Valley View Haven, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Belleville, Pennsylvania.
- Location
- 4702 East Main Street, Belleville, Pennsylvania 17004
- CMS Provider Number
- 395787
- Inspections on file
- 22
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Valley View Haven, Inc during CMS and state inspections, most recent first.
The facility failed to conduct the required tri-annual 4-hour load test for their Essential Electrical System, as per NFPA standards. The last test was documented in December 2021, indicating non-compliance with the 36-month testing schedule. This deficiency was confirmed during an interview with the CEO and Director of Campus Services.
The facility failed to maintain the automatic sprinkler system free of obstructions in one of two smoke zones. Several sprinkler heads in the Laundry Room were covered with debris, including in the Dryer Chase Room, Wash Machine Room, and Laundry Folding Room. This deficiency was confirmed during an exit interview with the CEO and Director of Campus Services.
The facility did not maintain hazardous area doors within allowed gap margins or ensure they were self-closing in one smoke zone. Observations revealed that the Mechanical Room and Storage Room doors in the basement exceeded the 1/8 inch gap margin and failed to self-close due to faulty coordinators.
The facility was found to have a building construction deficiency, as it is a two-story, Type III (200), unprotected ordinary structure, which is not permitted for health care facilities. This was confirmed during an exit interview with the CEO and Director of Campus Services.
The facility failed to maintain documentation verifying that the battery back-up emergency lighting system underwent the required annual testing, as identified during a document review. The absence of such documentation was confirmed by the CEO and Director of Campus Services, affecting the entire emergency lighting component.
The facility was found to have a smoke compartment on the 1st floor that exceeded the NFPA 101 maximum size of 22,500 square feet, as observed during a survey. This deficiency was confirmed in an exit interview with the CEO and Director of Campus Services.
The facility failed to maintain food safety standards, with issues such as grease buildup, dust, and open food in the kitchen, and undated juice containers in unit refrigerators. These deficiencies were confirmed by the Assistant Director of Nutritional Services and reviewed with the Nursing Home Administrator and DON.
The facility failed to implement proper infection control measures, including covering a resident's shingles rash, storing supplies correctly, and posting necessary signage for Enhanced Barrier Precautions. These deficiencies were confirmed through observations and staff interviews.
A facility failed to ensure the accuracy of a resident's discharge assessment. A discharge MDS inaccurately indicated that a resident was discharged to a hospital, while records showed the resident was discharged to home. This discrepancy was identified during a clinical record review and confirmed through interviews with the resident and staff.
A resident with a sacral ulcer did not receive timely reassessment and care updates, leading to wound deterioration. Initial observations of changes in the wound were not promptly addressed, resulting in a delay of 3.75 days before a registered nurse reassessed the wound, which had worsened by then.
A facility failed to provide appropriate respiratory care for a resident who required oxygen therapy. Observations revealed an oxygen concentrator with undated and improperly stored nasal cannula tubing. The resident confirmed not using oxygen recently, and the facility did not adhere to proper cleaning protocols for respiratory equipment, as emphasized by the American Association for Respiratory Care.
A facility failed to ensure nursing staff had the necessary competencies for medication administration and care of residents with indwelling urinary catheters and PEG tubes. A resident required specific catheter care, and another needed both catheter and PEG tube management. However, a registered nurse lacked documented competencies in these areas, as confirmed by the facility's administrator.
A facility failed to develop and implement a person-centered care plan for a resident diagnosed with dementia. Despite the resident's diagnosis, there was no evidence of a care plan addressing dementia and cognitive loss. This deficiency was confirmed by the Nursing Home Administrator and DON during a survey.
A resident was prescribed Lunesta, a sedative hypnotic, upon admission, but the facility failed to include this in the care plan or monitor target behaviors. Interviews with the administration confirmed the absence of a care plan or monitoring for the medication use.
A resident did not receive the recommended pneumococcal immunization due to the facility's failure to offer it when she became eligible. Despite having received previous pneumococcal vaccines, the resident required an updated vaccine according to CDC guidelines. The facility missed obtaining consent and offering the vaccine, as confirmed by the infection control preventionist.
The facility was found to have unsanitary conditions in the main kitchen and across five nursing units. Observations included dried food splatter, dust-covered vents, and improper food storage practices, such as storing ice cream with therapeutic ice packs and frozen meat products. These deficiencies were noted during a survey and discussed with the DON.
A resident's privacy was compromised when an audio monitoring system was used without documented consent. The facility's policy requires consent for sound monitoring, but during observations, voices were heard on an audio monitor at the nurses' station, including a conversation about toileting needs. The resident's clinical record lacked the necessary consent documentation, as confirmed by the Nursing Home Administrator and DON.
A facility failed to implement its abuse policy by not thoroughly investigating a missing Phenobarbital pill for a resident. Despite policies requiring investigation protocols for misappropriation, the facility did not conduct a thorough investigation, and there was no documented evidence of an investigation or witness statements. The DON confirmed these findings.
The facility failed to provide written notice of its bed hold policy to residents or their representatives during hospital transfers. This deficiency was identified for three residents who were transferred due to a change in condition. In each case, there was no documentation of the required notice being given. These findings were confirmed through clinical record reviews and interviews with the DON and the Nursing Home Administrator.
A facility failed to ensure accurate MDS assessments for a resident, as records incorrectly indicated active pneumonia and sepsis diagnoses, despite the resident not having these conditions since the previous year. An interview with the Administrator confirmed these findings.
A facility failed to follow physician orders for a resident's care, including the placement of bilateral halo enabler bars on the bed and the proper management of a boot for a right ankle fracture. The resident's clinical records showed no documentation of daily removal, washing, and proper reapplication of the boot as instructed by the podiatrist.
The facility failed to assess bed rail entrapment risks for two residents, only evaluating zones one, two, and three, while neglecting zones four, six, and seven. This oversight was identified through observations and clinical record reviews, indicating a deficiency in the facility's safety protocols.
The facility failed to provide required written notifications to residents and their responsible parties for hospital transfers. A resident was transferred without notification on two occasions, while another resident was transferred without notification on a separate occasion. The notifications should have included reasons for transfer, effective dates, new locations, and contact information for the State Long-Term Care Ombudsman and appeal rights.
Failure to Conduct Required 4-Hour Load Test for Essential Electrical System
Penalty
Summary
The facility failed to comply with the National Fire Protection Association (NFPA) standards for maintaining and testing their Essential Electrical System (EES). Specifically, the facility did not conduct the required tri-annual 4-hour load test for their generator and associated equipment. This test is crucial to ensure that the generator can supply power within 10 seconds in case of an emergency, as stipulated by NFPA 110 and NFPA 111 guidelines. During a document review and interview conducted on April 22, 2025, it was discovered that the last documented 4-hour load test was performed in December 2021. This indicates a lapse in the facility's adherence to the mandated testing schedule, which requires this test to be conducted every 36 months. The absence of this critical test could potentially compromise the facility's ability to provide essential power during emergencies. The deficiency was confirmed during an exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025. They acknowledged the failure to perform the tri-annual 4-hour load test, which is a significant oversight in maintaining the safety and operational readiness of the facility's electrical systems.
Plan Of Correction
Facility cannot retroactively correct the missed documentation. 4-hour load test will be completed. The maintenance director will be educated on the completion of the 4-hour load test completion. An audit will be completed quarterly to ensure the 4-hour load test is completed as required. Results of this audit will be reported to the Quality Assurance Steering Committee. Facility cannot retroactively correct the missed documentation. 4-hour load test will be completed. The maintenance director will be educated on the completion of the 4-hour load test completion. An audit will be completed quarterly to ensure the 4-hour load test is completed as required. Results of this audit will be reported to the Quality Assurance Steering Committee. Facility cannot retroactively correct the missed documentation. 4-hour load test will be completed. The maintenance director will be educated on the completion of the 4-hour load test completion. An audit will be completed quarterly to ensure the 4-hour load test is completed as required. Results of this audit will be reported to the Quality Assurance Steering Committee.
Sprinkler System Obstruction in Laundry Room
Penalty
Summary
The facility failed to maintain the automatic sprinkler system free of obstructions in one of two smoke zones. During an observation on April 23, 2025, between 10:15 AM and 10:20 AM, it was noted that several sprinkler heads were covered with debris. Specifically, debris was found on sprinkler heads in the Laundry Room's Dryer Chase Room, Wash Machine Room, and Laundry Folding Room, with four sprinkler heads affected in the latter. This deficiency was confirmed during an exit interview with the Chief Executive Officer and Director of Campus Services on the same day at 1:15 PM.
Plan Of Correction
The Sprinklers in the laundry room, dryer chase, and wash machine room were cleaned. Maintenance and Laundry was educated on how to complete cleaning on the sprinkler heads in the laundry room. Sprinklers will be audited weekly for 4 weeks, then monthly for 3 months, and then quarterly following. Results will be reported to the Quality Assurance Steering Committee.
Failure to Maintain Hazardous Area Doors
Penalty
Summary
The facility failed to maintain the doors of hazardous areas within the allowed gap margins and ensure they were self-closing in one of five smoke zones. During an observation on April 22, 2025, it was noted that the doors to the Mechanical Room and Storage Room in the basement exceeded the 1/8 inch gap margin and did not self-close due to faulty coordinators. This deficiency was confirmed during an exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025.
Plan Of Correction
Mechanical room door coordinator was corrected and door gaps are being adjusted to correct gap tolerances. Storage room door gap adjusted to correct gap tolerances. Maintenance staff will be educated on proper door enclosures. An audit of hazardous area enclosures will be completed monthly for 3 months and then quarterly following. Results of the audit will be reported to the Quality Assurance Steering Committee.
Building Construction Deficiency in Facility
Penalty
Summary
The facility failed to maintain building construction requirements as observed during a survey conducted on April 22, 2025. The building was identified as a two-story, Type III (200), unprotected ordinary structure, which is not permitted for health care facilities. This type of construction exceeds the maximum allowable story height for such a structure. The deficiency was confirmed during an exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025.
Plan Of Correction
The facility submits this Plan of Correction based on the Department of Health's identification of areas that are determined to represent deficient practice. Facility submits this Plan of Correction for the identified tag. The facility will request Division of Safety to conduct an FSES survey.
Failure to Document Annual Emergency Lighting Tests
Penalty
Summary
The facility failed to maintain proper documentation verifying that the battery back-up emergency lighting system had undergone the required annual testing. This deficiency was identified during a document review conducted on April 22, 2025, between 9:30 AM and 11:15 AM. The review revealed that there was no documentation available to confirm that the emergency lighting system, which is supposed to provide at least 1-1/2-hour duration of lighting automatically, had been tested annually as required by NFPA 101 standards. During an exit interview on April 23, 2025, at 1:15 PM, the Chief Executive Officer and the Director of Campus Services confirmed the absence of documentation verifying the annual tests of the battery back-up lighting system. This lack of documentation affects the entire component of the emergency lighting system, indicating a failure to comply with the necessary safety standards for emergency preparedness.
Plan Of Correction
Battery back-up emergency lighting testing will be completed. Maintenance staff will be educated on completion of battery back up emergency light testing. Battery back-up emergency lighting testing will be conducted and repeated annually. Random audit will be completed quarterly to ensure that battery back-up emergency lighting testing has been completed. Results will be reported to the Quality Assurance Steering Committee. Battery back-up emergency lighting testing will be completed. Maintenance staff will be educated on completion of battery back up emergency light testing. Battery back-up emergency lighting testing will be conducted and repeated annually. Random audit will be completed quarterly to ensure that battery back-up emergency lighting testing has been completed. Results will be reported to the Quality Assurance Steering Committee. Battery back-up emergency lighting testing will be completed. Maintenance staff will be educated on completion of battery back up emergency light testing. Battery back-up emergency lighting testing will be conducted and repeated annually. Random audit will be completed quarterly to ensure that battery back-up emergency lighting testing has been completed. Results will be reported to the Quality Assurance Steering Committee.
Smoke Compartment Size Exceeds NFPA 101 Standards
Penalty
Summary
The facility failed to comply with the NFPA 101 requirements for smoke compartments on the 1st floor, as observed during a survey conducted on April 22, 2023. The smoke compartment exceeded the maximum allowable size of 22,500 square feet, which is a violation of the standards set for smoke barriers in buildings with a patient bed capacity of 30 or more. This deficiency was confirmed during an exit interview with the Chief Executive Officer and Director of Campus Services on April 23, 2025.
Plan Of Correction
The facility will request the Division of Safety to conduct an FSES Survey.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations in the main kitchen and two nursing units. In the main kitchen, there was a moderate amount of black grease buildup in the fryer, dust accumulation on clean pans stored on top of the oven, and dried brown spills inside the food warmer. Additionally, the dishwashing area had a windowsill caked with white debris, and the walk-in freezer contained open boxes of hamburger patties and chicken breasts exposed to air. Food debris was also found under shelving units in the freezer, and a piece of metal wall covering was hanging off the wall in the walk-in cooler. Clean dishwashing racks had dried food debris, and an ice scoop was left uncovered on top of the ice machine, with dust and debris on the floor beneath it. The downstairs dry storage area had stained ceiling tiles and dried liquid inside a ceiling light cover. In the 200 and 300-unit nourishment rooms, refrigerators were stocked with individual juice containers without any indication of when they were placed there, their expiration dates, or when they needed to be used by. Employee 3, the Assistant Director of Nutritional Services, confirmed that the juices are delivered frozen and dated when removed from the freezer, but once stored in the unit refrigerators, they are not dated. Manufacturer instructions indicated that the juices should be used within 14 days of thawing, but there was no evidence to show when the juices were thawed or when the 14-day expiration would occur. These findings were reviewed with the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
All deficient items found in the kitchen, dishroom and pantries were corrected. Staff will be reeducated on proper food storage, dating and the daily, weekly and monthly cleaning list. Proper food storage, dating and labeling will be added to the closing list of each position to ensure each station is being checked before the employee leaves for the day. Kitchen walk throughs by management to ensure cleaning lists are being completed and that dating and labeling of food is correct. A weekly audit for 4 weeks to ensure that employees are completing cleaning lists and storing food properly. Results of this audit will be reported to the Quality Assurance Committee.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures for several residents, leading to deficiencies in care. Resident 96, who was admitted with a shingles rash, was observed in communal areas with the rash exposed, despite having orders for contact isolation. The rash was not covered, and the resident was seen interacting closely with others, which posed a risk of spreading the infection. The infection control nurse confirmed that the rash should have been covered to prevent transmission. Additionally, the facility did not adhere to proper storage protocols for resident supplies, as observed in the bathrooms of Residents 62 and 77. Supplies such as bladder pads and maxi pads were stored directly on the floor, which could contribute to the spread of infection. These observations were confirmed with the Nursing Home Administrator and Director of Nursing. The facility also failed to implement Enhanced Barrier Precautions (EBP) for Resident 101, who had an indwelling urinary catheter. There was no visible signage outside the resident's room to indicate the need for EBP, and the facility's policy did not include guidelines for posting such signage. Interviews with staff confirmed the lack of proper communication and education regarding EBP, which is necessary to protect both residents and staff from potential infections.
Plan Of Correction
Facility cannot retroactively correct implementation of signs for EBP for resident 101. Resident 101 discharged from facility. Transmission based precautions have been discontinued for residents 96 due to resolution of condition. Items stored on the floor for residents 62 and 77 were moved and appropriately stored. Signage for residents with EBP have been moved to the outside of the door. There are currently no other residents on contact precautions. Resident rooms will be checked to ensure proper storage of personal hygiene products. The policy for EBP will be updated to reflect the use of signage and its placement. Nursing staff will be educated on policy change, maintaining contact precautions and storage of personal hygiene products. An audit of sign placement for residents on EBP will be completed weekly x 4 weeks. An audit for contact precautions compliance will be completed weekly x 4 weeks. Random audits of resident rooms for storage of personal hygiene products will be completed weekly x 4 weeks. Results of this audit will be reviewed by the Quality Assurance Committee to evaluate the need for ongoing auditing or further education.
Inaccurate Discharge Assessment for a Resident
Penalty
Summary
The facility failed to ensure the accuracy of assessments regarding a resident's discharge status. Specifically, for Resident 105, a discharge MDS dated February 3, 2025, inaccurately indicated that the resident was discharged to a hospital. However, further review of the clinical records, including a discharge summary from the same date, revealed that the resident was actually discharged to home. This discrepancy was identified during a clinical record review and confirmed through interviews with the resident and staff. The issue was discussed with the Nursing Home Administrator and Director of Nursing on April 10, 2025.
Plan Of Correction
This Plan of Correction is submitted under Federal and state regulations and status applicable to long-term care providers. This Plan of Correction does not constitute an admission of liability on the part of the facility and such liability is hereby denied. The submission of this Plan of Correction does not constitute agreement by the facility that the surveyor's findings or conclusions are accurate, that the findings constitute a deficiency, or that the scope and severity regarding any of the deficiencies are cited correctly. Please accept this plan as our credible allegation of compliance. Discharge MDS for Resident 105 was corrected on 4/10/2025. Discharge MDS' completed over the last 30 days will be reviewed to ensure accuracy of section A2105. Assessment Coordinators will be re-educated on ensuring the accuracy of assessments prior to submission. An audit of discharged MDS will be completed monthly for 3 months to ensure accuracy. Results of this audit will be reviewed by the Quality Assurance Committee to evaluate the need for ongoing auditing or further education.
Failure to Provide Timely Wound Care Assessment
Penalty
Summary
The facility failed to provide the highest practicable care for a resident with a sacral ulcer. Resident 150 was admitted with a sacral ulcer, and an initial assessment was conducted with measurements recorded. However, on a subsequent date, staff found the resident's dressing missing and noted changes in the wound, including yellow slough and a slight odor. Despite these observations, there was a delay in reassessment by the registered nurse, assistant director of nursing/infection preventionist, who did not evaluate the wound until 3.75 days later. During this delayed assessment, the nurse observed further deterioration, including the presence of bone at the wound base and purulent drainage. The delay in timely assessment and intervention for Resident 150's sacral ulcer led to a failure in providing care in accordance with professional standards. The staff's initial observations of changes in the wound were not promptly addressed by the responsible nurse, resulting in a lack of timely updates to the resident's care plan. This deficiency was identified during a clinical record review and staff interview, highlighting the facility's failure to ensure timely and appropriate wound care management for the resident.
Plan Of Correction
Resident 150's wound continues to be assessed by Employee 1 during wound rounds. Staff present during clinical rounds on April 7, 2025, were educated on the action of the treatment ordered and assessing characteristics of an evaluation of wound odor only after the area is cleansed. The RN present during the dressing change to the wound on April 6, 2025, entered a late entry note with her assessment of the wound. The physician's assistant evaluated Resident 150's wound on 4/17/25 with Employee 1. New orders were received for testing and treatment of the sacral ulcer. Other residents with pressure injuries will continue to be evaluated by the wound nurse. Any concerns will be addressed with the provider. Any identified educational need from licensed nursing will be addressed by a Registered Nurse. Licensed nursing staff will be educated on evaluation of wound characteristics and expected outcomes with a debriding agent. Nursing staff will also be educated on notification of the RN present in the facility when a wound concern arises, assessment of the concern by the RN, and notification to the provider when the concern needs to be addressed. An audit of residents with pressure injuries will be completed weekly for 6 weeks to ensure that any concern for healing is evaluated by the Registered Nurse and addressed by the provider. Results of this audit will be reported to the Quality Assurance Committee.
Failure to Provide Proper Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for a resident, identified as Resident 28, who required respiratory care. The deficiency was identified through observation, clinical record review, and interviews. According to the clinical records, Resident 28 had a physician's order for oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation levels above 91 percent. However, it was noted that the resident last used oxygen on March 28, 2025, and during observations on April 8 and April 9, 2025, an oxygen concentrator was found beside the resident's bed with an undated humidification cannister and unbagged, undated nasal cannula tubing draped over the concentrator and onto the floor. The resident confirmed during an interview on April 8, 2025, that they had not used oxygen recently. The American Association for Respiratory Care emphasizes the importance of proper cleaning of respiratory equipment to reduce infection risk, which was not adhered to in this case. The findings were reviewed with the Nursing Home Administrator on April 10, 2025, highlighting the facility's failure to ensure proper respiratory care and equipment maintenance for Resident 28.
Plan Of Correction
Oxygen concentrator for resident 28 was removed from the room due to non-use. Residents utilizing oxygen will be reviewed to ensure the need for respiratory equipment in their room. Equipment not in use will be removed. Equipment being utilized will be checked to ensure that it is dated and bagged appropriately. Nursing and housekeeping staff will be educated on oxygen equipment dating and bagging will be completed. Staff will be further educated to remove medical equipment upon resident admission to the hospital. Clinical coordinators/ RN supervisors or designee will check rooms of residents that are transferred to the hospital to ensure no respiratory equipment that is not in use remains. This audit will be completed weekly for 4 weeks. Results of this audit will be reviewed by the Quality Assurance Committee to evaluate the need for ongoing auditing or further education.
Deficiency in Nursing Staff Competency for Specialized Care
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies and skill sets related to medication administration, care, and assessment of residents with indwelling urinary catheters and gastrostomy tubes. This deficiency was identified through a review of facility documentation, clinical records, employee personnel records, and staff interviews. Specifically, Employee 2, a registered nurse, did not have documented competencies in these areas, which are critical for the care of residents with specific medical needs. The facility's assessment, last updated in March 2025, indicated that RN competency and training should include catheter insertion and flushing, as well as medication administration, but did not explicitly cover RN care for artificial feeding systems. Resident 101 had active physician orders for urinary catheter irrigation and changes, while Resident 57 required specific care for both an indwelling urinary catheter and a PEG tube. Despite these needs, the facility could not provide evidence of Employee 2's competencies in these areas, as confirmed by the Nursing Home Administrator. The RN orientation checklist lacked verification of competencies in medication administration, indwelling catheter care, or PEG tube care, highlighting a gap in ensuring that nursing staff were adequately trained to meet the residents' care requirements.
Plan Of Correction
Employee number 2 competency related to medication administration, the care and assessment of residents with indwelling urinary catheters and gastrostomy tubes will be completed. A baseline audit of nurses will be reviewed and ensure competencies are completed. Skills competency will be added to orientation checklist to be completed during orientation period. Registered Nurses will be educated on completion of the competency. An audit of newly hired nurses will be completed to ensure completion of competency monthly for 3 months. Results of this audit will be reviewed by the Quality Assurance Committee to evaluate the need for ongoing auditing or further education.
Failure to Implement Dementia Care Plan
Penalty
Summary
The facility failed to develop and implement individualized person-centered care plans for a resident diagnosed with dementia, as required by regulations. Resident 27 was admitted to the facility with a diagnosis of dementia, which affects memory, language, problem-solving, and other cognitive abilities. Despite this diagnosis, a review of the resident's care plan revealed no evidence of a person-centered care plan addressing the resident's dementia and cognitive loss. This deficiency was identified during a clinical record review and staff interview, and confirmed by the Nursing Home Administrator and Director of Nursing, who acknowledged the absence of documentation for such a care plan prior to the surveyor's inquiry.
Plan Of Correction
The care plan for resident 27 was revised to reflect behavioral approaches related to cognitive loss and dementia. Other residents with dementia/cognitive loss care plans will be revised to reflect person-centered approaches to care. Staff will be educated on the implementation of person-centered care plans for residents with cognitive loss/dementia. A random audit of residents with dementia/cognitive loss will be completed to ensure person-centered care plans are implemented monthly for three months. Results of this audit will be reviewed by the Quality Assurance Committee to evaluate the need for ongoing auditing or further education.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from potentially unnecessary medication. Resident 101 was admitted on March 14, 2025, with an active physician order for Lunesta, a sedative hypnotic medication, to be administered at bedtime. The admission Minimum Data Set (MDS) completed on March 19, 2025, indicated that the resident was receiving a hypnotic medication, and the facility planned to develop a care plan for the psychotropic medication use. However, upon review, it was found that the care plans for Resident 101 did not include the use of a sedative hypnotic for sleep, nor did they include non-pharmacological interventions or identify target behaviors to support the continued use of the medication. Interviews with the Nursing Home Administrator, Director of Nursing, and an assistant director of nursing confirmed that there was no plan of care or monitoring of target behaviors for the resident's use of the sedative hypnotic.
Plan Of Correction
Resident 101 is no longer a resident of the facility. A baseline audit of residents utilizing psychotropic medications will be reviewed to ensure that care plans are in place to address target behaviors and non-pharmacological interventions. Nursing staff, Social Service, and Assessment Nurses will be educated on the implementation of care plans for residents utilizing psychotropic medications. An audit of residents with new orders for psychotropic medications will be reviewed to ensure the appropriate care plan is in place weekly for 4 weeks. Results of this audit will be reviewed by the Quality Assurance Committee to evaluate the need for ongoing auditing or further education.
Failure to Provide Updated Pneumococcal Immunization
Penalty
Summary
The facility failed to provide the recommended pneumococcal immunization to a resident, identified as Resident 4, as required by their policies and procedures. Resident 4 was admitted to the facility in February 2022 and had previously received two pneumococcal vaccines, Pneumovax 23 and Prevnar 13, prior to admission. According to CDC guidance, Resident 4's pneumococcal vaccinations would not be complete until she received a Prevnar 20 or Prevnar 21 at least five years after her last dose. However, there was no documented evidence that the facility offered Resident 4 the updated pneumococcal vaccination when she became eligible. An interview with the infection control preventionist, Employee 1, confirmed that the facility missed obtaining consent and offering the updated pneumococcal vaccination to Resident 4 when she became eligible. Employee 1 acknowledged that at the time of sending Prevnar 20 consents in January 2024, Resident 4 was not yet eligible. When she became eligible, the facility failed to follow up and offer the vaccination. This oversight was confirmed during a staff interview, and Resident 4's family later indicated their desire for her to receive the vaccination.
Plan Of Correction
Responsible party for resident number 4 was contacted and offered pneumonia vaccine. He initially consented, but due to resident's decline in condition, he has revoked his consent. A baseline audit of current residents was conducted. Consents for those that are eligible this year will be sent to responsible parties/residents. Residents that consented for pneumonia vaccines will be scheduled based on eligibility date. An audit of eligible residents will be conducted to ensure administration of pneumonia vaccine as ordered monthly for 3 months. Results of this audit will be reviewed by the Quality Assurance Committee to evaluate the need for ongoing auditing or further education.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in its main kitchen and across five nursing units, as observed by surveyors. In the main kitchen, significant dried food splatter was found on the wall near the dish machine, extending from the ceiling to the floor and onto adjacent areas. The exterior of a garbage can near the pot washing sink was covered with dried liquid spills and food. Additionally, the vents on the hood unit above the cooking area were covered in dust, and a [NAME] by the food serving line had a buildup of crumbs, dried food, and debris. In the nourishment areas of the nursing units, various unsanitary conditions were noted. On the 400 unit, a large brown water stain was observed under the sink, and a drawer with beverage mugs and thickening packets was significantly worn, exposing a paperboard surface. The 500-unit nourishment area had a refrigerator/freezer with a folded towel and therapeutic ice packs stored alongside ice cream cups, and the bottom storage bins contained dust, debris, and a dried brown substance. Similar issues were found in the 200, 600, and 700-unit kitchen areas, where ice cream was stored with therapeutic ice packs and frozen meat products, indicating improper food storage practices.
Privacy Breach Due to Unauthorized Audio Monitoring
Penalty
Summary
The facility failed to respect a resident's privacy by improperly using an audio monitoring system without obtaining the necessary consent. The policy on sound monitoring, last reviewed on May 22, 2024, states that sound monitoring systems may be used in a resident's room to alert staff when a resident attempts to rise without assistance, but only after other interventions have proven ineffective. Consent from the resident or their representative must be documented in the resident's electronic medical record before initiating sound monitoring. However, during observations on May 28 and 29, 2024, voices were heard on an audio monitor at the nurses' station, including a conversation about toileting needs involving a resident. A review of the clinical records for the resident involved revealed that the facility admitted the resident on August 11, 2022, and added a sound detection monitor to their care plan on October 4, 2023, to be used during sleeping hours. Despite this, there was no documented consent for the use of the audio monitor in the resident's clinical record. Interviews with the Nursing Home Administrator and Director of Nursing confirmed the lack of consent documentation and that the audio monitor was intended for use only during sleeping hours. This oversight resulted in a breach of the resident's right to privacy.
Failure to Investigate Missing Medication
Penalty
Summary
The facility failed to implement its abuse policy regarding the thorough investigation of missing medications for a resident. The policy, titled Abuse Prevention Program, requires the development of investigation protocols for the misappropriation of property, including medications. However, the facility was unable to provide further policies or procedures regarding these investigation protocols. Additionally, the Medication Error Guidelines policy states that a search should be conducted for missing medication, and if it cannot be found, the responsible staff member may be suspended pending an investigation. Despite these policies, the facility did not conduct a thorough investigation into the missing Phenobarbital pill for the resident. The clinical record review revealed that a narcotic count discrepancy was noted for the resident, with one Phenobarbital pill missing and not signed out by the medication nurse. Employee 1, an LPN, was unable to account for the missing pill, and it was unclear if an extra dose was given to the resident. The facility's investigation only concluded that Employee 1 might have given an extra dose, without thoroughly investigating the possibility of misappropriation. There was no documented evidence of an investigation, including witness statements from Employee 1, the previous shift medication nurse, or the registered nurse supervisor. The Director of Nursing confirmed these findings.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to provide written notice of its bed hold policy to residents or their representatives at the time of transfer to a hospital, as required. This deficiency was identified for three residents who were transferred to the hospital due to a change in condition. Specifically, Resident 97 was transferred on April 26, 2024, Resident 105 was transferred on April 2 and April 27, 2024, and Resident 56 was transferred on April 9, 2024. In each case, there was no documentation indicating that the facility provided the required written notice regarding the bed hold policy to the residents or their responsible parties upon their transfer to the hospital. These findings were confirmed through clinical record reviews and interviews with the Director of Nursing and the Nursing Home Administrator.
Inaccurate MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for a resident. A review of the resident's clinical record revealed discrepancies in the MDS assessments dated February 21, 2024, and May 14, 2024. These assessments incorrectly indicated that the resident had an active pneumonia infection and a sepsis diagnosis, despite the resident not having these conditions since December 16, 2023. An interview with the Administrator on May 30, 2024, confirmed these findings.
Failure to Follow Physician Orders for Resident Care
Penalty
Summary
The facility failed to provide the highest practicable care for a resident, identified as Resident 105, by not adhering to physician-ordered interventions and treatments. A clinical record review revealed a current physician order for the placement of bilateral halo enabler bars on the resident's bed, which were not observed during a surveyor's visit. Additionally, the resident had attended a podiatry appointment for a right ankle fracture, resulting in an order for a boot on the right lower extremity (RLE). The podiatrist instructed that the boot be removed daily, the leg washed, and the boot reapplied with a sock, ensuring the foot was flat and the heel was in the back of the boot. However, there was no documentation indicating that these instructions were followed from the date of the order until the surveyor's identification of the issue.
Failure to Assess Bed Rail Entrapment Risks
Penalty
Summary
The facility failed to adequately assess the risk of side rail entrapment for two residents, identified as Residents 97 and 106, during a survey for accident hazards. The facility's assessment process only evaluated zones one, two, and three, neglecting to assess zones four, six, and seven, which are critical for ensuring resident safety. Specifically, for Resident 97, the facility's documentation indicated that zones four, six, and seven were marked as not applicable, despite the presence of bilateral halo enabler bars on the bed. Similarly, for Resident 106, there was no documentation of an assessment for zones six or seven, even though a halo enabler bar was present on the door side of the bed. The oversight in assessing these zones was identified through observations and clinical record reviews conducted by the surveyors. The lack of comprehensive assessment for all potential entrapment zones represents a significant deficiency in the facility's safety protocols. The Director of Nursing was informed of these findings during an interview with the surveyor, highlighting the need for a more thorough evaluation process to prevent potential safety risks associated with bed rail use.
Failure to Provide Required Transfer Notifications
Penalty
Summary
The facility failed to provide timely written notification to residents and their responsible parties regarding hospital transfers, as required by regulations. Specifically, for Resident 97, there was no documentation of written notification to the responsible party when the resident was transferred to the hospital on April 26, 2024, following a change in their condition. The notification should have included the reason for the transfer, the effective date, the new location, contact information for the State Long-Term Care Ombudsman, and details about the resident's appeal rights. Similarly, Resident 105 was transferred to the hospital on two occasions, April 2 and April 27, 2024, without the required written notification to the resident or their responsible party. Additionally, Resident 56 was transferred to the hospital from April 9 to 11, 2024, without evidence of written notification to their responsible party. These deficiencies were confirmed by the Nursing Home Administrator and Director of Nursing during interviews conducted by the surveyor.
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Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Failure to Coordinate Hospice Services in Care Plans: The facility failed to coordinate hospice services with facility services for three residents receiving hospice care. One resident’s care plan did not include hospice needs despite hospice enrollment, and two residents’ comprehensive care plans lacked hospice agency contact information and access to the hospice 24-hour on-call system. The RNAC confirmed the omissions during interview; the residents had diagnoses including HTN, heart failure, kidney disease, diabetes, hypokalemia, and vitamin D deficiency.
Cross contamination occurred during a dressing change when an LPN placed a resident’s foot directly on the wheelchair seat without a barrier and did not clean the bedside table after the procedure. The facility also lacked infection surveillance documentation for several months, and its Legionella water management plan was incomplete, with no mapping of high-risk areas, no temperature logs, and no documented preventive measures for unused areas.
Failure to implement an antibiotic stewardship program. The facility’s infection control policy stated that antibiotic use protocols and a system to monitor antibiotic use would be part of the infection control program, but the Infection Control Program lacked documented evidence of antibiotic monitoring or review of appropriate antibiotic use for 3 months. The RN IP stated she had taken over the program, was also supervising the building, and had not been able to complete the program work or review the binders; administration confirmed the lapse.
Failure to Use Resident’s Preferred Name: A resident with HTN, anxiety, and depression had a preferred name documented in the care plan and MDS, but the name tag at the room entrance did not reflect that preference. When staff greeted the resident using the name on the door, the resident stated she did not like being called that and gave her preferred name. Staff interviews confirmed the preferred name was not listed at the door, and the ADON and DON acknowledged the omission.
A resident's confidential medical information was left visible on the East med cart computer screen at the nurses station when the cart was unattended. An RN confirmed the observation and acknowledged that resident personal and clinical information was exposed to anyone passing by.
The facility failed to provide written bed-hold policy notice to two residents or their representatives during hospital transfers. One resident had HTN, kidney disease, and hypokalemia, and another had hyperlipidemia, CHF, and a right femur fracture; records showed hospital transfers, but no documentation that the required bed-hold information was given at the time of transfer.
Failure to monitor weight and individualize nutrition care plans: one resident did not have a required monthly weight recorded, despite facility policy requiring monthly weights by the 7th day of each month, and two residents had care plans that did not reflect their specific nutritional needs. One resident had dx including HTN, PVD, and a thyroid disorder with orders for a renal diet, mechanical soft texture, and Magic Cup BID, while another resident had documented significant wt loss, a regular lactose-free diet, and nutritional juice with meals. Staff confirmed the missing weight and the lack of individualized care plan interventions.
Unlocked treatment cart and improper medication storage were observed in multiple areas. An unlocked, unattended treatment cart was found in a hallway, and the East Medication Room contained personal items mixed with medication supplies. Opened Tubersol vials in two refrigerators and multiple opened meds in the A Hall and C Hall medication carts were not dated, and an LPN confirmed several of the findings.
Failure to Maintain a Qualified Infection Preventionist: The facility did not maintain a consistent qualified onsite IP responsible for infection prevention and control for one month after the former IP resigned. An RN assumed the role while also supervising the building, reported limited time to perform the duties, and could not produce a certificate for completion of the Nursing Home Infection Preventionist Training Course.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
Failure to Coordinate Hospice Services in Care Plans
Penalty
Summary
The facility failed to ensure coordination of hospice services with facility services to meet the end-of-life care needs of three residents. Review of the facility’s hospice policy showed that coordinated care plans for residents receiving hospice services were to include the most recent hospice plan of care and the care and services provided by the facility. For Resident R9, the record showed admission to hospice with a diagnosis of hypertensive heart disease, and the MDS indicated hospice care was received while a resident; however, the current care plan did not include a hospice care plan. During interview, the RNAC confirmed the facility failed to implement a care plan for Resident R9’s hospice needs. For Resident R24 and Resident R78, the records showed physician orders to admit each resident to hospice services. Their current comprehensive care plans did not include coordination details for hospice services, including contact information for the hospice agency or how to access the hospice’s 24-hour on-call system. During interview, the RNAC confirmed the facility failed to include this information in the plan of care and failed to ensure coordination of hospice services with facility services for these residents. Resident R24’s diagnoses included high blood pressure, kidney disease, and hypokalemia, and Resident R78’s diagnoses included high blood pressure, kidney disease, and vitamin D deficiency.
Cross Contamination During Dressing Change and Infection Control Program Deficiencies
Penalty
Summary
Cross contamination occurred during a dressing change for Resident R24. The resident was admitted to the facility and had diagnoses including peripheral vascular disease and diabetes. A physician order dated 4/27/26 directed the right lateral foot to be cleansed with normal saline, patted dry, treated with Santyl ointment, and covered with a dry dressing daily and as needed. During observation of the dressing change on 5/5/26, the LPN prepared a clean area on the resident’s over-bed table with a barrier and supplies, cleansed the foot, then placed the resident’s right foot directly on the wheelchair seat without placing a barrier before applying the ointment and dressing. After the dressing was completed, the LPN gathered and discarded supplies, removed the barrier from the over-bed table, and exited the room. During interview, the LPN confirmed that a clean barrier had not been placed on the wheelchair seat before the resident’s foot was placed there and confirmed that the bedside table was not cleaned after the supplies and barrier were removed. The LPN also confirmed the failure to prevent cross contamination during the dressing change. The facility also failed to maintain infection control surveillance for three months, as the infection control documentation did not show tracking of resident infections for February 2026, March 2026, and April 2026. When asked about the surveillance system, the RN who had taken over the program stated she had not done anything since taking over on 4/4/26 and had not looked at the infection control binders. The NHA confirmed the facility failed to implement an infection control program that included a system of surveillance to identify possible communicable diseases or infections for those months. In addition, the facility’s Legionella water management plan lacked mapping of high-opportunity areas, water temperature logs, and evidence of preventive measures for areas not in use, and staff could not provide logs or explain required temperatures during interviews.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an antibiotic stewardship program for 3 of 10 months, specifically February 2026, March 2026, and April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that an antibiotic stewardship program would be part of the overall infection control program and that antibiotic use protocols and a system to monitor antibiotic use would be implemented. However, review of the Infection Control Program for February 2026, March 2026, and April 2026 found no documented evidence that antibiotic monitoring or review of appropriate antibiotic use was completed. During a telephonic interview on 5/6/26, the RN infection preventionist stated she took over the Infection Control program on 4/4/26, was also supervising the building, had only been looking at records for reportable issues, had not been able to do the program since starting, and had not seen the binders. Nursing home administration confirmed during an interview on 5/6/26 that the facility failed to implement an antibiotic stewardship program for those 3 months.
Failure to Use Resident’s Preferred Name
Penalty
Summary
The facility failed to treat a resident with respect by not addressing the resident by the preferred name. Review of the resident’s care plan showed the name the resident preferred to be called, and the MDS also documented that preferred name. The resident had diagnoses of high blood pressure, anxiety, and depression. During an observation and interview, the resident’s name tag at the entrance of the room did not show the preferred name, and when the resident was greeted using the name listed on the door, the resident stated she did not like being called that and stated the preferred name. Staff interviews confirmed that residents are asked about name preferences on admission and that preferred nicknames are included in the care plan, but the Activities Director was unsure who was responsible for ensuring the preferred name was listed at the door. A nurse aide stated nurses are usually responsible for placing the name tag at the entrance of the door, though aides sometimes do it. Subsequent observations confirmed the preferred name was still not listed on the door, and the ADON and DON both confirmed that the resident’s preferred name choice was not listed at the entrance of the door.
Failure to Protect Confidential Resident Information
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's medical information on the East Medication Cart. Facility policy titled Quality of Life - Dignity, dated 1/6/26, stated that staff shall maintain an environment in which confidential clinical information is protected. During an observation on 5/4/26 at 11:38 a.m., the East Medication Cart at the nurses station was left unattended with the computer screen open, and identifiable resident personal and confidential information was visible to anyone passing by. During an interview at the same time, RN Employee E9 confirmed the observation and acknowledged that the facility failed to maintain the confidentiality of residents' medical information.
Failure to Notify Residents of Bed-Hold Policy During Hospital Transfers
Penalty
Summary
The facility failed to notify the resident or the resident’s representative of its bed-hold policy for two hospital transfers. Facility policy stated that at the time of transfer for hospitalization or therapeutic leave, the facility would provide written notice explaining the duration of the bed-hold policy and information about the resident’s return to the next available bed, and that in an emergency transfer the notice would be provided within 24 hours. For Resident R24, who had diagnoses including high blood pressure, kidney disease, and hypokalemia, the record showed a hospital transfer on 3/31/26 and return on 4/5/26, but there was no documented evidence that written bed-hold information was provided at the time of transfer. For Closed Resident Record CR87, the record showed diagnoses including hyperlipidemia, congestive heart failure, and a right femur fracture. On 2/6/26, staff received venous doppler results indicating a nonocclusive thrombus in the right common femoral vein, relayed the results to the CRNP, and obtained orders to increase Eliquis temporarily and repeat an ultrasound. After the resident’s daughter called and staff reported the situation to the CRNP, the resident was sent to the hospital around 5:50 p.m. The emergency room transfer form and the clinical record did not include documented evidence that CR87 or the representative were provided written information about the facility’s bed-hold policy at the time of transfer.
Failure to Monitor Weight and Individualize Nutrition Care Plans
Penalty
Summary
The facility failed to properly monitor weight and nutrition status for two residents. For one resident, no monthly weight was recorded for April 2026, even though the facility policy required monthly weights to be obtained by the 7th day of each month and documented in the electronic medical record. That resident’s record showed diagnoses of high blood pressure, PVD, and a thyroid disorder, and the physician had ordered a renal diet, mechanical soft ground meat texture with a low fat diet for low protein, and Magic Cup twice daily for additional nutrition. A nurse aide confirmed that the monthly weight was not obtained. The facility also failed to individualize care plans to address resident-specific nutritional concerns for two residents. For one resident, the care plan identified potential nutritional problems related to dysphagia and the need for a mechanically altered and therapeutic diet, but it did not include resident-specific interventions for the ordered renal diet, mechanical soft diet, or supplements. For the second resident, the MDS indicated a 5% or greater weight loss in the last month or 10% or greater in 6 months, and the resident was not on a physician-prescribed weight loss regimen. That resident had orders for a regular lactose-free diet and nutritional juice with meals, but the care plan only included a general intervention to serve the diet as ordered and did not address the weight loss or the ordered diet and supplement needs. An RNAC confirmed the care plans were not individualized for these nutritional concerns.
Unlocked Treatment Cart and Improper Medication Storage
Penalty
Summary
The facility failed to properly secure a treatment cart while it was not in use and failed to properly store medications in the East Medication Room, the A Hall Medication Cart, and the C Hall Medication Cart. Facility policies reviewed indicated medication carts are to be kept closed and locked when out of sight of the medication nurse, and compartments containing drugs and biologicals are to be locked when not in use. The policy also stated that when opening a multi-dose container, the date opened shall be recorded on the container. During an observation on the East side, the treatment cart was found in the hallway near a room, unlocked and unattended. An LPN confirmed the cart had been left unlocked and unattended. In the East Medication Room, surveyors observed personal items and clothing stored with medication-related supplies, including cups, a tote bag, sweaters, pants, blankets, wheelchair cushions, and leg rest bags. The East first hall and second hall refrigerators each contained two opened vials of Tubersol solution that were not labeled with a date. In the A Hall Medication Cart, surveyors observed opened Nystatin liquid, Latanoprost eye drops, and a Trelegy Ellipta inhaler that were not dated, along with a coffee cup, pastry, sliced red peppers, and a personal cell phone in the cart compartment; an LPN confirmed the items belonged to her. In the C Hall Medication Cart, surveyors observed opened Robitussin cough suppressant, Milk of Magnesia, Miralax powder, and lactulose liquid that were not labeled with a date, and an LPN confirmed the findings.
Failure to Maintain a Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a consistent qualified individual onsite who was responsible for implementing programs and activities to prevent and control infections for one of 10 months, identified as April 2026. The facility’s Infection Control Plan, Program and Committee policy, last reviewed on 1/6/26, stated that the designated Infection Preventionist is responsible for oversight of the infection control program and serves as a consultant to staff on infectious diseases, resident room placement, isolation precautions, staff and resident exposures, and surveillance and epidemiological investigations. During interviews, Human Resource staff stated that the former Infection Preventionist resigned, with the last day of employment on 4/4/26. A Registered Nurse who took over the infection control program stated she assumed the role on 4/4/26, was also supervising the building, looked at records to see if any were reportable, and had not been able to fully do the work since starting, estimating about 12 hours per week. She also stated that her infection control training and certification had been completed long ago and she would need to find it. Review of the facility-provided certification courses showed training completed in 2022, but there was no certificate for completion of the Nursing Home Infection Preventionist Training Course. Nursing Home Administration confirmed the facility failed to designate a consistent qualified individual onsite responsible for infection prevention and control during that month.
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