Emerald Nursing & Rehab Legacy Pointe Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Omaha, Nebraska.
- Location
- 3110 Scott Circle, Omaha, Nebraska 68112
- CMS Provider Number
- 285239
- Inspections on file
- 31
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Emerald Nursing & Rehab Legacy Pointe Llc during CMS and state inspections, most recent first.
Staff did not follow hand hygiene protocols during peri-care for two residents who required extensive assistance due to significant medical conditions. Nurse assistants changed gloves without using hand sanitizer or washing their hands and failed to perform hand hygiene before leaving the rooms. Both staff and the DON confirmed these lapses, and the facility lacked a specific peri-care policy.
A resident with significant communication and functional impairments exhibited respiratory symptoms and was ordered a STAT chest x-ray, which revealed possible pneumonia. The results were not promptly communicated to the healthcare practitioner, resulting in a delay in antibiotic treatment. The DON confirmed the delay in notification and subsequent care.
Surveyors found that the facility did not document or implement required Legionella water management practices and failed to ensure staff used Enhanced Barrier Precautions (EBP) during high-contact care for two residents with multidrug-resistant organisms and indwelling devices. Staff provided care such as showers and catheter care without wearing gowns, contrary to facility policy and posted EBP signage.
Kitchen staff did not follow prescribed menu portion sizes for residents on regular textured diets, serving inconsistent amounts of meatballs and failing to use dietary cards, which led to 48 residents receiving incorrect meal portions as outlined in the facility's menu and diet spreadsheet.
Kitchen staff did not maintain required food temperatures, resulting in multiple resident complaints about cold and unappetizing meals. Observations confirmed that hot foods were served below the required temperature, and cold foods were not kept sufficiently cool. Staff interviews supported these findings, and the Dietary Service Manager confirmed the facility's obligation to follow food safety codes.
Facility staff did not notify practitioners when insulin doses were omitted for three residents with ESRD and diabetes who were out of the facility for hemodialysis. MARs showed multiple missed doses marked as 'Out of Facility,' and staff interviews confirmed a lack of awareness and failure to communicate these omissions, despite facility policy requiring such notifications.
Two residents with complex medical conditions were transferred to the hospital without receiving written notice of transfer, including the reason for transfer, as required. In both cases, the Bed Hold/Therapeutic Leave Forms were incomplete, and the Director of Nursing confirmed that neither the residents nor their representatives were provided with the necessary written documentation.
A resident with dementia, hypertension, and major depressive disorder, who was dependent on staff for toileting, did not have a bowel movement for six consecutive days. Despite physician orders for daily and PRN laxatives, staff did not assess bowel function, administer the PRN medication, or document interventions. The care plan lacked constipation interventions, and interviews confirmed no assessment or policy was in place.
Facility staff did not administer scheduled insulin doses to several residents with ESRD and diabetes while they were out of the facility for dialysis, repeatedly marking the doses as missed on the MAR and failing to notify practitioners or adjust medication regimens as required by facility policy.
A resident with multiple chronic conditions received daily polyethylene glycol for constipation without a documented stop date or evidence of ongoing prescriber evaluation, contrary to facility policy and medication guidelines. The medication was administered consistently, and staff confirmed there was no documentation of reassessment for continued use.
Two residents with significant dental needs did not receive required dental services, including follow-up with a dentist or oral surgeon after referrals were made. Despite documented oral health problems and care plans noting poor dentition, the facility did not ensure that dental appointments were scheduled or completed as needed.
A resident with multiple chronic conditions and a stated religious preference for avoiding pork was offered meals containing pork. The facility did not document the resident's religious dietary restrictions on the tray card or care plan, despite conducting an admission food preferences interview and having information about the resident's religious beliefs in other records.
A resident with quadriplegia and severe cognitive impairment, fully dependent on staff for ADLs, was observed to have long, untrimmed fingernails over multiple days. Despite being scheduled for bathing and nail care, staff confirmed that nail trimming was not performed, and the resident verbally requested their nails be cut.
A resident with ESRD and diabetes, who required partial assistance and attended hemodialysis three times weekly, did not receive an individualized activity program that accommodated their schedule and preferences. The facility did not offer activities in the evenings or on weekends, and there was no documentation of activity participation for the resident after readmission, despite their expressed interests and care plan directives.
A resident with multiple chronic conditions and limited mobility did not receive interventions to prevent further decline in range of motion, despite facility policy and therapy recommendations. The resident's records showed no restorative nursing program or documented interventions, and both the resident and DON confirmed the absence of such measures.
Staff failed to maintain a medication error rate below 5%, with errors including a CMA not instructing a resident to rinse their mouth after using an Advair Diskus inhaler, and an LPN priming insulin pens with 1 unit instead of the 2 units required by manufacturer instructions for two residents. These actions resulted in a medication error rate of 10.71%.
A resident at risk for pressure ulcers was observed with heels not elevated off the mattress, contrary to care plan and guidelines. Despite having a low loss air mattress and a treatment order for an existing wound, staff failed to follow the facility's policy and national guidelines for heel elevation, leading to a deficiency in care practices.
A resident with multiple health issues, including a wound and feeding tube, did not have Enhanced Barrier Precaution (EBP) implemented as required. Observations showed no EBP indications in the resident's room, and an LPN performed treatments without a gown. The DON confirmed the resident should have been on EBP, but the LPN was unaware of the protocol.
The facility failed to secure the east medication room, leaving keys in the lock, which could have been accessed by 22 self-mobile residents and two unauthorized staff. Observations showed the keys were left unattended, and interviews confirmed this was against policy. A resident with severe cognitive impairment was nearby, and the Director of Nursing acknowledged the breach.
The facility failed to maintain a safe and clean environment, affecting 55 residents. Observations included damaged walls, dusty ventilation covers, a broken wheelchair armrest, and poor water pressure in bathrooms. Rusty tiles were noted in shower rooms. The Maintenance Director confirmed the issues, with no work orders in place.
A facility failed to address PTSD triggers for a resident, as their care plan lacked interventions for managing PTSD despite the resident's cognitive intactness and expressed needs. Interviews revealed that the resident experienced nighttime difficulties and preferred specific conditions to avoid being startled. The facility's policy emphasized individualized care, but no assessment or interventions were documented for the resident's PTSD.
A resident alleged that a family member stole their Net Spend card, but the facility failed to investigate and submit a written report to the state agency within the required 5 working days. The Director of Nursing confirmed that the investigation and results were not completed or sent, despite the facility's policy requiring timely reporting to authorities.
Failure to Follow Hand Hygiene Procedures During Peri-Care
Penalty
Summary
Staff failed to follow established hand hygiene procedures during the provision of peri-care for two residents. Facility policy and infection control standards require staff to perform hand hygiene before and after direct contact with residents, after contact with blood or body fluids, and before and after wearing gloves. Observations revealed that nurse assistants changed gloves without using hand sanitizer or washing their hands and did not perform hand hygiene prior to exiting the residents' rooms after providing peri-care. One resident involved was chairfast, required maximum to total assistance for mobility and hygiene, and had multiple chronic conditions including venous stasis ulcers and chronic respiratory failure. During peri-care, two nurse assistants donned appropriate PPE but failed to use hand sanitizer or wash their hands when changing gloves and before leaving the room. Both confirmed in interviews that they did not follow proper hand hygiene protocols. Another resident, admitted for skilled nursing care following a cerebral infarction and with moderate cognitive impairment, also required substantial assistance with personal hygiene and was always incontinent of bowel and frequently incontinent of urine. During peri-care, two nurse assistants used hand sanitizer before entering the room and donned gloves, but did not change gloves or perform hand hygiene during care or before exiting. Both acknowledged in interviews that they should have performed hand hygiene as required by facility policy. The Director of Nursing confirmed the expectation for glove changes and hand hygiene during peri-care and noted the absence of a specific peri-care policy.
Delay in Notification of Chest X-ray Results Leading to Treatment Delay
Penalty
Summary
Facility staff failed to promptly notify the resident's healthcare practitioner of chest x-ray results that indicated new left midlung and right lower lobe opacities, which may represent pneumonia. The resident, who was rarely able to make themselves understood and required total assistance with all activities of daily living, exhibited symptoms including audible moist wheezes, green nasal drainage, and glassy eyes. A STAT portable chest x-ray was ordered and obtained, but the results were not communicated to the healthcare practitioner until two days later, resulting in a delay in ordering antibiotics for pneumonia. The Director of Nursing confirmed the delay in notification and subsequent treatment.
Failure to Implement Infection Control Program and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and document an effective infection prevention and control program, specifically regarding the mitigation of Legionella growth and the use of Enhanced Barrier Precautions (EBP) for residents with multidrug-resistant organisms (MDROs). During an interview, the Maintenance Director confirmed there was no documentation of flushing holding tanks or other areas prone to stagnant water, despite the facility's policy requiring surveillance and control measures for Legionella. The policy outlined the need to identify and monitor areas at risk for Legionella growth, such as storage tanks and water heaters, and to document control measures, but these actions were not carried out or recorded. For two residents with MDROs, staff did not follow the facility's EBP policy during high-contact care activities. One resident, who required total assistance with toileting and bathing and had an active MDRO in the urine, was observed receiving a shower from a nursing assistant who did not wear a gown as required by EBP protocols. The nursing assistant and another staff member confirmed that a gown should have been worn during this activity. Another resident with ESBL resistance and an indwelling urinary catheter was also not provided care in accordance with EBP. During catheter care, the nursing assistant performed hand hygiene and wore gloves but did not don a gown, despite EBP signage and policy requirements. The nursing assistant acknowledged that a gown should have been worn during the procedure. The facility's policy specified that EBP, including gown and glove use, must be followed during high-contact care for residents with wounds or indwelling medical devices.
Failure to Follow Prescribed Menu Portion Sizes for Regular Diet Residents
Penalty
Summary
Kitchen staff failed to follow the prescribed menu serving sizes for 48 residents on regular textured diets. Observations revealed that dietary assistants did not use dietary cards, which provide essential information on diet type, portion sizes, food consistency, preferences, and allergies. Instead, staff served inconsistent and incorrect portions of meatballs, with one dietary assistant serving 5 meatballs and another serving between 5 and 12 meatballs per resident, contrary to the menu's specified portion of 3 one-ounce meatballs. The Food Service Director later confirmed that the correct serving size should have been 6 half-ounce meatballs, and acknowledged that the menu portion sizes were not followed. Record reviews showed that the menu and diet spreadsheet clearly outlined the required portion sizes for each food item, but these were not adhered to during meal service. Staff interviews indicated a lack of knowledge regarding the correct serving sizes, and the absence of dietary card usage contributed to the inconsistency. The deficiency affected a significant portion of the facility's census, as 48 out of 63 residents on regular textured diets did not receive meals in accordance with the established menu and portion guidelines.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
Facility kitchen staff failed to ensure that food served to residents was maintained at appetizing and palatable temperatures, as required by the Nebraska Food Code. Observations and interviews revealed that hot foods were not held at the required temperature of 135 degrees Fahrenheit or above, and cold foods were not consistently kept at 41 degrees or below. Multiple entries in the facility grievance log documented resident complaints about cold food, unappetizing meal presentation, and dissatisfaction with food temperature and quality. Specific grievances included reports of cold breakfast items, cold food delivered to rooms, and mismatched temperatures of meal components such as hot cucumbers and cold zucchini. Direct observation of meal service showed that food items on a test tray, including meatballs, potatoes, green beans, and hot dog alternates, were served below the required hot holding temperatures, with some items as low as 96.0 degrees Fahrenheit. Pudding, intended to be served cold, was found to be too warm. Staff interviews confirmed that the food was not at appropriate temperatures and did not taste good. The Dietary Service Manager acknowledged that the facility is expected to follow the Nebraska Food Code for food holding temperatures.
Failure to Notify Practitioners of Omitted Insulin Doses During Dialysis Absences
Penalty
Summary
Facility staff failed to notify residents' practitioners when scheduled insulin doses were omitted for three residents who were out of the facility receiving hemodialysis. Each of these residents had orders for insulin administration and required dialysis on specific days of the week. The Medication Administration Records (MARs) for these residents showed that insulin doses were marked as 'Out of Facility' (OF) on multiple occasions corresponding to their dialysis appointments, indicating the medication was not administered. Interviews with nursing staff, including agency nurses, LPNs, and the unit manager, revealed a lack of awareness regarding responsibility for insulin administration when residents were out for dialysis. Staff confirmed that practitioners should be notified when insulin is not given, but this notification did not occur for any of the affected residents. The facility's own policy required immediate notification to the resident, their representative, and the attending physician or delegate when there was a change in condition or treatment, including omitted medications. The residents involved had significant medical histories, including End Stage Renal Disease (ESRD), Diabetes Mellitus, and dependence on hemodialysis. Their cognitive status ranged from intact to moderately impaired, and they required varying levels of assistance with activities of daily living. Despite these complexities, the facility did not communicate missed insulin doses to practitioners, as confirmed by record review and staff interviews.
Failure to Provide Written Notice of Transfer to Residents or Representatives
Penalty
Summary
The facility failed to provide written notice of transfer, including the reason for transfer, to two residents or their representatives as required by regulations. For one resident with a history of COPD, diabetes mellitus type 2, heart failure, and major depressive disorder, the facility transferred the resident to the emergency department due to chronic diarrhea and abdominal pain. Although the resident opted for a bed hold, the Bed Hold/Therapeutic Leave Form did not include the reason for transfer, and no written notice of transfer was found in the resident's electronic health record or progress notes. The Director of Nursing confirmed that the required written notice was not provided. Similarly, another resident with diagnoses including hemiplegia, hemiparesis, systemic inflammatory response syndrome, and COPD was transferred to the hospital and was expected to return. The Bed Hold/Therapeutic Leave Form for this resident also lacked the reason for transfer, and no written notice of transfer was present in the electronic health record or progress notes. The Director of Nursing confirmed that the facility did not provide the resident or their representative with the required written notice of transfer.
Failure to Evaluate and Manage Bowel Function for a Resident
Penalty
Summary
Facility staff failed to evaluate and manage bowel function for a resident with dementia, hypertension, and major depressive disorder, who was dependent on staff for toileting. The resident had physician's orders for daily polyethylene glycol and PRN Senexon-S for constipation. Despite documentation showing no bowel movement for six consecutive days, there was no record of an assessment being performed or the PRN laxative being administered during this period. The resident's comprehensive care plan did not include interventions for constipation. Review of the electronic medical record and medication administration record confirmed the absence of both PRN medication administration and evaluation of bowel function. Interviews with the Unit Manager and DON confirmed the lack of assessment, intervention, and a facility policy on bowel and bladder elimination. The DON stated that staff should utilize PRN laxatives, perform evaluations, or notify the provider when a resident has not had a bowel movement for six days, but this was not done in this case.
Failure to Manage Insulin Administration for Dialysis Residents
Penalty
Summary
Facility staff failed to identify and implement a plan to manage medications, specifically insulin, for residents receiving dialysis services. Facility policy required that care and treatment, including medication management, be consistent with professional standards, physician orders, and care plans, and that communication with outside providers be maintained to ensure safe, continuous care. However, for three residents with End Stage Renal Disease and diabetes who were receiving hemodialysis and insulin injections, staff documented that insulin doses scheduled during dialysis times were not administered, marking them as 'Out of Facility' (OF) on the Medication Administration Record (MAR). For each of these residents, the MARs showed repeated instances where scheduled insulin doses were omitted on dialysis days, with no evidence that the residents' practitioners were notified of the missed doses. Interviews with nursing staff and unit managers confirmed that staff were unaware of who was responsible for administering insulin while residents were at dialysis and that practitioners were not notified when insulin was not given. There was also no indication that the insulin regimens were modified to account for the dialysis schedule or missed doses. The residents involved had significant medical histories, including End Stage Renal Disease, diabetes, and other chronic conditions, and required varying levels of assistance with activities of daily living. Despite these needs and the facility's own policy requirements, the lack of communication with practitioners and failure to adjust medication administration for dialysis schedules resulted in a deficiency in providing safe and appropriate dialysis care and services.
Failure to Evaluate Ongoing Use of Laxative Medication
Penalty
Summary
The facility failed to evaluate the ongoing use of a laxative medication, polyethylene glycol, for a resident diagnosed with dementia with behavioral disturbance, hypertension, and major depressive disorder. The resident had a physician's order for daily administration of polyethylene glycol for constipation, with no stop date indicated. Review of the resident's electronic medication administration record showed the medication was administered daily, except for one refusal, and there was no documentation that the prescriber had reassessed the need for continued use of the medication. Facility policy requires the attending physician to regularly review each resident's medication regimen, including dose, duration, indication, monitoring, and adverse consequences. However, there was no evidence in the resident's health record that the continued use of polyethylene glycol had been evaluated by the prescriber, despite drug manufacturer guidance that it should not be used for more than seven days without reassessment. The unit manager confirmed the lack of documentation regarding evaluation of the medication's ongoing use.
Failure to Provide or Obtain Required Dental Services
Penalty
Summary
The facility failed to ensure that dental services were provided or obtained for two residents, as required by policy and regulation. One resident, who was cognitively intact and required partial assistance with activities of daily living, had been assessed as having obvious or likely cavities and broken natural teeth. This resident had been referred for oral surgery due to the need for multiple extractions and removal of residual root tips, but had not seen a dentist since the initial referral and had no dental services currently scheduled. Observation confirmed the presence of broken, discolored teeth, and interviews with staff verified the lack of follow-up dental care. Another resident was observed to be missing multiple teeth and to have several broken teeth, with documentation indicating no dental visit since the previous year. Although the care plan acknowledged poor dentition and included interventions to monitor and report oral health issues, records showed that the resident had not been seen by a dentist or oral surgeon as recommended. Staff interviews and record reviews confirmed that necessary dental referrals had not resulted in completed or scheduled dental services for this resident.
Failure to Document and Honor Resident Religious Dietary Preferences
Penalty
Summary
Facility staff failed to evaluate and document a resident's food preferences related to religious beliefs, specifically for a resident who identified as Seventh Day Adventist and reported not eating pork. During an interview, the resident stated that meals containing pork were offered despite their religious dietary restrictions. The Food Services Director confirmed that while a food preferences interview was conducted at admission and results are typically recorded on the resident's tray card, this resident's religious dietary preferences were not included on the tray card. Record reviews showed that the resident's admission record, social services data, and comprehensive care plan did not include interventions or documentation regarding religious dietary preferences. The resident's tray card only listed a controlled carbohydrates diet with regular texture, omitting any mention of religious dietary restrictions. The resident's medical history included chronic obstructive pulmonary disease, type 2 diabetes mellitus, heart failure, and major depressive disorder. The annual MDS indicated that religious services or practices were somewhat important to the resident, but no cognitive assessment was documented.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
Facility staff failed to provide necessary nail care for a resident with quadriplegia who was completely dependent on staff for all activities of daily living, including personal hygiene. The resident was assessed as having severe cognitive impairment and required total assistance with eating, hygiene, dressing, toileting, bathing, transfers, and bed mobility. The resident's care plan documented a functional deficit with ADLs and indicated dependence on staff for personal hygiene. Multiple observations over two days revealed the resident's fingernails were approximately 1 centimeter in length and remained untrimmed despite being scheduled for a bath and receiving a shower. Nursing assistants confirmed the resident's nails were long and had not been trimmed during bathing or showering, even though nail care was expected to be provided at those times. The resident verbally requested that their nails be cut, but this care was not provided as required.
Failure to Provide Individualized Activity Program for Resident Receiving Dialysis
Penalty
Summary
The facility failed to implement an individualized activity program for a resident who was assessed as cognitively intact and had a diagnosis of End Stage Renal Disease (ESRD) and Diabetes Mellitus. The resident required partial assistance with activities of daily living and was receiving hemodialysis three days a week, returning to the facility in the late afternoon. The resident expressed that there were no activities offered in the evening or on weekends, which was confirmed by a review of the facility's activity calendar for the month. Documentation showed that the resident had not participated in any activities since readmission following a hospital stay, despite previously documented interests in activities such as animals/pets, arts/crafts, bingo, family/friend visits, movies, music, and special events, and a preference for activities two to five times per week. The resident's care plan indicated a dependence on staff for activity participation and a need to provide materials for individual activities as desired. However, there was no evidence that the facility provided or facilitated access to activities that matched the resident's preferences or schedule, particularly considering the resident's dialysis treatments and late return to the facility. Interviews and record reviews confirmed the lack of scheduled activities during evenings and weekends, and the absence of documented activity participation for the resident after readmission.
Failure to Implement Interventions to Prevent Decline in Range of Motion
Penalty
Summary
Facility staff failed to implement interventions to prevent further decrease in range of motion (ROM) for a resident with multiple medical diagnoses, including pain, type 2 diabetes mellitus, heart failure, and major depressive disorder. The resident was admitted with these conditions and was identified as having limited mobility. Despite the facility's policy to provide maintenance and restorative programs to assist residents in achieving and maintaining the highest practicable outcome, there was no evidence in the resident's records of any restorative nursing program or interventions aimed at maintaining or improving ROM. Therapy screenings indicated that the resident would benefit from skilled services due to lack of mobility, but the resident refused out-of-bed activity and was only monitored and screened as needed. Observations revealed decreased ROM and nodules in the resident's left hand, and both the resident and the DON confirmed that no interventions were in place to prevent further decline in ROM. The comprehensive care plan and electronic health record lacked documentation of any such interventions.
Medication Error Rate Exceeds Regulatory Threshold Due to Administration Errors
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5%, as required by regulation, with observations revealing a rate of 10.71% based on 3 errors out of 28 medication administrations. The errors involved three residents. For one resident, a Certified Medication Assistant (CMA) administered an Advair Diskus inhaler but did not instruct the resident to rinse their mouth after use as ordered, instead providing water to drink. The CMA confirmed during interview that the resident was not cued to rinse their mouth. For two other residents, a Licensed Practical Nurse (LPN) administered insulin using insulin pens but primed the pens with only 1 unit instead of the 2 units specified in the manufacturers' instructions. The LPN confirmed during interviews that the pens were primed with 1 unit for both residents. Manufacturer instructions for both Lispro and Lantus insulin pens require priming with 2 units to ensure proper dosing. These actions resulted in medication administration errors as observed and documented by surveyors.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility staff failed to implement necessary interventions to prevent the development of pressure ulcers for a resident identified as being at risk. The resident, who was admitted with diagnoses including pain, hypertension, hemiplegia, and hemiparesis related to a cerebral infarction, was assessed to have moderately impaired cognition and was dependent on staff for various activities of daily living. The resident's care plan included the use of a low loss air mattress to prevent pressure ulcers, and a treatment was ordered for an existing wound on the buttock/coccyx area. Despite these measures, observations revealed that the resident's heels were consistently not elevated off the mattress, contrary to the facility's pressure ulcer prevention policy and national guidelines. Multiple observations over two days showed the resident's heels were in contact with the mattress, and interviews with staff confirmed that the heels should have been elevated, such as on a pillow, to prevent pressure ulcers. The facility's policy and national guidelines emphasize the importance of heel elevation to prevent pressure ulcers, particularly as the heel is a common site for such injuries. The failure to elevate the resident's heels as required by the care plan and guidelines represents a deficiency in the facility's care practices.
Failure to Implement Enhanced Barrier Precaution
Penalty
Summary
The facility staff failed to implement Enhanced Barrier Precaution (EBP) for a resident, identified as Resident 7, who was admitted with diagnoses including pain, hypertension, hemiplegia, and hemiparesis related to a cerebral infarction. The resident was dependent on assistance for eating, toilet use, dressing, personal hygiene, and rolling, and was at risk for pressure ulcer development. The resident also received tube feedings and had a treatment order for a wound on the buttock/coccyx to be completed three times a day. Despite these conditions, observations revealed that there were no indications in the resident's room or at the entrance that EBP was being implemented. Further observations showed that an LPN performed treatments on the resident without wearing a gown, and during an interview, the LPN admitted to not knowing what EBP was. The Director of Nursing confirmed that the resident should have been on EBP. The facility's infection control policy for EBP, revised earlier in the year, required staff to use gowns and gloves during the care of residents with wounds or indwelling medical devices, such as feeding tubes, which was not adhered to in this case.
Medication Room Security Breach
Penalty
Summary
The facility failed to ensure the security of the east medication room, which had the potential to affect 22 of 64 residents who were self-mobile and resided in the facility, as well as two unauthorized staff members. On the morning of May 23, 2024, observations revealed that the keys were left in the lock of the medication storage room door on the east side of the building, beside the nurses' station. This door was visible to anyone passing by in the hallway, and there were no staff present at the nurses' station at that time. Registered Nurse (RN)-A was observed at the end of the east hall, and a resident with severe cognitive impairment was in a wheelchair beside the nurses' station. Further observations showed that RN-A entered the medication room and removed the keys from the door at 4:40 AM. Interviews with RN-A and the Director of Nursing (DON) confirmed that the keys, which also included the key for the medication fridge padlock, should not have been left in the lock. The DON confirmed that the medication storage rooms are to be locked at all times and acknowledged that the east medication room was unsecured when the keys were left in the lock. The facility's policy requires that compartments containing drugs and biologicals be locked when not in use, and that access to controlled medications be separate from non-controlled medications.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and functional environment for its residents, as observed during a survey. Specific deficiencies were noted in seven resident rooms and two shower rooms, affecting 55 out of 64 residents. Observations included multiple scrapes on walls, irregular holes around air conditioner power intake covers, and dust-covered ventilation covers in several rooms. Additionally, a resident's wheelchair had a broken armrest with a sharp edge, and bathroom doors and baseboards showed significant wear and dust accumulation. The bathroom faucet in one room had poor water pressure, and there were gouges in the drywall around soap dispensers. Further observations revealed rusty and discolored ceramic tiles in the east and west shower rooms. Interviews with the Maintenance Director and the Director of Nursing confirmed these issues, with the Maintenance Director acknowledging the absence of work orders for the identified concerns. The Director of Nursing confirmed that 55 residents used the affected shower rooms, highlighting the widespread impact of these deficiencies on the facility's residents.
Failure to Address PTSD Triggers in Resident Care Plan
Penalty
Summary
The facility failed to evaluate and implement interventions to manage triggers for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD). The resident, who was admitted on September 20, 2023, was found to be cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. Despite this, the resident's Comprehensive Care Plan (CCP) did not include any mention of PTSD or interventions to mitigate triggers associated with the condition. Interviews with the resident revealed that they experienced difficulties at night and preferred having the TV on and a soft voice to wake them up, as sudden movements by staff could be frightening. Further interviews with the Director of Nursing (DON) and the Social Worker (SW) confirmed that there were no documented triggers or interventions for the resident's PTSD in their medical record. The SW admitted that no interview, assessment, or interventions had been completed for the resident's PTSD. The facility's Mood and Behavior Policy and Procedure, dated January 2024, emphasized a resident-centered approach to care, requiring individualized plans based on comprehensive assessments. However, this policy was not adhered to in the case of the resident with PTSD, leading to the deficiency.
Failure to Investigate and Report Alleged Misappropriation
Penalty
Summary
The facility staff failed to investigate and submit a written investigation of an alleged misappropriation to the state agency within the required 5 working days. This deficiency involved a resident who reported that a family member had stolen their Net Spend card, which is similar to a debit card. The facility had a census of 64 residents at the time of the incident. The Adult Protective Services (APS) report dated January 2, 2024, indicated that APS was notified of the alleged theft on the same day at 11:57 AM. During an interview conducted on May 22, 2024, the Director of Nursing (DON) confirmed that the investigation and the results had not been completed or sent to the required state agency. The facility's policy on abuse protection, dated January 2024, outlines the procedures for reporting and responding to incidents of abuse, neglect, or misappropriation. It specifies that reports must be made to the Department of Health and Human Services (DHHS) and local law enforcement within 24 hours after forming a reasonable suspicion, or within two hours if the events could result in serious bodily injury. However, the facility did not adhere to these procedures in this case.
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Surveyors found that the facility did not maintain a medication error rate below 5%, identifying multiple late and improperly timed medication administrations and a missing medication. A medication aide gave a cholesterol medication and wound-healing supplements significantly later than their scheduled times, and another aide administered acetaminophen well outside the ordered time window and could not obtain a prescribed dose of Ingrezza because it had not arrived from the pharmacy. An LPN administered fast-acting Humalog insulin before a meal when no food was available and was unaware of the required timing of insulin in relation to meals, while the facility’s insulin policy lacked guidance on meal-related timing despite manufacturer instructions specifying administration within 15 minutes before or immediately after eating.
A resident with severe cognitive impairment, a history of CVA, and total dependence for ADLs developed a new right ankle wound and a new DTI to the left heel. Facility policy and licensure rules require immediate notification of the resident representative and physician for significant changes in condition, but review of progress notes showed no documentation that the representative was informed. An LPN confirmed the representative was not updated about the new wounds, despite the requirement to do so.
A family member filed a written grievance about a staff member’s attitude toward a resident and the family member, but the facility did not complete the grievance documentation or ensure timely communication of the specific resolution. The grievance form lacked documented resolution and administrator review, the ADM was initially unaware of the grievance, and the SW delayed completing the form while awaiting permanent interventions from nursing leadership. Although staff reported discussing a general resolution with the resident and family, the family member later stated they had not been informed of the actual grievance resolution, and the grievance form was not fully completed until well beyond the facility’s stated 10–14 day timeframe for resolving grievances.
The facility failed to report an allegation of physical abuse to law enforcement as required by its abuse reporting policy. A cognitively intact resident with dementia, anxiety, bipolar disorder, and major depressive disorder reported refusing a shower when a NA placed a lift sling under them, after which the situation escalated and both the resident and the NA exchanged punches. Skin assessments documented multiple new bruises on both of the resident’s arms and hands that were not present the prior day. Although facility policy required timely notification of law enforcement for such allegations, documentation in the abuse report form and EHR showed no law enforcement notification, and facility leadership confirmed that the incident and bruising were not reported to police.
A resident receiving hospice services with a condition expected to limit life expectancy had a DNR order requested by their representative and entered into the medical orders, but the comprehensive care plan (CCP) was not updated to reflect this change in code status. Facility policy required the CCP to be reviewed and revised by the interdisciplinary team following MDS assessments, yet the CCP continued to show an earlier full code status instead of the current DNR. The SSS acknowledged that the code status should have been updated when the change was made.
A resident with ESRD on dialysis, Type 2 DM, A-fib, COPD, and CHF, and requiring total assistance with ADLs, had physician orders for sacral and coccyx skin care, including cleansing, application of preventative ointment up to four times daily and PRN, and use of a sacral mepilex dressing. The order appeared on the Order Listing Report but was absent from the Nurse Administration Record, so staff were not cued to provide the treatment. During observed incontinence care, the resident’s sacral area was pink and no mepilex dressing was in place. An LPN confirmed the treatment was ordered but not provided and attributed the omission to a possible electronic medical record glitch.
Two residents at risk for or with existing pressure ulcers did not receive appropriate, individualized pressure ulcer prevention and treatment. One resident with hemiplegia, severe cognitive impairment, total ADL dependence, and incontinence developed multiple heel and ankle wounds after initial blanchable redness was noted; ordered Prevalon boots were repeatedly unavailable, the order to use them at all times was not promptly updated in the NAR, a turning schedule was not entered into the EHR, tissue analytics were missed on a scheduled date, and a nutrition consult and initiation of ordered supplements for wound healing were significantly delayed. Another resident with a stage 2 pressure ulcer was repeatedly observed on a DermaFloat LAL mattress left on the firmest setting, and the DON confirmed staff had not followed the manufacturer’s instructions to adjust and verify the mattress setting to prevent bottoming out.
A resident with ESRD on dialysis, along with multiple comorbidities including CHF, COPD, A-fib, and Type 2 DM, had physician orders and a care plan for a therapeutic renal diet, a 1200 ml/day fluid restriction divided across meals and med passes, and no water pitcher in the room, consistent with facility policy for dialysis residents. Observations showed a full water pitcher at the bedside and meal trays providing more than the ordered 240 ml of fluid per meal, while documentation also reflected conflicting fluid restriction amounts. Staff confirmed the resident had been offered more fluid than ordered and that a water pitcher had been present. In addition, on a dialysis day, multiple scheduled 9 a.m. medications were not administered because the resident was away at dialysis and the facility had not coordinated medication timing around dialysis services, contrary to its own policy.
The facility failed to respond to resident call lights within its stated goal of 7 minutes, with documented response times exceeding 30 minutes for multiple residents. A cognitively intact resident reported being left on the toilet for extended periods, and call system data showed call lights active for well over an hour on several occasions. Another resident with moderately impaired cognition had call lights unanswered for more than an hour, including after returning from dialysis. A third cognitively intact resident reported waiting up to two hours, with records confirming multiple call light activations lasting over an hour. The DON acknowledged that call light times over 30 minutes were not timely.
A resident with ESRD on thrice-weekly dialysis, along with DM2, A-fib, COPD, and CHF and moderate cognitive impairment, did not receive scheduled morning medications, including metoprolol and linagliptin, while away at dialysis. The MAR documented that the 9 AM metoprolol dose was not given because the resident was away from the facility without medications, and a progress note confirmed that morning medications were not administered due to the dialysis appointment. The DON later confirmed these omissions and identified them as medication errors.
Failure to Maintain Acceptable Medication Error Rate and Proper Medication Timing
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with surveyors identifying 5 errors out of 39 opportunities, resulting in a 12.82% error rate. The facility’s policy allowed medications to be given within one hour before or after the scheduled time, but staff did not adhere to this window. One medication aide administered pravastatin 10 mg to a resident at 8:52 PM when it was scheduled for 7:00 PM, and confirmed it was given late. The same aide also administered LiquaCel 30 cc and Juven 1 packet to another resident at 9:20 PM, despite orders for these supplements to be given twice daily with morning and evening medications at 8:00 AM and 7:00 PM, and confirmed these were also late. Additional errors involved improper timing and availability of medications. An LPN administered 4 units of Humalog, a fast-acting mealtime insulin ordered to be given before meals, to a resident at 7:37 AM when the resident had no food present and did not receive a meal tray until 8:18 AM; the LPN stated they did not know how quickly food should be provided after fast-acting insulin. The facility’s insulin policy lacked guidance on timing relative to meals, while the manufacturer’s prescribing information specified administration within 15 minutes before or immediately after a meal. Another medication aide administered acetaminophen 500 mg (two tablets) at 7:30 AM instead of the scheduled 6:00 AM dose and was unable to locate the resident’s ordered Ingrezza 80 mg capsule, confirming the medication had not arrived from the pharmacy and required reordering. The DON confirmed that the acetaminophen should have been given at 6:00 AM.
Failure to Notify Resident Representative of New Wounds
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition, specifically the development of new wounds. The facility’s policy titled "Change in Condition" dated 05-21-2023 states that changes in a resident’s condition or treatment are to be immediately shared with the resident and/or resident representative and reported to the attending physician or delegate. The policy requires notification of the resident, resident representative, and physician for events such as accidents resulting in injury with potential need for physician intervention, significant changes in physical, mental, or psychosocial status, and the need to significantly alter treatment. Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) also requires immediate notification of the resident, the resident’s doctor, and a family member of situations that affect the resident. Record review showed that one resident, admitted on a specified date, had a history of cerebrovascular accident (stroke) affecting the right side, severe cognitive impairment with a BIMS score of 5, total dependence for toileting, hygiene, dressing, bed mobility, transfers, and bathing, frequent urinary incontinence, and constant bowel incontinence, and did not have a pressure ulcer at the time of the MDS dated 01-26-2026. A Tissue Analytics Document dated 03-03-2026 revealed the resident had developed a new wound on the right ankle and a new deep tissue injury to the left heel. Progress notes contained no indication that the resident’s representative was informed of these new wounds. In an interview, an LPN confirmed that the resident’s representative was not updated about the new wounds and acknowledged that they should have been.
Failure to Timely Complete and Communicate Grievance Resolution
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to resolve and communicate the resolution of a grievance submitted on behalf of a resident. The facility’s written policy required Social Services and department managers to investigate written grievances, submit a written report of findings to the administrator, and ensure the resident or complainant was informed of the investigation findings and corrective actions in a timely manner, with documentation on the grievance form. A family member filed a written grievance concerning a staff member’s attitude toward the resident and the family member. The initial grievance form obtained from the social worker showed the grievance was received, but the sections for resolution and administrator review were incomplete, and the administrator reported being unaware of the grievance until it was brought to attention by surveyors. Interviews revealed that the social worker left the grievance form incomplete because they were waiting for permanent interventions from nursing leadership and did not document the final, grievance-specific resolution until much later. The social services supervisor stated the grievance was being processed, and the assistant DON reported speaking with the staff member involved, who denied the allegation, and removing that staff member from the resident’s care. Although facility staff reported that grievance resolution had been provided to the resident and family through a one-to-one discussion, the resident’s family member later stated they had not been notified of the grievance resolution. The administrator indicated that a reasonable timeframe for grievance resolution, including completion and review of the form, was 10–14 days, but the grievance form was not fully completed until nearly two months after the grievance was filed, and the permanent, grievance-specific resolution was not communicated to the family at the time the grievance was initially addressed.
Failure to Report Alleged Physical Abuse and Resulting Bruising to Law Enforcement
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of physical abuse to law enforcement within the required timeframe. Facility policy, revised 08/08/2024, required the administrator or designee to notify multiple entities, including law enforcement, no later than two hours after an allegation involving serious bodily injury or within 24 hours if there was no serious bodily injury. The policy also specified notification of the state licensing authority, Ombudsman, resident representative, APS, the resident’s attending physician, and the facility medical director. Despite this written requirement, documentation showed that law enforcement was not notified following an allegation of physical abuse involving a resident. The resident involved had been admitted in 2019 and had diagnoses including moderate vascular dementia with agitation, generalized anxiety disorder, bipolar disorder, and major depressive disorder. A recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact, and noted episodes of care rejection but no documented physical behavioral symptoms toward others. On the date of the incident, a NA entered the resident’s room, placed a lift sling under the resident, and informed the resident they would be taking a shower; the resident reported refusing the bath and stated that the situation escalated into both the resident and the NA exchanging punches. Subsequent skin assessments documented multiple bruises on both upper extremities that were not present the day before. A Potential Resident Abuse Report Form and the EHR contained no evidence that law enforcement was notified, and both the Administrator and Social Services Supervisor confirmed in interviews that the allegation of physical abuse and associated bruising were not reported to law enforcement, contrary to facility policy and reporting requirements.
Failure to Update Comprehensive Care Plan to Reflect Current DNR Status
Penalty
Summary
The facility failed to update a resident’s comprehensive care plan (CCP) to reflect the current resuscitation status after a change in code status was ordered. Facility policy on Comprehensive Care Plans, last reviewed/revised on 09/02/2025, required the CCP to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Record review showed that the resident was admitted on 09/23/2024, had a condition or chronic disease that may result in a life expectancy of less than six months, and was receiving hospice services. A Do-Not-Resuscitate (DNR) order dated 04/03/2026 documented that the resident’s representative requested DNR status, and an order listing report showed a DNR order dated 04/22/2026. However, the resident’s CCP printed on 04/28/2026 at 9:18 AM still reflected a “full code, do not resuscitate” status dated 10/02/2024, indicating the CCP had not been updated to match the current DNR order. In an interview, the Social Services Supervisor confirmed that the code status should have been updated at the time of the code status change.
Failure to Implement Physician-Ordered Sacral Skin Treatment
Penalty
Summary
The deficiency involves the facility’s failure to implement physician-ordered skin integrity interventions for a resident with multiple comorbidities. The resident’s MDS dated 03-24-2026 documented End Stage Renal Disease with dialysis dependence, Type 2 Diabetes Mellitus, A-Fib, COPD, and Chronic Heart Failure, as well as moderate cognitive impairment with a BIMS score of 12. The resident required setup and cleanup assistance with eating and total assistance with hygiene, toileting, bathing, dressing, bed mobility, and transfers, and was receiving dialysis services. The physician’s order, as shown on the Order Listing Report printed 04-28-2026, directed staff to cleanse the buttocks and coccyx with foam soap and water, pat dry, apply preventative ointment up to four times daily and as needed for soiling, and secure the area with a sacral mepilex dressing. Despite this order, the Nurse Administration Record for April 2026 contained no entry for the ordered wound care to the buttocks and coccyx, meaning the treatment was not listed to cue staff for administration. During an observation of incontinence care on 04-30-2026 at 10:40 AM, the resident’s sacral area showed pink skin discoloration and there was no mepilex dressing present on the sacral or coccyx area, indicating the ordered treatment had not been provided. In an interview later that day at 2:30 PM, an LPN confirmed that the resident was supposed to receive wound care to the sacral and coccyx area, acknowledged that the treatment had not been provided, and stated there must have been a glitch in the electronic medical record program because the order did not appear on the NAR.
Failure to Implement and Adjust Pressure Ulcer Prevention and Treatment Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop, implement, and reevaluate effective interventions to prevent pressure ulcer development and to promote wound healing for two residents at risk or with existing pressure injuries. Facility policy required Braden Scale risk assessments on admission, weekly for four weeks, then quarterly or with significant change, and mandated a systematic approach including prompt assessment and treatment, monitoring, and modification of interventions as needed. The policy also required that interventions be adjusted when risk changed, when new or recurrent pressure injuries developed, when there was lack of healing progression, or when residents were non-compliant. The Braden Scale reference used by the facility defined scores of 10–12 as high risk and 13–14 as moderate risk for pressure ulcer development. One resident with a history of stroke, right-sided hemiplegia, severe cognitive impairment, total dependence for ADLs, and bowel and bladder incontinence was identified as at moderate to high risk for pressure ulcer development on admission, with a baseline care plan including a pressure-relieving wheelchair cushion and a comprehensive care plan identifying high risk for skin breakdown. The care plan listed general interventions such as Braden evaluations, observation and documentation of skin condition, use of a special mattress, skin hygiene, and nutritional and lab monitoring. A skin check initially showed no pressure ulcers, but a subsequent skin check documented blanchable redness to the right heel. An order was in place for Prevalon boots to be worn in bed, but progress notes over several consecutive days documented that the boots were not available, and heels were instead floated on a pillow. A pressure ulcer on the right heel was then identified, and later tissue analytics showed the wound had significantly enlarged, with additional findings of a new dark area consistent with a deep tissue injury on the right heel, a new wound on the right ankle possibly related to pressure or boot straps, and a deep tissue injury on the left heel. Practitioner instructions were to protect the heels at all times, including when out of bed and to avoid resting the feet on foot pedals, but the medication/nurse administration record was not updated to reflect the “at all times” order until many days after it was given. For this same resident, the facility did not promptly obtain a nutritional evaluation for wound healing, as the dietician’s assessment and recommendation for a nutritional supplement occurred several weeks after the first pressure ulcer was identified, and the ordered supplement was not started until several days after the recommendation. Tissue analytics documentation was also not completed on one of the scheduled dates, and interviews with nursing staff confirmed that a turning/repositioning schedule was not entered into the electronic health record to cue staff, despite the resident’s high risk and existing wounds. Staff interviews further confirmed that the resident was non-compliant with Prevalon boots and that the interdisciplinary team had not re-evaluated pressure-relief interventions for the feet during this period. Another resident, cognitively intact but totally dependent for bed mobility, transfers, and personal care, and always incontinent of bowel and bladder, was assessed as at risk for pressure ulcers and already had a stage 2 pressure ulcer. This resident was observed on multiple occasions lying in bed on a Joerns DermaFloat low air loss mattress that was consistently set at the firmest setting. The manufacturer’s instructions for this mattress required individualized adjustment of the comfort setting using a hand-check method to prevent bottoming out and directed that the proper setting be documented and re-evaluated as the resident’s condition warranted. The DON confirmed that the facility had not followed the mattress manual for setup for this resident and could not confirm that the mattress was at the correct setting to prevent bottoming out as described in the manual.
Failure to Adhere to Dialysis Resident Fluid Restriction and Medication Scheduling
Penalty
Summary
Surveyors identified that the facility failed to follow its own policy for dialysis residents and to adhere to physician-ordered fluid restrictions and medication timing for one dialysis-dependent resident. The facility’s policy required that dialysis residents receive fluids only as ordered by the physician, that nursing and dietary staff organize the division and distribution of fluids, that no water pitcher be present when restricted, and that medications be administered before departure and after return from dialysis so as not to interfere with treatment. The resident had end stage renal disease on dialysis, Type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, with a care plan and orders specifying a therapeutic diet, low potassium, no added salt, double protein, and a 1200 ml/day fluid restriction divided as 240 ml at each meal and 120 ml with each med pass, and no water pitcher in the room. Despite these orders and care plan interventions, observations showed a 600 ml water pitcher in the room filled to the 500 ml mark, and lunch trays that included a 240 ml milk carton plus additional juice and ice, exceeding the ordered 240 ml fluid allotment at meals. Record review further showed conflicting fluid restriction documentation, with an After Visit Summary listing a 1500 ml fluid restriction while the facility’s orders and care plan reflected a 1200 ml restriction, and staff interviews confirmed that the resident had been offered more than the ordered 240 ml of fluid with meals and that a water pitcher had been present contrary to the care plan. Additionally, the facility failed to coordinate medication administration around dialysis treatments. The Medication Administration Record documented that multiple scheduled 9 a.m. medications, including atorvastatin, fluticasone nasal spray, linagliptin, sennosides-docusate, metoprolol tartrate, mucinex ER, carboxymethylcellulose eye drops, and ipratropium-albuterol inhalation solution, were not given on a dialysis day because the resident was away from the facility without medications. The DON confirmed that these medications were omitted due to the resident being at dialysis and acknowledged not knowing that medication administration should be scheduled around dialysis services, contrary to the facility’s dialysis care policy.
Failure to Respond Timely to Resident Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely response to resident call lights, with multiple documented instances of response times far exceeding 30 minutes. One cognitively intact resident (BIMS score 13) reported being left on the toilet for a very long time in mid-January and again on a later date in April, though for a somewhat shorter period. Alarm Average Response Time Reports (AARTR) showed that this resident’s call light remained on for 167 minutes and 51 seconds on one January date, and for 46 minutes and 32 seconds and 73 minutes and 34 seconds during two separate call light activations in April. Another resident with moderately impaired cognition (BIMS score 12) had a family member report that the resident had to wait an hour to be laid down after dialysis. AARTR data for this resident showed call light durations of 61 minutes and 38 seconds and 76 minutes and 33 seconds on separate occasions in April. A third cognitively intact resident (BIMS score 15) reported having waited as long as two hours for a call light to be answered, and AARTR records documented call light durations of 65 minutes and 18 seconds and 63 minutes on two separate occasions. The DON stated that the facility’s goal for call light response was 7 minutes and confirmed that call light times over 30 minutes were not timely.
Failure to Administer Ordered Medications During Dialysis Absence
Penalty
Summary
The facility failed to ensure a resident was free from significant medication errors when required medications were not administered as ordered while the resident was away from the facility for dialysis. The resident had multiple serious diagnoses, including end stage renal disease requiring dialysis, type 2 diabetes mellitus, atrial fibrillation, COPD, and chronic heart failure, and was assessed with moderate cognitive impairment. The resident required extensive assistance with most activities of daily living and was receiving dialysis services three times weekly. The comprehensive care plan documented scheduled dialysis on Monday, Wednesday, and Friday. On a documented dialysis day, the resident did not receive the scheduled 9 AM dose of metoprolol tartrate 25 mg because the resident was away from the facility without medications. The medication administration record showed a code indicating the medication was not given due to the resident being away, and a progress note stated that morning medications were not administered because the resident was at dialysis that morning. Later, the physician ordered metoprolol to be given after the resident’s heart rate was found to be 116. In an interview, the DON confirmed that the resident did not receive metoprolol and linagliptin on that date and acknowledged that the omission constituted a medication error.
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Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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