccine had been offered, received, or refused. During record review and interview with the IP, the deficiency was confirmed.
The facility failed to maintain safe, unobstructed egress routes when two of three ground-floor exits were blocked by significant snow accumulation, leaving only an employee entrance cleared. Surveyors observed deep snow on the front walkways and ramps, while 25 residents would have needed to be moved either through locked doors and narrow corridors to the side employee entrance or through the snow-obstructed front exits. Two maintenance staff were seen performing other tasks, and the Administrator reported that she had instructed maintenance to clear the egresses, but this had not yet been done.
The facility failed to maintain a documented, routine program for inspecting bed frames, mattresses, and bed rails for safety and entrapment risks. Although a resident’s bed and four other beds with air mattresses and side rails were observed by the DON and found to have proper mattress fit and no unsafe gaps, the Maintenance Supervisor stated that while he measures and assesses beds for proper fit and entrapment hazards when placing new mattresses, he does not document these assessments and does not perform regular, scheduled safety checks of all beds.
A facility did not notify a resident's current legal representative about a change in representative status and a significant change in the medical plan of care. Another family member presented a revoked POA and requested end-of-life care, which was implemented without verifying the legal status or informing the designated representative. The DON confirmed the failure to contact the appropriate legal representative regarding these changes.
A resident identified as an elopement risk exited the facility on two occasions after staff failed to fully implement the care plan, which required one-on-one supervision during exit-seeking behaviors. Instead, staff only redirected the resident multiple times, and no one sat with the resident as directed, resulting in unwitnessed elopements.
A resident with a known history of wandering and identified as an elopement risk was able to exit the facility on two occasions due to staff failing to ensure exit alarms were functioning and not providing adequate supervision. In one instance, the resident left through a door with a malfunctioning alarm, and in another, the resident exited through an alarmed door but staff presence was insufficient to prevent the elopement. Facility policy regarding immediate notification of elopements was also not followed.
The facility employed an unqualified Activity Director (AD) to manage activities for 24 residents. The Administrator and the AD confirmed that the AD had not completed the State-approved program required for qualification. The AD is currently enrolled in the program to meet the necessary requirements.
The facility's quality assurance committee failed to implement and ensure the effectiveness of the Plan of Correction for deficiencies identified during a survey. These included issues with comprehensive assessments, care plan updates, quality of care, and accident hazards. The facility lacked evidence of staff education and monitoring activities. Additionally, an Elopement/Wandering policy was not established, and respiratory care and drug storage deficiencies were not addressed, leading to repeated findings during a revisit survey.
A facility failed to complete an annual Comprehensive MDS 3.0 assessment for a resident on hospice care. The resident's admission MDS was completed, and quarterly assessments were conducted, but an annual Comprehensive MDS was not done. The Interim DON acknowledged the oversight, noting it had been 592 days since the last Comprehensive assessment.
A facility failed to complete a significant change in status MDS 3.0 assessment within 14 days after a resident transitioned to hospice care. The Interim DON confirmed that the required assessment was not completed following the resident's change in condition.
A facility failed to develop a comprehensive care plan for a resident with heart failure and afib. The care plan did not include management strategies for these conditions or the use of anticoagulant medication. An interview with the Interim DON confirmed the care plan lacked provisions for monitoring heart failure and afib.
The facility failed to follow a doctor's order for daily weight checks for a resident with heart failure and did not appropriately address a pharmacist's recommendation regarding the timing of a psychotropic medication for another resident. The misunderstanding of the pharmacist's recommendation was later clarified, but initially, the PMHNP declined the suggestion, thinking it was a request for a dose reduction.
A resident identified as an elopement risk exited the facility unnoticed during a fire alarm when the wander guard system was disabled. The resident was outside for three minutes in bare feet on a snowy day before being brought back inside. The incident was confirmed through video surveillance, and staff interviews indicated a lack of door monitoring during the alarm.
The facility failed to maintain physician-ordered oxygen settings and ensure the cleanliness of respiratory equipment for two residents. A resident's oxygen concentrator was set incorrectly at 3.5 LPM instead of the ordered 2 LPM, and the equipment was soiled. Another resident's oxygen concentrator had a heavily soiled air intake filter. These issues were confirmed by an LPN.
A facility failed to remove an expired vial of Novolog insulin from the medication storage room. An LPN and a surveyor found the vial, which was still in use 16 days past its expiration date. The LPN confirmed the expiration and discarded the vial.
The facility's Water Management Program lacked necessary testing protocols to prevent Legionella and other waterborne pathogens. A review revealed no evidence of control measures, acceptable test ranges, or monitoring procedures. The Maintenance Supervisor confirmed the absence of a plan or protocol for testing and monitoring waterborne pathogens.
A resident with bilateral sensorineural hearing loss was not provided with a hearing aid daily, as required by physician orders. Despite staff education, the resident often lacked the hearing aids, impacting communication. A family member noted staff's lack of knowledge on using the aids, and the DON admitted to not placing the aid on a specific day, with no system in place to ensure daily use.
Poor Housekeeping and Maintenance in Common Areas
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to keep the building in good repair during two environmental tours. During the tour on 2/09/26 with the Administrator and DON, flooring was observed peeled up facing a room and to the right, at the threshold to the nurse's station and toward the left, and in front of another room, with each area identified as a potential tripping hazard. In the laundry room, the clothes dryer with an open back was heavily covered with dust inside the back and on top, and the metal tubing leading into the back of the second dryer was also covered with dust. During the initial and second kitchen tours on 2/9/26 and 2/10/26, yellow and black tape was observed on the floor around the stove and other kitchen fixtures, and the Food Service Director identified the area as an uncleanable surface.
PASRR Level II services and referral requirements not followed
Penalty
Summary
The facility failed to incorporate recommendations from a PASRR Level II determination and PASARR evaluation report into one resident’s assessment, care plan, and transitions of care, and failed to ensure the State mental health authority was notified after a resident was newly diagnosed with, or experienced symptoms related to, a mental disorder. For one resident, the PASRR Level II dated 6/2/25 stated the resident met Maine’s definition for serious mental illness due to schizophrenia, with intermittent functional limitations in interpersonal functioning, concentration, and adaptation to change, and noted that symptom onset and persistence caused significant distress and impairment in independent functioning. The PASRR Level II required ongoing psychiatric services by a psychiatrist to evaluate psychotropic medications and behavioral health needs, as well as rehabilitative services including socialization/leisure/recreation activities, family involvement in care, and supportive counseling from NF staff. During record review and interview with the MDS nurse, there was no evidence that these Level II services were included in the resident’s care plan or provided, and the MDS nurse stated the Mental Health Nurse Practitioner who sees other residents had not seen this resident. For a second resident, the clinical record showed a new mental health disorder diagnosis on 4/6/21, but there was no evidence of referral to the State mental health authority for a new PASRR Level II determination after the new qualifying diagnosis; the MDS nurse confirmed that an updated PASRR had not been submitted.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to ensure baseline care plans were developed and implemented within 48 hours of admission for 2 of 4 sampled residents, R12 and R15. For R15, the clinical record showed the resident was a recent admission, but there was no evidence that a baseline care plan was developed within 48 hours to direct staff on the resident’s care needs; the DON confirmed on 2/11/26 at 10:50 a.m. that a baseline care plan was not developed. For R12, surveyors were told the baseline care plan was kept in paper form in front of the clinical record, but the form labeled “Interim Plan of Care” was found incomplete and did not include the instructions needed to provide minimum healthcare information necessary to properly care for the resident. There was also no evidence in the clinical record that a baseline care plan was completed or that the resident or resident representative was informed of or provided a copy within 48 hours, and the surveyor confirmed these findings with the charge nurse LPN1 and RN2.
Infection Control Deficiency: Soiled Bed Pan Stored Under Resident Bed
Penalty
Summary
The facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for 2 of 3 days of survey. On 2/9/26 at 11:12 a.m., a surveyor observed a soiled bed pan stored on the floor under R3's bed. On 2/10/26 at 10:37 a.m., an LPN stated that bed pans are reused, washed, bagged, and should not be stored under a resident's bed. At 10:41 a.m., a surveyor and the LPN observed and confirmed that a used bed pan was stored under R3's bed.
Failure to Monitor Antibiotic Use
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program (ASP), including antibiotic use protocols and a system to monitor antibiotic use, for 2 of 2 months reviewed (December 2025 and January 2026). Review of the facility’s Antibiotic Stewardship policy, last revised 08/2024, stated that the Infection Preventionist (IP), or designee, would review antibiotic utilization as part of the ASP and identify situations not consistent with appropriate antibiotic use, including when the organism was not susceptible to the chosen antibiotic, when a narrower-spectrum antibiotic was appropriate, when therapy was ordered for prolonged surgical prophylaxis, or when therapy was started while awaiting culture results but culture and clinical findings did not support continued antibiotic use. The policy also stated that after review, the provider would be notified of the findings. During interview on 2/10/26, the IP stated she was unable to provide evidence that antibiotic stewardship had been completed because the pharmacist had taken the only copy. She stated that she tracked which residents were on antibiotics to ensure the order was placed correctly, but did not track culture and sensitivity results for the ASP. Later that day, the IP confirmed that after checking multiple locations, she still could not find evidence of antibiotic stewardship monitoring.
Failure to Document Influenza and Pneumococcal Vaccine Offers
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations. Based on record review, interview, and facility policy review, the facility failed to ensure residents were offered influenza and pneumococcal vaccinations in accordance with CDC recommendations for 4 of 5 residents reviewed for immunizations. Resident #2 was admitted on [DATE], and the clinical record lacked evidence that the resident had received, been offered, or refused a pneumococcal vaccination, despite the CDC recommendation to review, offer, and/or receive one dose of PCV15, PCV20, or PCV21 to complete the vaccine series. Resident #3 was admitted on [DATE], and the clinical record lacked evidence that the resident had received, been offered, or refused the influenza vaccination. Resident #5 was admitted on [DATE], and the clinical record lacked evidence that the resident had received, been offered, or refused a pneumococcal vaccination. Resident #10 was admitted on [DATE], and the clinical record lacked evidence that the resident had received, been offered, or refused a pneumococcal vaccination, although the CDC recommendation was based on shared clinical decision-making to administer one dose of PCV20 or PCV21 to complete the vaccine series. On 2/10/26 at 3:00 p.m., the surveyor and the Infection Preventionist reviewed the vaccine records and confirmed these findings.
Incomplete CNA Training Records
Penalty
Summary
An effective training program for all new and existing staff members was not maintained because 5 of 5 CNAs reviewed did not have evidence of completing required in-service trainings. CNA1’s record lacked documentation for dementia, behavioral, infection control (IC), communication, and Quality Assurance and Performance Improvement (QAPI) training. CNA2, CNA3, and CNA4 each lacked documentation for Abuse, Neglect and Exploitation, dementia, communication, IC, behavioral training, and QAPI. CNA5’s record lacked documentation for Abuse, Neglect and Exploitation, dementia, communication, IC, behavioral training, Resident Rights, and QAPI. During an interview and record review with the Administrator on 2/11/26 at 11:30 a.m., the missing and incomplete CNA trainings were reviewed. The Administrator stated she had not assigned all required trainings and was using the list in the Health Care Academy system, but was not aware additional trainings were needed. The surveyor confirmed the missing training documentation during the interview.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity during care for 2 of 2 residents reviewed for dignity, identified in the report as R10 and R3. For R10, a surveyor observed a CNA place the resident’s lunch tray on the bedside table and remove two beverages, including water and a brown drink. R10 told the CNA that another CNA had brought the beverages but had not boosted the resident up in bed or raised the head of the bed to allow drinking, and stated the resident still wanted the hot cocoa. R10 also complained that he or she had not been washed up and could not eat or drink without sitting up. When CNA3 later came to the room, CNA3 stated that R10 kept refusing care and would not let the CNA touch him or her, and said no one would take the resident when attempts were made to trade the assignment. For R3, during morning care, the curtain between the foot of the bed and the door was not pulled to provide privacy from the doorway. While R3 was exposed from the waist down, CNA6 pressed the call bell for the nurse and CNA5 left the room to find the nurse. Two additional staff opened the door and held it open to ask about the call bell, and the door was left open again when the LPN entered and later left to get supplies. The surveyor requested the curtain be pulled to protect R3’s privacy from the door, and the ADON later confirmed the findings.
Failure to Complete Ordered PT Evaluation
Penalty
Summary
The facility failed to follow a physician order for in-house PT for Resident #24, who was observed with a deficit on the right side and stated that staff did not help with ROM exercises and that he/she had been told therapy was not allowed in the facility. The clinical record showed a physician order dated 1/20/26 for in-house OT and PT for strengthening and behavioral modification. Therapy notes in a binder outside the Administrator’s office showed OT was evaluated on 1/20/26 and was to receive OT up to 16 times in 8 weeks, but PT notes showed no PT evaluation had been completed. During interviews, the Charge Nurse confirmed OT had been working with the resident but PT had not, and the Administrator confirmed PT evaluation and treatment had not occurred as of 2/10/26. PT later stated he did not complete the evaluation because he thought the order was for OT only and acknowledged the evaluation was not completed until 2/11/26.
Failure to Offer Updated COVID-19 Vaccine
Penalty
Summary
The facility failed to offer the updated COVID-19 vaccine for 1 of 5 residents reviewed, Resident #3. During record review and interview with the Infection Preventionist, the surveyor confirmed that the clinical record showed Resident #3 was admitted on [DATE], but there was no evidence in the record that the resident had received, been offered, or refused the updated COVID-19 vaccination.
Snow-Blocked Egresses Limit Safe Exit Routes
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards when two of three ground-floor egresses used by residents were blocked by snow and not easily passable. On the morning of 1/27/26 at 9:00 a.m., surveyors observed that the walkways to the two front entrance/egress doors were hindered by snow measuring approximately 15 inches at the street and approximately 4 to 6 inches on the walkways and ramps leading to these doors. The only walkway and door that had been shoveled free of snow was the employee entrance located at the left side of the building. To exit through the only unobstructed egress, the 25 current residents would have to be taken through one of two locked doors and navigated through narrow corridors to reach the side employee entrance, or alternatively attempt to exit through the front egresses that remained hindered by snow. During this time, two maintenance staff were observed inside the building performing other tasks. In an interview shortly after 9:00 a.m., the Administrator stated that she had asked the maintenance staff to clear the egresses of snow, but they had not yet done so.
Lack of Documented and Ongoing Bed Safety Inspections
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document regular inspections of all bed frames and mattresses as part of a maintenance program to ensure mattress–bed frame compatibility and identify areas of entrapment. During an observation of one resident’s bed with the DON, the mattress was found to fit the bed frame appropriately, and no unsafe gaps were noted around the quarter bedrails; additional observations of four other residents’ beds with air mattresses and side rails also revealed no entrapment or safety issues. In an interview, the Maintenance Supervisor reported that he measures bed mattresses and frames to ensure proper fit and assesses the mattress, frame, and bed rails for gaps or entrapment hazards when placing a new mattress. However, he acknowledged that he does not document these assessments and does not have a regular, ongoing maintenance program for checking beds for safety, leading to the cited deficiency.
Failure to Notify Legal Representative of Changes in Resident Status and Care
Penalty
Summary
The facility failed to notify the current legal representative of a resident about a change in the resident's representative status and a significant change in the resident's medical plan of care. The resident's clinical record indicated that a family member was designated as the legal representative in 2017. However, during a physician visit, another family member presented a document claiming Power of Attorney (POA) and requested a transition to end-of-life care, which was acted upon without verifying the validity of the POA or notifying the original legal representative. Later, it was discovered that the POA presented had been revoked years earlier, and the original legal representative had not been informed of the changes until after they occurred. The DON confirmed that the facility did not contact the correct legal representative regarding the conflicting POA status and the changes to the resident's care plan.
Failure to Implement Comprehensive Elopement Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident identified as an elopement risk, resulting in two separate incidents where the resident exited the building unwitnessed. The resident wore a wander guard bracelet intended to trigger secured exits, and the care plan directed staff to redirect the resident from exits and, when the resident was upset and attempting to leave, to have staff sit with the resident. However, during both incidents, staff only redirected the resident multiple times and did not provide the one-on-one supervision as outlined in the care plan. On both occasions, the resident was able to leave the facility without being witnessed, despite staff being aware of the resident's repeated exit-seeking behaviors. Interviews with staff and the DON confirmed that no one sat with the resident during these episodes, and staff were unable to provide adequate supervision, particularly during times of limited staffing. The care plan interventions were not fully implemented, as staff did not follow the directive to have someone sit with the resident when exhibiting elopement behaviors.
Failure to Provide Adequate Supervision and Maintain Secured Exits for Resident at Risk of Elopement
Penalty
Summary
The facility failed to provide adequate supervision and maintain a safe environment for a resident identified as an elopement risk, resulting in two separate incidents of elopement. The resident, who had a history of wandering behavior for at least four years and wore a wander guard bracelet, was able to exit the building on two occasions. In the first incident, the resident was observed multiple times attempting to open a Sunroom exit door. Staff redirected the resident several times but left the area unattended despite knowing the door's alarm system was not functioning due to a loose power connection. The resident ultimately managed to open the unsecured door and leave the building without staff witnessing the exit, and the alarm did not sound as required by facility policy. In the second incident, the same resident exited the building through a different door (Smoker's exit) that was equipped with an alarm. The alarm functioned properly, alerting staff, who then located and redirected the resident back inside. However, staff interviews revealed that the resident had made multiple attempts to elope that evening, and there were only three staff members present, which was insufficient to provide adequate supervision for the resident's known exit-seeking behavior. Additionally, the Charge Nurse failed to immediately notify the DON or Administrator of the elopement, contrary to the facility's Elopement and Wandering Policy. Both incidents demonstrate that the facility did not follow its own policies regarding secured exits and immediate notification of elopements. The failure to ensure that exit alarms were functioning and to provide adequate supervision for a resident with a known risk of elopement directly led to the resident being able to leave the facility on two occasions.
Unqualified Activity Director Employed
Penalty
Summary
The facility failed to employ a qualified Activity Director (AD) to manage resident-centered activities for all 24 residents. During an interview with a surveyor, the Administrator acknowledged that the current AD had not completed a State-approved program necessary to become qualified as an AD. Further confirmation came from the AD herself, who admitted she had not completed the required program or taken the exam to become an Activity Professional. Both the Administrator and the AD stated that the AD is currently enrolled in the program and is in the process of completing it to meet the qualification requirements.
Facility Fails to Implement Plan of Correction for Multiple Deficiencies
Penalty
Summary
The facility's quality assurance committee failed to ensure the implementation and effectiveness of the Plan of Correction (PoC) for deficiencies identified during the Recertification Survey. These deficiencies included issues with comprehensive assessments and timing, assessments after significant changes, care plan development and implementation, quality of care, and accident hazards. The facility lacked evidence that the PoC for these deficiencies was implemented, as there was no documentation of education provided to staff, education received by the MDS coordinator, or monitoring activities completed. During interviews with the Administrator and the Director of Nursing, it was confirmed that the facility did not implement the PoC for several deficiencies, including those related to comprehensive assessments, care plan updates, and quality of care. The facility also failed to establish and educate staff on an Elopement/Wandering policy, which was supposed to be in place by a specified date. The Director of Nursing indicated that the policy had not been approved by the board of directors, and staff had not received the necessary education, leaving a resident at risk of elopement. Additionally, the facility did not fully implement the PoC for respiratory care and the proper labeling and storage of drugs and biologicals. There was no evidence of education provided to staff, nor were there documented weekly audits or monitoring activities. These deficiencies were identified again during a revisit survey, indicating that the facility had not addressed the issues effectively by the anticipated date of compliance.
Failure to Complete Annual Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete an annual Comprehensive Minimum Data Set 3.0 (MDS 3.0) assessment in a timely manner for a resident receiving hospice care. The resident was admitted on an unspecified date, and the admission Comprehensive MDS assessment was completed and submitted on June 17, 2023. Subsequent quarterly MDS assessments were conducted on September 15, 2023, December 14, 2023, March 15, 2024, June 16, 2024, September 15, 2024, and December 16, 2024. However, there was no evidence of an annual Comprehensive MDS assessment being completed. During an interview on January 29, 2025, the Interim Director of Nursing acknowledged that the MDS completed on June 16, 2024, should have been an annual Comprehensive MDS assessment. At the time of the interview, it had been 592 days since the last Comprehensive assessment for the resident.
Failure to Complete Significant Change MDS for Hospice Transition
Penalty
Summary
The facility failed to complete a significant change in status Minimum Data Set 3.0 (MDS 3.0) assessment within 14 days of a resident's transition to hospice care. The deficiency involved a resident who was admitted to the facility and had an Admission MDS completed and submitted. However, when the resident transitioned to hospice level of care, the facility did not complete the required significant change in status MDS. This oversight was confirmed during an interview with the Interim Director of Nursing, who acknowledged that the change in condition assessment was not completed for the resident after the transition to hospice care.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the physical needs of a resident who was admitted with diagnoses of heart failure and atrial fibrillation (afib). The care plan did not include management strategies for heart failure, afib, or the use of anticoagulant medication, which is essential for preventing blood clots. During a record review and interview with the Interim Director of Nursing, it was confirmed that the care plan lacked provisions for monitoring and managing heart failure, such as daily weight monitoring as ordered by the provider, and did not address the monitoring and management of afib, including the use of anticoagulant medication.
Failure to Follow Provider Orders and Address Pharmacist Recommendations
Penalty
Summary
The facility failed to adhere to a doctor's order for daily weight checks for a resident diagnosed with heart failure. The order, dated 1/16/25, required daily weight monitoring and notification to the provider if the resident's weight increased by more than 3 pounds in one day or 5 pounds in one week. However, upon review of the clinical records on 1/28/25, it was found that there was no evidence of daily weights being recorded as ordered. This deficiency was confirmed during an interview with the Interim Director of Nursing and a surveyor. Additionally, the facility did not appropriately address a pharmacist's recommendation regarding the timing of a psychotropic medication for another resident. The pharmacist suggested reviewing the timing of olanzapine doses due to the resident being awake much of the evening. The PMHNP initially declined the recommendation, misunderstanding it as a request for a gradual dose reduction. It was later clarified that the recommendation was to adjust the timing of the doses, not reduce them. This misunderstanding was confirmed during an interview with an LPN and a surveyor.
Resident Elopement Due to Unmonitored Door During Fire Alarm
Penalty
Summary
The facility failed to adequately monitor an unlocked and non-alarmed door, resulting in an elopement incident involving a resident identified as an elopement risk. The resident, who has diagnoses including Schizophrenia, Major Depressive Disorder, and Alzheimer's disease, was wearing a wander guard alert device. However, during a fire alarm test, the doors unlocked, and the wander guard system was disabled, allowing the resident to exit the building unnoticed. A staff member observed the resident outside, unattended, and alerted other staff members to bring the resident back inside. The incident occurred when the resident was outside for approximately three minutes, standing near the edge of the property with bare feet on a snowy day. The Interim Director of Nursing confirmed through video surveillance that the resident exited through the day room door during the fire alarm. The resident was assessed and treated for exposure to salt and gravel on their feet, with no lasting effects reported. Staff interviews revealed that the lack of monitoring during the fire alarm contributed to the resident's unnoticed elopement.
Deficiency in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to maintain a physician-ordered oxygen setting and ensure the cleanliness of respiratory equipment for two residents. During an initial tour, a surveyor observed that the oxygen regulator on a resident's oxygen concentrator was set at 3.5 liters per minute (LPM), contrary to the physician's order of 2 LPM. Additionally, the concentrator was soiled with dried liquid and dust, and the air intake filter was heavily soiled with dust. Another resident was observed wearing oxygen via nasal cannula attached to an oxygen concentrator, which also had a heavily soiled air intake filter. These observations were confirmed by an LPN, who acknowledged the discrepancies in oxygen settings and the unsanitary condition of the equipment.
Expired Medication Not Removed from Storage
Penalty
Summary
The facility failed to remove an expired medication from the supply available for use in one of the two locations where medications are stored. During an observation, a surveyor and an LPN found an opened vial of Novolog insulin in the medication storage room, which was intended for a resident. The vial was labeled with an open date, indicating it was still being used 16 days after it should have been discarded, as Novolog is only good for 28 days once opened according to the manufacturer's directions. The LPN confirmed the expiration and discarded the vial upon discovery.
Deficiency in Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to fully develop and implement a comprehensive Water Management Program to prevent the growth and spread of Legionella and other water-borne pathogens. During a review conducted on January 28, 2025, it was found that the facility's Water Management Program, last revised on May 24, 2022, lacked evidence of testing protocols necessary for water testing. Specifically, there were no protocols for control measures, acceptable test ranges, monitoring procedures, or interventions to be used if water tested positive for Legionella or other opportunistic waterborne pathogens. In an interview conducted on the same day, the Maintenance Supervisor admitted to the surveyor that there was no evidence of a plan or protocol in place for testing Legionella or other waterborne pathogens, nor were there any established acceptable test ranges or monitoring procedures.
Failure to Provide Daily Hearing Aid to Resident
Penalty
Summary
The facility failed to ensure that a resident with bilateral sensorineural hearing loss was provided with a hearing aid device daily. The resident was admitted with a diagnosis requiring the use of hearing aids, as per physician orders, to be installed in the morning and removed at bedtime. Despite staff education on the importance of hearing aids in the resident's care plan, the resident often did not have the hearing aids in place. A family member reported that staff were unaware of how to use the hearing aids, and the resident was observed without them during a visit. The Director of Nursing admitted responsibility for not placing the hearing aid on a specific day and acknowledged the absence of a system to monitor the daily use and care of the hearing aid.
Latest citations in Maine
The facility failed to follow physician orders for medications and treatments for multiple residents. One resident did not receive a scheduled IM antibiotic dose as ordered. Another resident with constipation and diarrhea had PRN Loperamide and scheduled Sennosides administered inconsistently with bowel-related orders, and an ordered oral antibiotic was delayed for many days after it was received from the pharmacy, without documented timely provider follow-up. A resident with complaints of SOB did not receive a PRN nebulizer treatment despite an active order. During a med pass, a CNA-M gave a resident 14 pills to swallow at once, contrary to an order requiring meds to be given whole with water, one at a time, in an upright position.
Two residents experienced deficiencies in clinical record documentation when multiple active physician orders for medications, treatments, monitoring, positioning, and meal-related care were not documented as completed on the MAR/TAR, and when a provider progress note contained outdated wound care and foley catheter information that did not match current orders. The DON confirmed that the records lacked evidence of completion for ordered interventions and that the provider note did not accurately reflect the resident’s current wound care regimen.
The facility failed to develop and maintain complete, accurate care plans for two residents. One resident with a diagnosis of dementia did not have a comprehensive dementia care plan in place, as confirmed by record review and the Regional Director of Clinical Operations. Another resident with repeated falls and gait/mobility abnormalities, who had sustained an unwitnessed fall resulting in multiple fractures, lacked documented fall-related goals and interventions and had a care plan that inaccurately listed toileting as independent and did not include the toileting schedule described in the facility’s follow-up report; the DNS confirmed that the fall care plan had been resolved despite these ongoing needs.
A resident experienced lethargy, AMS, abnormal VS, and hypoxia with a history of urosepsis. Nursing staff contacted the on‑call provider, obtained orders for STAT labs, oral antibiotics, IV NS, and neuro checks, and applied supplemental O2. After this, the resident was unable to swallow the antibiotic, staff could not start the IV due to lack of supplies, and STAT labs were delayed until the next lab day. The resident’s temperature later increased and the POA requested transfer, leading to EMS transport to the ED for AMS, abnormal VS, and increased weakness. The record contained no evidence that the provider was notified of these subsequent changes in condition or of the inability to carry out ordered treatments, and the Administrator confirmed the physician was not notified.
A resident with Alzheimer’s disease, dementia with psychosis, severe cognitive impairment (BIMS 8/15), history of falls, and documented confusion and hallucinations was placed in a room directly across from an unsecured exit door, despite staff concerns and family reports of wandering-type behaviors. The resident was assessed as zero risk for elopement, and no elopement policy or Roam Alert was implemented even after earlier wandering and a stairwell incident. Video showed the resident repeatedly wandering the hall, exiting through the unsecured door once and returning unnoticed, then exiting again without staff awareness, passing through to a locked courtyard where reentry was not possible. Staff later discovered the resident missing and found the resident face down on snow-covered ground in the courtyard, inadequately dressed for the cold, leading to an Immediate Jeopardy determination for failure to prevent avoidable accidents and environmental hazards.
A resident left their room, exited through an exit door, and was later found outside on facility grounds lying on the grass, after previously being observed in a stairwell and returned to their room while remaining restless. Facility documentation and a SERCA confirmed staff did not re‑evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and had no elopement policy in place. The Administrator and DON acknowledged they knew of the incident when it occurred but did not notify the State agency or submit a 5‑day follow‑up report, as they treated the event as a fall rather than an elopement because the resident was found on facility property.
Housekeeping and maintenance services were not adequately provided in multiple resident areas and the laundry room. Surveyors observed food particles and debris on sit-to-stand lifts, commode buckets and a wash basin left on bathroom floors, ripped or torn floor mats and shower threshold strips, broken and disrepair conditions, chipped and missing paint, dried feces and urine on and under a toilet and seat riser, taped-over holes in a shower wall, and untreated wooden pallets in the clean laundry area. The ADON/housekeeping and maintenance leadership confirmed the findings.
Failure to Report Multiple Abuse Allegations: A resident with Alzheimer's disease and dementia had repeated incidents of aggression toward other residents, CNAs, and a visitor, including slapping, grabbing, pulling, verbal abuse, and attempting to swing a chair. The record and DLC portal review showed no evidence these abuse allegations were reported to the state agency, and the Administrator confirmed the incidents were not reported.
Incomplete Transfer/Discharge and Bed-Hold Notices: The facility failed to provide written transfer/discharge and bed-hold notices to resident representatives for multiple residents who were transferred to acute care. The notices reviewed were missing required appeal information, including contact details for the appeal entity and the State LTC Ombudsman, and lacked instructions for obtaining and completing an appeal form. Staff stated that transfer/discharge and bed-hold notices are not sent to resident representatives and that the bed-hold notice does not include appeal rights or contact numbers.
A resident’s baseline care plan was not developed and implemented within 48 hours of admission with the instructions needed to provide minimum healthcare information for care. The record showed repeated aggression toward staff, other residents, and a visitor, along with wandering, agitation, destructive behavior, and combative episodes during care, but the care plan lacked goals and interventions for these behaviors. The DON confirmed the care plan did not address the concerns.
Failure to Follow Physician Medication and Treatment Orders
Penalty
Summary
The deficiency involves multiple failures by facility staff to follow physician orders for medications and treatments for several residents. One resident had a physician order dated 4/23/26 for Ceftriaxone Sodium 1 gram IM daily for 5 days for a urinary tract infection. Review of the Treatment Administration Record showed the antibiotic was administered on 4/23, 4/24, 4/26, and 4/27, with no evidence of administration on 4/25. The DON confirmed that the ordered dose on 4/25 was not given. Another resident with ongoing issues of constipation and diarrhea had active orders for Loperamide 2 mg PO PRN after loose stool, with one repeat dose allowed, and Sennosides 8.6 mg, 2 tablets PO twice daily for constipation, to be held for loose stools in the last 24 hours. Review of the bowel elimination history and MAR showed repeated instances where Loperamide was given when there was no bowel movement or when bowel movements were normal, and not given after documented loose/diarrhea stools as ordered. Sennosides was administered within 24 hours of loose stools, contrary to the order to hold it under those circumstances. Additionally, this resident had an antibiotic received from the pharmacy on 3/21/26 with a faxed order on 4/1/26 indicating it should be taken every 8 hours for 7 days following a 3/18/26 office visit; however, the MAR showed the first dose was not given until 4/1/26, 12 days after the antibiotic was received from the pharmacy, and the record lacked evidence of timely follow-up with the urologist regarding the antibiotic and progress note. A further deficiency was identified when a resident with a provider response indicating an existing PRN nebulizer order for shortness of breath had no documented PRN nebulizer treatment administered on the date the nurse requested nebulizer treatments for complaints of shortness of breath, despite the active order. In another case, during a medication pass observation, a CNA-M handed a resident a cup containing 14 pills, which the resident placed in the mouth and swallowed all at once with water. This was inconsistent with a physician order dated 4/9/26 specifying that medications were to be given whole with water, one at a time, with the resident in an upright position. The CNA-M later confirmed that the medications had been given all at once rather than one at a time as ordered.
Incomplete and Inaccurate Clinical Records for Medication, Treatment, and Wound Care Orders
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident when multiple active physician orders were not documented as completed on the MAR and TAR for the month of April. For one resident, there was no evidence of documentation for ordered interventions including daily lavage of the left ear with warm water, application of Triad cream to a left buttocks stage 2 area, monitoring for signs and symptoms of respiratory infection/COVID every day and night, use of an air mattress on the bed every shift, documentation of shortness of breath, encouragement of off-loading of the right hip, maintaining the head of bed (HOB) elevated greater than 30 degrees every shift, monitoring for difficulty swallowing food or medications, keeping the HOB upright for one hour after meals, use of a right side half bedrail as an enabler for bed mobility, nurse education that supervision with meals was medically recommended, and being out of bed in a wheelchair for all meals. The DON confirmed that the MAR and TAR lacked evidence of completed documentation for these physician orders. The facility also failed to ensure that a resident’s clinical record contained accurate information regarding wound care. A physician progress note documented that the resident had a stage 2 upper medial posterior thigh pressure ulcer with interval improvement and directed continuation of calcium alginate and island dressing changes and continuation of a foley catheter for moisture management. However, the clinical record showed that the calcium alginate/foam/Tegaderm wound care order had been discontinued earlier and replaced with an order for Triad hydrophilic wound dressing paste, and that the resident’s foley catheter had been removed during a recent hospitalization. The DON confirmed that the provider note did not contain accurate information related to the resident’s current wound care orders.
Failure to Develop and Maintain Comprehensive Care Plans for Dementia and Falls
Penalty
Summary
The facility failed to develop a comprehensive care plan addressing dementia care needs for one resident. This resident was admitted in July 2025 with a diagnosis of dementia. A review of the most recent care plan, dated 2/9/26, showed no evidence that a care plan specific to dementia care had been developed. During an interview on 4/15/26, the Regional Director of Clinical Operations confirmed that the care plan lacked a comprehensive dementia care component. The facility also failed to ensure that a care plan addressing falls and toileting needs was developed and accurately maintained for another resident with a history of repeated falls and gait and mobility abnormalities. Following an unwitnessed fall on 10/21/25 that resulted in multiple fractures and hospitalization, the facility’s follow-up report stated that a toileting schedule had been added to the resident’s care plan to reduce fall risk. However, review of the clinical record and care plan showed the resident was documented as independent with toileting and there was no evidence of an intervention for a toileting schedule or of goals and interventions related to falls. In an interview on 4/14/26, the DNS confirmed that the care plan did not contain goals and interventions for falls and stated that the fall care plan had been resolved on 2/26/26.
Failure to Notify Physician of Resident’s Worsening Condition and Barriers to Ordered Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a significant change in condition and related care issues for one resident who was later hospitalized. Facility policy required informing the resident, consulting with the healthcare provider, and notifying the legal representative or family when there was a significant change in physical, mental, or psychosocial status, or a decision to transfer the resident, and required documentation of physician/family notification in the EHR. For this resident, a progress note documented that the resident became lethargic, was unable to answer simple questions, had vital signs reflecting an infectious process (BP 159/88, pulse 108, temp 99.1, O2 sat 88% on room air), appeared off baseline, and had a history of urosepsis. The nurse applied 2 L/min supplemental O2 and contacted the on‑call provider, who ordered STAT CBC, CMP, procalcitonin, UA, Augmentin 875 mg for 5 days, IV NS at 75 ml/hr for one bag, neuro checks, and to notify on‑call for any changes in condition. Subsequent documentation showed that the resident was unable to swallow the ordered antibiotic, the nurse was unable to start the IV due to lack of supplies, and the labs ordered STAT were instead entered for a Monday morning draw because the lab drop‑off center was closed on Sunday. Later, the resident’s temperature increased to 101.2, and the POA requested that the resident be sent to the hospital; the resident was transferred to the ED via EMS for AMS, abnormal vitals, and increased weakness. A review of the clinical record found no evidence that the provider was notified of the resident’s further change in condition, the inability to obtain STAT labs, the lack of IV supplies, or the resident’s inability to swallow the antibiotic after the initial provider contact. In an interview, the Facility Administrator confirmed that the physician was not notified of the resident’s further change in condition.
Resident Found Outside in Snow After Unmonitored Exit Through Unsecured Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents and environmental hazards, resulting in an immediate jeopardy situation. The resident had been admitted following a fall at home with fractured ribs and had diagnoses of Alzheimer’s disease and dementia with psychosis, along with chronic confusion, short-term memory loss, mobility limitations, a history of falls, and a need for cues and assistance with personal care. An admission BIMS score of 8/15 indicated severe cognitive impairment. Despite these conditions and family reports of increased confusion, sundowning, agitation, hallucinations, delusions, and falls, the facility’s elopement risk assessment scored the resident as zero, identifying the resident as not at risk for elopement. The resident was placed in a room directly across from an exit door that did not lock, and both the unit secretary and a CNA expressed concerns about this placement due to the unsecured door and the resident’s diagnoses and behaviors. On the night and early morning in question, staff documented that the resident was restless, had gone into a stairwell earlier, and continued to be confused and hallucinating, including insisting on moving a truck and talking to people who were not there. Video surveillance showed the resident wandering the hallway multiple times between late evening and early morning. At approximately 5:02 a.m., the resident opened the exit door across from the room, exited, and later returned to the room without staff awareness. At approximately 5:08 a.m., the resident again opened the same exit door and exited the unit; this time the resident did not return, and staff were again not observed in the area or aware of the exit. The exit configuration allowed the resident to pass through a first door and then a second door into an enclosed courtyard/patio that locked behind the resident, preventing reentry. At about 5:34 a.m., staff noticed the resident was not in the room and began searching. By approximately 5:38 a.m., video of the courtyard/patio showed staff outside with the resident lying face down on the snow-covered ground, wearing a long-sleeve shirt, pants, and socks, in overnight temperatures recorded at 20 degrees Fahrenheit. The facility’s internal Sentinel Event Root Cause Analysis identified that staff did not re-evaluate the resident when behaviors changed, did not implement a Roam Alert after the first wandering incident, and that there was no elopement policy in place at the time. The DON stated the incident was initially treated as a fall and was not reported to the State Agency because the resident was found on facility property and the facility did not consider it an elopement. Based on these findings, Immediate Jeopardy was called for the facility’s failure to ensure a resident known to be wandering and able to exit through an unsecure door was adequately monitored and supervised.
Failure to Report Resident Elopement and Submit Required Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to timely report a resident’s elopement and subsequent neglect incident to the State agency within 24 hours and to submit a 5‑day follow‑up report. Facility records, including nursing documentation, video surveillance, written staff statements, and interviews, confirmed that on March 21, 2026, a resident left their room and exited the unit through an exit door, later being found outdoors on facility grounds. A fall/details note documented that the resident was in bed at 5:00 a.m., was not in their room at 5:30 a.m., and was found outside lying on the grass at 5:40 a.m. A late entry note stated the resident had gone into the stairwell, was observed by staff, brought back to their room, and remained restless. A Sentinel Event Root Cause Analysis (SERCA) documented that the resident was found outside in the patio space at 5:38 a.m. wearing a flannel shirt and jeans. The SERCA identified contributing factors and root causes, including that staff did not re‑evaluate the resident when their behaviors changed and that a Roam Alert was not implemented by the nurse on duty after the first wandering incident. The SERCA also stated the facility did not have an elopement policy in place at the time. During an interview on April 8, 2026, the Administrator and DON confirmed they were aware of the incident when it occurred but did not report it to the State agency because the resident was found on facility property and they did not consider the event an elopement, initially treating it as a fall. As a result, the State agency was not notified within 24 hours, and no 5‑day follow‑up report was submitted for this investigated incident of neglect.
Housekeeping and Maintenance Deficiencies in Resident Areas and Laundry Room
Penalty
Summary
The facility failed to adequately provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment on the East, [NAME], and South Units, as well as in the laundry room. On the East Unit, a surveyor observed a sit-to-stand patient lift near the central sitting area and another by the nurse's station near resident room [ROOM NUMBER], both with food particles and debris in the foot base areas. The same unit also had a commode bucket on the floor in the bathroom of resident room [ROOM NUMBER], and a CNA/Medication Technician confirmed the finding during interview. During an environmental tour of the South Unit, surveyors observed multiple room and bathroom conditions including ripped or torn floor mats and shower threshold strips, commode buckets and a wash basin left on bathroom floors, a broken baseboard heater, chipped and missing paint on walls, and a toilet, toilet seat, and seat riser with dried feces and urine on and under them. One resident room had multiple layers of white tape covering holes in a shower wall. On the [NAME] Unit, a resident room had a ripped or torn shower threshold strip. In the laundry room, surveyors observed four untreated wooden pallets under supplies in the clean section, creating uncleanable surfaces. The Maintenance Director, Housekeeping Director, and Administrator confirmed the observed findings during interviews.
Failure to Report Multiple Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse to the Division of Licensing and Certification (DLC) for multiple incidents involving one resident with diagnoses of Alzheimer's disease and dementia. Record review showed repeated episodes in which the resident was aggressive toward other residents, staff, and a visitor, including slapping a resident in the face, slapping a CNA in the ribcage, smacking another resident on the upper arm, slapping an aide across the face after grabbing her breast, verbally attacking a resident and that resident's daughter, slapping another resident on the shoulder, grabbing a staff member's arm and not letting go, trying to swing a chair at others, pulling a visitor's arm, pushing a staff member into another resident's room, and hitting a CNA's hand twice. The clinical record also documented that the resident was pacing with 1:1 staff supervision during some of the incidents and continued to become agitated and go toward other residents. Review of the DLC incident reporting portal showed no evidence that these abuse allegations were reported to the state agency. During an interview, the Administrator confirmed that the incidents were not reported to DLC.
Incomplete Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The facility failed to provide written transfer/discharge notices and bed-hold notices to resident representatives for 8 of 8 residents reviewed for hospitalization, including Residents #1, #3, #7, #11, #54, #64, #65, and #78. The report states that each of these residents was transferred to an acute hospital, and the clinical records were reviewed for the required notices related to transfer, discharge, and bed hold. For Resident #1, the record showed transfers to an acute hospital on 1/7/26 and 1/24/26, and the Transfer and Discharge Notice was incomplete. For Residents #3, #7, #11, #54, #65, #64, and #78, the records also showed acute hospital transfers, and the Transfer and Discharge Notices were incomplete. In each case, the notices lacked the name, mailing and email address, and telephone number of the entity that receives appeal requests, as well as information on how to obtain an appeal form and assistance in completing and submitting the appeal hearing request. The notices also lacked the name, mailing and email address, and telephone number of the Office of the State Long-Term Care Ombudsman. In addition, the notices indicated verbal consent was obtained, but there was no evidence that the facility issued written transfer and discharge notices or bed-hold notices to the residents' representatives. During an interview on 4/8/26 at 9:34 a.m., the Social Service Assistant and Social Service Director stated that transfer/discharge notices and bed-hold notices are not sent to the resident representative and that the bed-hold notice does not contain appeal process/rights or numbers to call if wanted.
Baseline Care Plan Not Developed for Behavioral Needs
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed and implemented within 48 hours of admission for Resident #61, and the care plan did not include the instructions needed to provide the minimum healthcare information necessary to properly care for the resident. Review of the resident’s clinical record showed multiple progress notes documenting escalating behavioral concerns after admission, including aggression toward staff and other residents, agitation, wandering into other residents’ rooms, physical assaults, verbal abuse, and destructive behavior such as tearing apart equipment and furniture, attempting to throw a TV out the window, and grabbing a visitor’s arm. The resident’s care plan, created on 3/4/26, lacked evidence that goals and interventions were put into place for these behaviors. The record also documented episodes of incontinence, combative behavior during care, and repeated incidents requiring staff intervention and redirection. During an interview on 4/9/26 at 1:45 p.m., the DON reviewed the care plan and confirmed that goals and interventions were not put into place for the identified concerns.
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