Life Care Center Of Athens
Inspection history, citations, penalties and survey trends for this long-term care facility in Athens, Tennessee.
- Location
- 1234 Frye Street Po Box 786, Athens, Tennessee 37371
- CMS Provider Number
- 445298
- Inspections on file
- 16
- Latest survey
- March 28, 2026
- Citations (last 12 mo.)
- 12 (1 serious)
Citation history
Health deficiencies cited at Life Care Center Of Athens during CMS and state inspections, most recent first.
Failure to protect residents from sexual abuse: A resident with severe cognitive impairment and dementia repeatedly displayed public sex acts, disrobing, and inappropriate touching toward other residents, staff, and visitors. Staff documented the behaviors over several months, but the DON did not treat them as sexual abuse because of the resident’s dementia and secured-unit placement, and the care plan was not updated with new interventions. Surveyors directly observed the resident exposing herself, touching another resident’s bare chest, and grabbing another resident’s buttocks.
Administration failed to provide effective oversight after a resident repeatedly displayed sexually inappropriate and abusive behaviors that were documented over several months. Staff reported incidents including kissing, touching, and exposure involving other residents, staff, and visitors, but the DON stated staff did not know how to manage the behaviors and that reporting depended on whether the resident had dementia. The Administrator confirmed there were no PIPs in place for sexually inappropriate behaviors or sexual abuse in the secured memory care unit.
QAPI failed to identify and track repeated sexual abuse and sexually inappropriate behavior involving a cognitively impaired resident with Alzheimer’s disease, TBI, and delusional disorder. The resident had repeated public sexual acts and inappropriate touching toward other cognitively impaired residents, staff, and surveyors, while the DON viewed the behavior as merely being "huggy" and the IDT had not formally discussed the specific abuse pattern.
Missing Physician and Resident Representative Signatures on Secured Unit Reviews: The DON confirmed that secured unit IDT evaluations for six residents lacked physician documentation of clinical criteria for continued placement and lacked required physician signatures. Two residents also had no resident or resident representative signature on the continued stay review. The affected residents had diagnoses including dementia, psychosis, mood disorders, anxiety, depression, and other cognitive impairments, and the facility policy required ongoing review and documentation for residents in a secure or locked area.
Wheelchair footrests were repeatedly missing for a resident who used a wheelchair for mobility and had severe cognitive impairment, bilateral extremity impairment, and dependence on staff for ADLs. Staff also left call lights out of reach for two residents with severe cognitive impairment; one resident’s call light was wrapped around the bed rail or on the floor, and another resident’s call light was wrapped behind the bed, with a CNA confirming both were out of reach.
Failure to Investigate Repeated Sexual Behaviors and Unexplained Bruising: The facility did not thoroughly investigate repeated public sex acts and sexually abusive touching by a resident with severe dementia, including incidents involving another resident, staff, and visitors. Staff and the DON acknowledged the behaviors but did not treat them as sexual abuse or complete documented investigations. The facility also did not investigate bruising and a scratch on the resident's breast and chest that persisted over several weeks and was not officially classified as an injury of unknown origin.
Failure to provide grooming assistance for two residents with ADL deficits. One resident with impaired mobility and another resident with severe cognitive impairment were observed with facial hair, and both were dependent on staff for hygiene. Staff stated shaving was to be offered on shower days, but the CNA did not recall offering it to either resident, and the ADON confirmed female residents were to be offered shaving when facial hair was observed.
Failure to provide foot and nail care: A resident with severe cognitive impairment, bilateral extremity functional impairment, and dependence for ADLs was observed in bed with heel protectors in place and long, jagged, untrimmed toenails curving over multiple toes on both feet. The care plan called for staff to keep nails trim and clean and refer to podiatry as needed, but the SSD was unaware the resident needed podiatry and an LPN/WCN confirmed she had not provided nail care or notified the SSD after skin assessments.
Soiled Nebulizer Circuit Left Improperly Stored: A resident with COPD and moderate cognitive impairment had a nebulizer circuit observed with dried residue between the corrugated rings, with the mouthpiece resting on the nightstand and part of an emesis bag lying across the tubing. Staff confirmed the circuit was not cleaned, covered, or stored appropriately, despite the resident’s nebulizer order and facility policy for clean, labeled, dated storage and weekly changes.
Expired and undated OTC medications were found available for resident use in a medication cart and the Central Supply room. Surveyors observed expired Prilosec OTC, an opened and undated bottle of Cetirizine, and several expired items including Iron tablets, Aspirin, Cholest Off Plus, and Acid reducer tablets. An LPN UM, the SC, and the ADON all confirmed the medications were expired or undated and had not been removed from inventory or discarded.
Expired Food and Unclean Resident Refrigerators: The facility failed to discard expired food items and keep personal refrigerators clean for two residents. One resident had severe cognitive impairment and another was cognitively intact, yet both refrigerators contained expired food and no thermometer or temperature log documentation was present. The DON stated there was no system in place for monitoring resident refrigerators for expired items or temperatures.
Hand hygiene was not offered to three residents during lunch tray service, including residents with severe or moderate cognitive impairment and ADL dependence. In a separate finding, an LPN unit manager confirmed that a resident with a neurogenic bladder and indwelling urinary catheter had an unsecured, exposed drainage evacuation tip hanging near the wheelchair wheel.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual abuse when Resident #49, who had Alzheimer’s disease, traumatic brain injury, delusional disorder, and severe cognitive impairment, repeatedly exhibited public sex acts, disrobing, and sexually inappropriate touching toward other residents, staff, surveyors, and visitors. The record showed multiple documented incidents from 11/2025 through 3/2026, including public sex acts on numerous dates, kissing male peers, wandering into other residents’ spaces, and grabbing or touching others inappropriately. The quarterly MDS assessments documented severe cognitive impairment and frequent sexually inappropriate behaviors, but the care plan was not revised with new interventions after those behaviors were identified. The facility also failed to notify the Medical Director and PMHNP of the sexually inappropriate behaviors documented and exhibited by Resident #49. The PMHNP note described chronic wandering, fixation on male residents, agitation, and difficulty with redirection, but the facility did not identify the behaviors as sexual abuse despite the resident’s inability to consent. The DON stated she was aware of the behaviors but did not categorize them as sexual abuse because the resident had dementia and lived on the secured memory care unit. Surveyors directly observed Resident #49 exposing her bare breasts, touching Surveyor #2’s breast, rubbing Surveyor #1’s back and buttocks, placing her hands inside Resident #88’s shirt and rubbing the resident’s bare chest, and grabbing Resident #15’s buttocks. Resident #49 was also observed holding hands with Resident #88 and lying with the resident in bed. Resident #88 had vascular dementia with severe cognitive impairment and daily behaviors, and Resident #15 had vascular dementia with severe cognitive impairment for daily decision making. The report states the facility failed to identify the conduct as abuse and failed to provide the necessary care, services, and interventions to prevent sexual abuse.
Failure to Identify and Manage Resident Sexual Abuse
Penalty
Summary
Administration failed to provide effective leadership and oversight after Resident #49 exhibited repeated sexually abusive behaviors that were documented by staff over several months. Facility records showed multiple entries for Public Sexual Acts in November, December, January, February, and March, and MDS assessments dated 10/10/2025, 12/29/2025, and 2/3/2026 documented behaviors of grabbing, disrobing, and abusing others sexually. The facility policies reviewed stated that abuse prevention included identifying, assessing, care planning, and monitoring residents with needs and behaviors, and that sexual abuse included non-consensual sexual contact with residents who lacked the capacity to consent. The record showed that staff documented Resident #49 engaging in sexually inappropriate behaviors with other residents, staff, and visitors, including unwanted kissing, intimate touching of the breasts, groin, and chest, and exposing breasts/nudity. The survey found resident-to-resident sexual abuse involving Residents #88 and #15, both of whom lacked the cognitive ability to consent, and the behavior affected all 26 residents on the secured memory care unit. During interview, the DON stated staff did not know how to manage the behaviors and that documentation of Public Sex Acts was an area needing improvement. The DON also stated that whether sexually inappropriate behavior should be reported would depend on whether the resident had dementia. CNA A stated she witnessed Resident #49 and Resident #88 lying in bed together, kissing on the cheeks and neck, and Resident #49 rubbing Resident #88's chest and shoulders under and over his shirt; she said these acts had been occurring for about 6 months and had been reported to the DON. CNA I stated she understood Public Sexual Acts to include hands up the shirt, down the pants, and kissing, and confirmed she had reported multiple occurrences to the DON without further interventions. The Administrator stated that identifying behaviors and documenting them were areas for improvement and confirmed no performance improvement plans were in place related to sexually inappropriate behaviors, non-consensual sexual activities, or sexual abuse for the secured memory care unit.
QAPI Failed to Recognize Repeated Sexual Abuse Patterns
Penalty
Summary
The facility failed to maintain effective QAPI and QAA oversight for repeated resident-to-resident sexual abuse and sexually inappropriate behaviors on the secured memory care unit. Facility policies reviewed stated that abuse must be identified, prevented, reported, and coordinated through the QAPI program, including analysis of why abuse occurred, review of risk factors, and tracking of similar occurrences. Despite those policies, the QAA committee continued the same approach to each interaction and did not identify the resident’s behavior as sexual abuse activity, even though the behavior was repeatedly documented and observed. Resident #49 had diagnoses including Alzheimer’s disease, traumatic brain injury, and delusional disorder, and MDS assessments showed severe cognitive impairment with inability to complete BIMS and behaviors including sexually abusing others, public sexual acts, and disrobing in public. Nurse progress notes documented public sexual acts repeatedly from 11/11/2025 through 3/24/2026, including 3 occurrences in 11/2025, 3 in 12/2025, 1 in 1/2026, 4 in 2/2026, and 17 in 3/2026. The report states the QAA committee failed to recognize the pattern and extent of these incidents and failed to implement interventions in response to each occurrence. Resident #88 had vascular dementia, severe agitation, delusional disorders, and adjustment disorder with mixed anxiety and depressed mood, and a quarterly MDS showed a BIMS score of 0 indicating severe cognitive impairment. Resident #15 had vascular dementia, adjustment disorder with mixed anxiety and depressed mood, and delusional disorder, and a significant change MDS showed severe impairment in cognitive skills for daily decision making. During the survey, staff and surveyors observed and confirmed repeated inappropriate sexual contact involving Resident #49 and these cognitively impaired residents, including kissing, touching of the chest and buttocks, and exposure of breasts. Staff also reported Resident #49 touched staff members and surveyors inappropriately. The DON stated she viewed the resident as a "Huggy, Touchy, and Feely person" and did not consider the acts sexually inappropriate or sexual abuse, while the Administrator stated the IDT had not formally discussed the residents’ specific sexually inappropriate or abusive behaviors and the facility had not identified sexual abuse on the memory care unit as an area needing to be addressed.
Missing Physician and Resident Representative Signatures on Secured Unit Reviews
Penalty
Summary
The facility failed to ensure documentation of physician participation in the Interdisciplinary Team (IDT) review for continued placement in the secured unit for six residents: Resident #4, #23, #49, #71, #72, and #88. The facility also failed to ensure that the resident or resident representative signed the IDT review for continued placement in the secure unit for Resident #72 and Resident #88. The deficiency was identified through review of the facility policy, secured unit placement documentation, medical records, and staff interview. The facility policy titled, Secure Unit Placement, stated that residents in a secure or locked area must be free from involuntary seclusion and that ongoing evaluations should be conducted as indicated. The policy also stated that the resident's medical record should reflect documentation of the clinical criteria met for placement in the secure or locked area by the resident's physician, along with information provided by members of the interdisciplinary team, and ongoing documentation of review and revision of the care plan as necessary, including whether the resident continues to meet criteria for remaining in the secured or locked area. Resident #4 had diagnoses including delusional disorders, unsteadiness on feet, protein calorie malnutrition, psychosis, anxiety disorder, depression, adjustment disorder, malignant neoplasm of breast, and vascular dementia, and had BIMS scores indicating severe cognitive impairment. Resident #23 had diagnoses including vascular dementia, unsteadiness on feet, generalized anxiety disorder, repeated falls, mood disorder, delusional disorders, major depressive disorder, and history of traumatic brain injury, with BIMS scores showing severe cognitive impairment and later moderate cognitive impairment. Resident #49 had diagnoses including Alzheimer's disease, dementia with severe agitation, frontal lobe and executive function deficit, delusional disorders, depression, anxiety disorder, and history of traumatic brain injury, with BIMS scores showing severe cognitive impairment. Resident #71 had diagnoses including fracture of the left femur, vascular dementia, anxiety disorder, protein calorie malnutrition, and adjustment disorder with mixed disturbance of emotions and conduct. Resident #72 had diagnoses including Alzheimer's dementia with early onset, dementia with psychotic disturbance, anxiety disorder, bipolar disorder, schizophrenia, major depressive disorder, and mood disorder, with BIMS scores showing moderate cognitive impairment and later cognitive intactness. Resident #88 had diagnoses including vascular dementia, unspecified symptoms and signs involving cognitive functions and awareness, delusional disorders, adjustment disorder, and protein calorie malnutrition, with documentation of moderate cognitive impairment for decision making and diagnoses including non-traumatic brain dysfunction and non-Alzheimer's dementia. For each of these residents, the Secured Unit Continued Placement Evaluation documents reviewed for the secured unit contained no documentation of the clinical criteria by the physician for continued placement and no physician signature for participation in the IDT review. For Resident #72 and Resident #88, the documents also lacked the resident or resident representative signature showing participation in the IDT review for continued stay in the secure unit. During interview, the DON confirmed that the IDT Secured Unit Evaluations did not contain the required physician documentation or required signatures for these residents and stated that the evaluation documents did not contain an area for physician signatures.
Wheelchair Footrests Missing and Call Lights Left Out of Reach
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of Resident #22 by not keeping the resident’s wheelchair footrests available for use. Resident #22 was admitted with diagnoses including traumatic ischemia of muscle, cerebral infarction affecting the left side, neuralgia, and neuritis, and a quarterly MDS showed severe cognitive impairment, bilateral upper and lower extremity functional impairment, dependence on staff for ADLs, and wheelchair use for mobility. The care plan stated the resident did not ambulate, used a wheelchair, and required assistance with mobility. During observation, the resident was in bed with bilateral heel protectors in place and a wheelchair at the bedside without bilateral footrests. The resident stated he wanted to use the wheelchair for mobility but could not because the footrests were missing, and he reported making multiple requests to staff for their return. The WCN later confirmed the resident could propel himself in a wheelchair and that the wheelchair was missing the footrests, and the DOR stated the footrests kept going missing and staff took them to use for someone else. The facility also failed to ensure call lights were within reach for Resident #40 and Resident #43. Resident #40 had diagnoses including myocardial infarction, respiratory failure, and need for assistance with personal care, and a quarterly MDS showed severe cognitive impairment with substantial/maximal assistance needed for ADLs. The care plan noted the resident preferred the call light and bed control draped across her for security. Observations showed the call light wrapped around the bed rail behind the bed and out of reach, and later lying on the floor and still out of reach. Resident #43 had diagnoses including dementia, adjustment disorder, and osteoporosis, and a significant change MDS showed severe cognitive impairment. The care plan directed that the call light be maintained within reach when unattended in the room. Observations on multiple occasions showed the call light wrapped around the bed rail behind the bed and out of reach. A CNA confirmed both residents’ call lights were out of reach, and the ADON stated staff were to ensure call lights were in reach before exiting the room.
Failure to Investigate Repeated Sexual Behaviors and Unexplained Bruising
Penalty
Summary
The facility failed to conduct thorough investigations after repeated sexually inappropriate and sexually abusive behaviors by one resident, failed to investigate sexual abuse involving another resident, and failed to investigate bruising of unknown origin for the same resident. Facility policies reviewed stated that allegations of abuse, including injuries of unknown source and sexual abuse, must be promptly and thoroughly investigated, with residents protected during the investigation and evidence collected through observations, interviews, and record review. Resident #49 had diagnoses including Alzheimer's disease, traumatic brain injury, and delusional disorder, and was documented as having severe cognitive impairment on multiple MDS assessments, including a BIMS score of 00. The record showed repeated documentation of public sex acts, sexually inappropriate behaviors, disrobing in public, and abusing others sexually over many months. Progress notes documented multiple incidents of public sex acts, including numerous occurrences in March 2026, and one note described the resident as sexually inappropriate by grabbing male and female staff and residents in inappropriate places. Despite these documented events, the record contained no documentation that investigations had been completed for the incidents. During observation, Resident #49 was seen touching a surveyor's neck, back, and buttocks, and on other occasions was observed kissing male peers, wandering into other rooms, and placing hands on other residents in a sexual manner. Resident #88 had diagnoses including severe vascular dementia with agitation, delusional disorders, and adjustment disorder with mixed anxiety and depressed mood, and also had severe cognitive impairment on MDS assessment. Staff observed Resident #49 and Resident #88 holding hands, lying together in bed, kissing, and engaging in intimate touching. CNA staff reported witnessing Resident #49 kissing Resident #88 on the cheek, mouth, and neck, placing hands inside Resident #88's shirt, and caressing the resident's chest and back, but stated they were not interviewed by facility staff and were not aware of any investigation. The DON stated she did not categorize these acts as sexual abuse because Resident #49 had dementia and lived on the secured memory care unit, and staff similarly stated the behaviors were not considered sexual abuse because cognitively impaired residents did not know what they were doing. The facility also failed to investigate bruising and a scratch on Resident #49's left breast and upper chest. Weekly skin assessments documented a light blue bruise with yellowed edges, a scratch to the left breast, and later bruises and discoloration that persisted over several weeks. The DON stated she thought the bruising might have come from the resident pushing on the exit door and did not consider it an injury of unknown origin. The DON confirmed that the facility had not completed an official investigation related to the bruising and scratch.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to ensure proper grooming was provided for 2 residents reviewed for ADLs. Facility policy titled, Activities of Daily Living, stated residents will receive assistance as needed with grooming and that residents who are unable will receive the necessary services to maintain good grooming. Resident #11 was admitted with diagnoses including multiple rib fractures, malnutrition, and heart failure. Her care plan identified an ADL self-care performance deficit related to impaired mobility with partial/moderate assistance needed for personal hygiene, and the MDS indicated she required substantial/maximal assistance with hygiene. During observation, she was lying in bed with long facial hair on her chin and stated she did not like the whiskers, was unable to shave herself, and had not been offered shaving. Resident #78 was admitted with diagnoses including dementia, depression, and diabetes. Her care plan identified an ADL self-care performance deficit related to impaired cognition, and the MDS indicated severe cognitive impairment and dependence with hygiene. During observation, she was sitting in her wheelchair with several facial hairs on her chin. During interview, the CNA stated residents were to be offered shaving on shower days but did not recall ever asking either resident if they preferred to be shaved and had not offered to shave them. The ADON confirmed residents were to be shaved on shower days and that female residents were to be offered shaving when staff observed facial hair.
Failure to Provide Foot and Nail Care
Penalty
Summary
The facility failed to provide foot and nail care to Resident #22, who had diagnoses including traumatic ischemia of muscle, cerebral infarction affecting the left side, neuralgia, and neuritis. A quarterly MDS assessment documented severe cognitive impairment with a BIMS score of 7, functional impairment to both upper and lower extremities, and dependence on staff for ADLs. The care plan dated 3/11/2026 directed staff to assist with keeping nails trim and clean and to refer the resident to podiatry as needed. During observations on 3/23/2026, 3/24/2026, and 3/25/2026, Resident #22 was resting in bed with bilateral heel protectors in place, and the toenails on both feet were long, jagged, untrimmed, and curved over the tips of the second, third, and fourth toes. The SSD stated she had not been aware the resident needed podiatry services and was not scheduled for them. The LPN/WCN observed the resident’s feet and stated she should have caught the long, jagged, untrimmed toenails before the observation, and confirmed she had not provided nail care after weekly skin assessments and had not notified the SSD of the need for podiatry services.
Soiled Nebulizer Circuit Left Improperly Stored
Penalty
Summary
The facility failed to maintain and store a nebulizer circuit in a clean and sanitary condition for Resident #7, who had diagnoses including COPD, neuromuscular dysfunction of the bladder, and moderate cognitive impairment based on a BIMS score of 10. The resident’s care plan included emphysema/COPD and an order for ipratropium-albuterol inhalation solution by nebulizer, with the nebulizer circuit to be changed every night shift every Tuesday. Facility policy stated that the nebulizer circuit should be stored in a patient-care-set-up bag labeled with the patient’s name and dated, and that the entire setup should be changed weekly. During observation in the resident’s room, the nebulizer circuit had a light brown dried substance between the corrugated plastic rings. The neck of a plastic emesis bag was laying partially across the circuit, and the mouthpiece was resting on the top of the nightstand. During interview, an RN stated the nebulizer circuits were changed weekly and said she usually placed the nebulizer circuit in the handle of the compact compressor, but acknowledged it should not be left exposed like that because it leaves it exposed to germs and bacteria. The RN Unit Manager confirmed the nebulizer circuit was soiled and had not been cleaned, covered, or stored appropriately.
Expired and Undated OTC Medications Left Available for Use
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles because expired and undated over-the-counter medications were left available for resident use. Facility policy required opened medications to follow manufacturer or supplier expiration guidance, required staff to record the date opened on primary containers when medications had a shortened expiration date, and stated that medications with a manufacturer expiration date listed by month and year expire on the last day of that month. During observation of the zone 2 medication cart, surveyors found Prilosec OTC 20 mg with an expiration date of 1/26/2026 and a bottle of Cetirizine 10 mg tablets that was opened, undated, and available for use. The LPN UM confirmed the Prilosec OTC was expired and the Cetirizine was opened, undated, and both were available for resident use. In the Central Supply room, surveyors found slow release Iron tablets with an opened date of 4/8/2024 and an expiration date of 12/2025, Aspirin 325 mg with an expiration date of 10/2025, Cholest Off Plus soft gels with an expiration date of 2/2026, and two boxes of Acid reducer 20 mg tablets with an expiration date of 11/2025. The SC stated she inventoried the medication cabinet once a month and removed all expired medications, but confirmed these items were expired, available for resident use, and had not been removed from inventory or discarded. The ADON also confirmed the expired medications in Central Supply and the zone 2 medication cart had not been discarded and were available for resident use.
Expired Food and Unclean Resident Refrigerators
Penalty
Summary
The facility failed to discard expired food items and maintain the cleanliness of personal refrigerators for 2 residents out of 5 resident refrigerators observed. The facility policy titled, Resident Refrigerators, dated 4/30/2025, stated that a designated staff member would document refrigerator temperatures daily and that staff would check individual food items weekly for expiration dates and discard outdated food promptly from residents’ personal refrigerators. During observation, Resident #32’s personal refrigerator contained dried brown particles scattered inside, along with a bottle of salad dressing expired 5/7/2025, a bottle of brown mustard expired 2/26/2026, and a container of yogurt expired 2/10/2026. No thermometer or temperature log readings were present. Resident #32 had diagnoses including Parkinsons Disease, Insomnia, Diabetes, and Heart Failure, and a quarterly MDS assessment showed a BIMS score of 00, indicating severe cognitive impairment. Resident #35 had diagnoses including COPD, cognitive impairment, anxiety, depression, adjustment disorder, and dependence on wheelchair, and a quarterly MDS assessment showed a BIMS score of 15, indicating cognitive intactness. During observation and interview, Resident #35’s personal refrigerator contained a container of ice cream expired 12/19/2025, a carton of milk expired 3/7/2026, and a bottle of ketchup expired 5/25/2023. Resident #35 stated she did not know who was responsible for cleaning out her refrigerator and was not aware of the expired food items. No thermometer or temperature log readings were documented, and the DON stated there was no system in place for monitoring resident refrigerators for expired items or temperatures.
Hand Hygiene Not Offered During Meals; Urinary Catheter Drainage Tip Left Exposed
Penalty
Summary
Hand hygiene was not offered to three residents during lunch meal service. Resident #40 was admitted with diagnoses including myocardial infarction, respiratory failure, and need for assistance with personal care, and had severe cognitive impairment with substantial/maximal assistance needs for ADLs. Resident #59 was admitted with diagnoses including dementia, heart failure, and depression, and also had severe cognitive impairment. Resident #85 was admitted with diagnoses including Parkinson disease, dementia, and dysphagia, had moderate cognitive impairment, and was dependent on staff for eating and personal hygiene. During observations, a CNA delivered each resident’s lunch tray, set up the tray, and failed to offer hand hygiene before the meal. In addition, Resident #7, who was admitted with diagnoses including neuromuscular dysfunction of the bladder and COPD, had moderate cognitive impairment, neurogenic bladder, and an indwelling urinary catheter. During observation, the resident was sitting in a wheelchair with the urinary drainage bag clipped to the arm rest, partially covered, and the evacuation tip unsecured, exposed, and hanging down near and touching the wheelchair wheel. The LPN unit manager confirmed the catheter evacuation tip was not secured appropriately and was exposed to the elements.
Latest citations in Tennessee
Electronic Medical Records Left Visible on Unattended Computers: Two residents' EMRs were left open and visible on unattended computers during wound care and med pass. One resident had HTN, DM, and malnutrition with moderate cognitive impairment, and another resident had acute respiratory failure with hypoxia, HTN, DM2, and Afib with intact cognition. Staff confirmed the screens were left open and available for public view.
Medication cart security was not maintained for Cart 700. Facility policy required the cart to be locked when out of the medication nurse’s sight, but an RN walked away from the cart and later entered a resident room while leaving it unlocked and unattended. The RN confirmed the cart should have been locked, and the President of Clinical Operations confirmed carts should be locked when unattended.
Staff failed to follow diabetes management policies and provider orders for multiple residents by not consistently notifying the MD/NP of blood glucose (BG) readings outside ordered and policy-defined parameters and not documenting required treatment for hypoglycemia. One resident with Type 2 DM, severe cognitive impairment, and a high A1C had repeated episodes of severe hyperglycemia and hypoglycemia over several months, with numerous BG values above 400–500 mg/dL and below 70 mg/dL that were neither reported to the provider nor accompanied by documented administration of Glutose or glucagon. This resident later experienced altered mental status, hypotension, and a BG of 600 mg/dL, was transferred to the ED with a BG of 1025 mg/dL and diagnosed with DKA and related complications, and subsequently had a large acute to subacute cerebral infarct. Another resident on Lantus and Humalog sliding-scale insulin had multiple high and low BG readings, including values in the 40s and 50s mg/dL, without consistent documentation of hypoglycemia treatment or provider notification when thresholds were met. Similar unreported abnormal BG readings were found in other residents, leading surveyors to cite noncompliance with F684 for failure to provide appropriate treatment and care according to orders and resident needs.
The facility failed to report an allegation of staff-to-resident physical and verbal abuse to the state survey agency within the required two-hour timeframe. A resident with severe dementia, muscle weakness, and difficulty walking, who required two-person assistance for ADLs, became combative during perineal care, and multiple CNAs later reported that a CNA had roughly grabbed the resident’s arms, slammed the resident’s wrists onto the chest, used profanity, made threats, and stated the resident belonged in a psychiatric ward. These CNAs did not report their concerns immediately, and the allegation was not submitted to the state reporting agency until two days after the incident, contrary to facility policy and the expectations stated by the DON and ADM.
A resident with COPD, lack of coordination, and anxiety disorder had a prior fall with a care plan intervention for nonskid strips at the bedside. The facility later failed to keep that intervention in place, and the resident was found on the floor beside the bed after hollering for help, resulting in a left hip fracture and surgical repair. Surveyors observed the nonskid strips were not at the bedside, and the DON, ADM, LPN, and RD confirmed they were missing.
Resident Trust Funds Exceeded Medicaid Asset Limit: The facility failed to keep resident trust fund balances under the $2,000 Medicaid asset limit for multiple residents. Record review showed several residents with diagnoses including dementia, CHF, CKD, diabetes, hemiplegia, bipolar disorder, Parkinson’s disease, and traumatic subdural hemorrhage had trust fund balances ranging from $2,769.53 to $9,020.33, and both the BOM and Administrator stated the limit was under $2,000.
Unsecured and unlabeled medications were found at a resident’s bedside and in a medication cart. A resident with multiple diagnoses, including HTN and delusional disorder, had several scheduled oral meds left unattended in a clear cup on the nightstand without a self-administration order or assessment, and an LPN identified the pills as the resident’s medications. In a separate observation, an LPN and the DON found prepared, unlabeled meds left in a med cart drawer instead of being administered or otherwise secured.
A resident with dementia, seizure disorder, repeated falls, and high fall risk was care-planned for a low bed with brakes locked, a fall mat, and call light within reach, and was totally dependent on staff for transfers and bed positioning. Despite this, staff accounts indicated the bed was often kept at about waist height, and several staff reported not seeing a fall mat at the bedside. The resident was later found supine on the floor with her head and torso under the bed, the bed frame resting on her chest and head, and the corded bed remote under her back, requiring staff to raise the bed to remove her. A detective observed that a fall alert device on the bed was not plugged in and that the call light was tucked behind the nightstand, out of the resident’s reach, though it worked when tested. EMS and police documented compression marks on the resident’s torso and face consistent with the bed frame and piston. The facility’s own safety policy required implementation of interventions to reduce accident risks, but records showed no care-plan revision with additional bed-related safety measures after prior falls and no documentation that existing interventions were consistently implemented, leading surveyors to cite a deficiency for failure to prevent accidents and maintain a hazard-free environment.
A cognitively intact resident with chronic kidney disease, hypertension, and type 2 DM was struck on two occasions by another resident with severe cognitive impairment and aphasia who entered the resident’s room and hit her after being asked to leave. After the first incident, the care plan was revised to include a stop sign on the door, but staff failed to consistently maintain this intervention, including not reattaching it after an appointment and forgetting to put it back up after exiting the room. Surveyors later observed the stop sign missing and no staff in sight while the resident sat on the bed, and the resident reported that the other resident had entered her room and struck her twice and that staff did not keep the stop sign up much. Skin assessments documented transient redness but no lasting injury, and the DON confirmed that physical contact occurred on both occasions.
A resident with chronic kidney disease, essential hypertension, and type 2 DM, who was cognitively intact per MDS/BIMS, had a comprehensive care plan that required a stop sign to be maintained on the room door, with staff assistance as needed to keep it in place. During observation, the stop sign was not on the door, no staff were in sight while the resident sat on the side of the bed, and the resident reported that staff did not keep the stop sign up much anymore. An LPN admitted forgetting to replace the stop sign after leaving the room, and the DON confirmed that the care plan intervention requiring the door stop sign was not followed.
Electronic Medical Records Left Visible on Unattended Computers
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when electronic medical records were left open and visible to others. Facility policy stated resident health information must remain private and that the MAR must remain closed or covered when not in direct use. Resident #76, who was admitted with diagnoses including hypertension, diabetes, and malnutrition and had a BIMS score of 8 indicating moderate impairment, was observed on 5/11/2026 at 2:37 PM with the wound care cart unattended and the computer on top of the cart open to the resident's electronic medical record and available for public view. The wound care nurse later returned and confirmed the screen had been left open to Resident #76's record. Resident #41, who was admitted with diagnoses including acute respiratory failure with hypoxia, essential hypertension, type 2 diabetes mellitus, and paroxysmal atrial fibrillation and had a BIMS score of 13 indicating cognitive intactness, was observed during medication administration on Cart 700 on 5/12/2026 at 7:40 AM when RN A walked away from the medication cart leaving the computer open and the resident's electronic medical record available for public view. A later observation at 8:01 AM showed RN A entering a room while the computer remained open with Resident #41's electronic medical information still visible. RN A confirmed the screen was open and available for public view, and the President of Clinical Operations later confirmed the electronic medical record should not be unattended and left open for public view.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure medications were securely stored in 1 medication cart, Cart 700, out of 3 medication carts reviewed. The facility policy titled, Medication Administration General Guidelines, dated 9/18, stated that during medication administration, the medication cart is to be kept closed and locked when out of sight of the medication nurse. During observation on 5/12/2026 at 7:40 AM, RN A walked away from Cart 700, leaving the cart unlocked and unattended. During another observation on 5/12/2026 at 8:01 AM, RN A entered room [ROOM NUMBER] and again left the medication cart unlocked and unattended. RN A later confirmed she should have locked the medication cart when it was left unattended, and the [NAME] President of Clinical Operations confirmed the medication carts should be locked when left unattended.
Failure to Follow Diabetes Management Policies and Notify Provider of Abnormal Blood Glucose Levels
Penalty
Summary
The deficiency involves the facility’s failure to follow its own diabetes management policies and physician/NP orders for monitoring and responding to abnormal blood glucose (BG) levels, including required provider notification and treatment for hypoglycemia and hyperglycemia. Facility policies defined hypoglycemia as BG <70 mg/dL and required immediate provider notification and administration of rapidly absorbed glucose or glucagon, and defined thresholds for hyperglycemia that required provider contact when BG values were >250 mg/dL more than once in 24 hours or >300 mg/dL more than once over two consecutive days. For residents with sliding-scale insulin orders, the MARs also contained explicit instructions to notify the physician or NP when BG readings exceeded specified ranges (e.g., >351–400 mg/dL and above). Despite these clear parameters, staff repeatedly failed to notify the provider or document required treatment when BG readings fell outside ordered or policy-defined ranges. Resident #1, who had Type 2 diabetes, acute kidney failure, depression, anxiety disorder, and a severely impaired BIMS score of 3, had an A1C of 9.2% in November 2025 and was on a consistent carbohydrate diet with dysphagia modifications and sliding-scale insulin lispro before meals. Throughout January, February, March, and April 2026, Resident #1’s Weights and Vitals Summary reports showed numerous episodes of severe hyperglycemia (often >400–500 mg/dL and above the sliding-scale notification thresholds) and multiple episodes of hypoglycemia with BG values as low as 42–54 mg/dL. On multiple dates, there was no documentation that Glutose or glucagon was administered for BG <70 mg/dL, and there was no evidence that the physician or NP was notified when BG values exceeded the facility’s policy thresholds or the sliding-scale notification parameters. The record also showed that after the sliding-scale insulin order was discontinued, staff still did not consistently notify the provider when BG values met the facility’s policy criteria for reporting. Resident #1 subsequently experienced clinical deterioration associated with very high BG levels. A progress note on 3/16/2026 documented altered mental status, functional decline, unresponsiveness, hypotension (BP 83/42), tachycardia, and a BG of 600 mg/dL, leading to transfer to the ED. Hospital records indicated presentation with gradually worsening condition over 2–3 days, hypoxia requiring oxygen, and a BG of 1025 mg/dL, with diagnoses including diabetic ketoacidosis (DKA), acute kidney injury, UTI, acute toxic metabolic encephalopathy, and hypotension, and treatment with an insulin drip in the ICU. After return to the facility, Resident #1 continued to have unreported hypoglycemic readings (e.g., 67–69 mg/dL with no documented Glutose or glucagon) and further episodes of severe hyperglycemia that met policy thresholds for provider notification but were not reported. Later in March, the resident was again sent to the hospital with left-sided weakness and facial droop, and imaging showed a large acute to subacute infarct involving the right parietal and occipital lobes. Other sampled residents also had unreported abnormal BG readings. Resident #2, with orders for Lantus and Humalog sliding-scale insulin, had multiple hyperglycemic readings above the sliding-scale notification thresholds (e.g., 376–478 mg/dL) and several hypoglycemic episodes with BG values between 43–54 mg/dL. On several of these occasions, there was no documentation that Glutose or glucagon was administered, and no evidence that the physician or NP was notified when BG values met either the sliding-scale notification parameters or the facility’s policy thresholds. For at least one hypoglycemic episode (BG 43 mg/dL), medication treatment was documented, but other low readings lacked such documentation. Similar patterns of unreported abnormal BG values and lack of documented hypoglycemia treatment were identified for additional residents reviewed for medication administration, contributing to the finding that the facility failed to ensure appropriate treatment and provider notification for out-of-parameter BG readings. Surveyors determined that the facility’s failure to ensure Resident #1 received care and services to maintain BG levels within a safe range, and to follow policies and orders for provider notification and hypoglycemia management, resulted in Immediate Jeopardy at F684. The Immediate Jeopardy period was identified as beginning on 1/1/2026 and was later removed, but noncompliance at F684 continued at a lower scope and severity for ongoing monitoring of the effectiveness of corrective actions.
Failure to Timely Report Staff-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical and verbal abuse to the state survey agency within the required two-hour timeframe. Facility policy required any partner with direct or indirect knowledge of events that might constitute abuse, neglect, misappropriation of patient property, or exploitation to report immediately, but not later than two hours if the events involved abuse or resulted in serious bodily injury, and not later than 24 hours if they did not. Resident #89, admitted with severe dementia with agitation, muscle weakness, and difficulty walking, required assistance of two staff for ADLs. A Facility Reported Incident form documented that on 01/12/2026 at 12:00 PM, the resident became combative during perineal care and witnesses observed CNA #4 strike and pinch the resident several times, hold the resident by the wrists, make threatening comments, and use inappropriate language. However, this allegation was not submitted to the state reporting agency until 01/14/2026 at 2:57 PM. Witness statements from CNAs #3, #5, and #6 described multiple episodes of rough and aggressive behavior by CNA #4 toward Resident #89 during care on 01/12/2026 and 01/13/2026, including roughly taking the resident’s arms, cursing at the resident, slamming the resident’s wrists onto the chest, making threats, and telling the resident they belonged in a psychiatric ward while pushing the resident’s arms into the chest. The DON stated that on 01/14/2026 these CNAs reported the allegations of abuse from the prior dates, and confirmed that her expectation was that allegations of abuse be reported immediately. The Administrator similarly stated that staff were expected to report allegations of abuse immediately and no later than two hours from when the abuse occurred, and that the facility had two hours to report the allegation to the state reporting agency. He acknowledged that CNAs #3, #5, and #6 did not report the allegations in a timely manner, resulting in the late reporting of the abuse allegation to the state survey agency.
Failure to Implement Fall Intervention After Prior Fall
Penalty
Summary
The facility failed to implement a fall-related care plan intervention for Resident #7 after a fall on 5/15/2025. The resident was admitted with diagnoses including COPD, lack of coordination, and anxiety disorder, and a quarterly MDS assessment indicated a BIMS score of 15, showing the resident was cognitively intact and independent with all aspects of care. After the 5/15/2025 fall, nursing documentation stated the resident was found sitting on the floor after trying to get to the bathroom and slipping, and the incident report identified the root cause as footwear, with a new intervention of nonskid strips to the exiting side of the bed. The comprehensive care plan dated 5/15/2025 included the intervention of nonskid strips to the bedside. However, the facility later failed to have those nonskid strips in place. On 4/12/2026, Resident #7 was again found on the floor beside the bed after hollering for help, and the incident report and nursing note documented the fall. A radiology report from that date showed a left intertrochanteric fracture, and an operative note dated 4/15/2026 documented internal fixation of the left hip. During observations on 4/21/2026, surveyors found no nonskid strips at the bedside, and both the LPN and DON confirmed they were not in place. The DON acknowledged the resident had fallen on 5/15/2025 and that nonskid strips had been the intervention, but they were not present at the time of the later fall. The ADM also confirmed the strips were not in place, and the RD stated they were placed only after the facility was informed on 4/21/2026 that they were missing.
Resident Trust Funds Exceeded Medicaid Asset Limit
Penalty
Summary
The facility failed to maintain resident trust fund balances under the $2,000 Medicaid asset limit for 10 of 111 sampled residents. Review of the American Council on Aging website showed that in 2026, a single Medicaid nursing home applicant in Tennessee must have assets under $2,000. Medical record and trust fund statement reviews showed multiple residents had balances above that limit, including residents with diagnoses such as atrial fibrillation, dementia, depression, dysphagia, anxiety, hemiplegia, heart failure, diabetes, chronic kidney disease, anemia, bipolar disorder, chronic respiratory failure, Parkinson’s disease, traumatic subdural hemorrhage, malnutrition, and hypertension. Resident trust fund statements dated 4/22/2026 showed balances of $4,945.96 for Resident #11, $7,764.26 for Resident #16, $3,324.09 for Resident #38, $2,950.01 for Resident #86, $5,350.97 for Resident #92, $3,874.46 for Resident #101, $3,931.97 for Resident #110, $2,769.53 for Resident #119, $5,911.60 for Resident #128, and $9,020.33 for Resident #177, all above the $2,000 limit. During interview, the BOM stated the resident trust account limit was $2,000.00, and the Administrator also stated resident trust accounts should be under $2,000.00.
Unsecured and Unlabeled Medications Found at Bedside and in Medication Cart
Penalty
Summary
Medications and biologicals were not properly stored in accordance with facility policy and accepted professional principles when medications were left unattended and unlabeled at a resident’s bedside and when prepared medications were left unsecured and unlabeled in a medication cart. The facility policy stated medications and biologicals are to be stored safely, securely, and properly, with access limited to authorized staff, and that all medications dispensed by the pharmacy are to be stored in the container with the pharmacy label. The self-administration policy required a physician order and interdisciplinary assessment before a resident could self-administer medications, along with a quarterly skill assessment as needed. Resident #41 was admitted with diagnoses including Autistic Disorder, Gilbert Syndrome, Delusional Disorders, Hypertension, Edema, Protein-Calorie Malnutrition, and Peripheral Vascular Disease. The physician ordered multiple 9:00 AM oral medications, but there was no physician order for self-administration and the resident was not assessed or care planned for self-administration, despite a BIMS score of 13 indicating cognitive intactness. During observation, 3 white tablets, 2 orange tablets, 2 light blue and yellow capsules, and 1 white half tablet were found in a clear cup on the resident’s nightstand unattended and unlabeled, and an LPN identified them as the resident’s scheduled medications. In a separate observation, a medication cart contained unsecured and unlabeled medication cups with tablets and a capsule in the drawers, and the DON stated medications that were prepared and unable to be administered should be wasted and not stored in the med cart.
Failure to Maintain Bed Safety and Hazard-Free Environment Resulting in Resident Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to implement and follow care-planned safety interventions for a resident with significant cognitive and physical impairments. The resident had diagnoses including Alzheimer’s disease, dementia, psychotic disorder with delusions, anxiety, obsessive-compulsive behavior, peripheral vascular disease, convulsions/seizure disorder, and a history of repeated falls. The care plan identified the resident as at risk for falls related to unstable balance, decreased safety awareness, impaired decision-making skills, and lack of coordination, and included interventions such as keeping the bed in the low position with brakes locked and, later, a fall mat to the left side of the bed. A fall risk assessment documented the resident as high risk for falls, and prior falls from bed had resulted in at least one laceration requiring sutures and antibiotic treatment. Despite these known risks and documented interventions, there was no evidence that the care plan was revised to add further bed-related safety interventions after repeated falls from bed. On the night of the fatal incident, the resident, who was dependent on staff for transfers, bed positioning, and turning, was last seen by a CNA around 3:40–3:45 a.m., when incontinence care was provided and the resident was reported to be “alive and fine in bed.” The same CNA later stated that at that time the bed was typically at about “waist high,” rather than in the lowest position. Around 4:50–4:55 a.m., the CNA found the resident lying supine on the floor, partially underneath the bed, with the bed in the lowest position and the corded bed control stretched across the resident’s neck area and pinned under her back near the left shoulder. Witness statements from CNAs and nursing staff, as well as EMS and police narratives, consistently described the resident’s head and torso as being under the bed frame, with visible compression marks on the chest, abdomen, and face consistent with the bed frame and piston, and a chunk of hair lodged in a bolt on the lower bed frame. Staff reported that the bed had to be raised using the remote, which was under the resident, before the resident could be pulled out from under the bed. Investigative interviews and external reports identified additional environmental and supervision-related hazards. A detective observed that a fall alert system was attached to the bed rail but was not plugged in or set up to provide any alert if the resident attempted to get out of bed or fell. The detective also found the call light tucked behind the nightstand, out of the resident’s reach, although it functioned when tested. Multiple staff, including CNAs, nurses, the OT, and the physician, confirmed that the resident could not walk, could not turn herself in bed, was a two-person assist, and was totally dependent on staff for bed position and care. Several staff stated they had never seen a fall mat at the bedside, despite the care plan calling for one, and confirmed that the bed was supposed to be kept in the lowest position due to the resident’s fall risk. The DON and previous administrator acknowledged that the resident was found under the bed with marks consistent with the bed frame and that the bed should have been all the way down to the floor, while also indicating that the incident was considered an accident and that no report had been made to the state survey agency. The surveyors concluded that the facility failed to ensure that care-planned safety interventions (bed in low position, fall mat) were implemented and that the environment (including bed equipment, fall alarm, and call light accessibility) was free of accident hazards, resulting in a serious injury and death for this resident. The facility’s own policy on “Safety and Supervision of Resident” stated that the environment should be made as free from accident hazards as possible and that interventions to reduce accident risks included communicating specific interventions to all relevant staff, providing training, and ensuring interventions are implemented. However, the record showed that after multiple falls, including one with injury, the care plan was not updated with additional bed-related safety measures beyond a single fall mat, and there was no documentation that the existing interventions (bed in low position, brakes locked, fall mat, call light within reach) were consistently implemented. Staff interviews revealed discrepancies about who initiated CPR and who raised the bed, but they consistently indicated that the resident was dependent, that the bed was expected to be in the lowest position, and that the resident’s ability to use the call light or bed remote was limited or absent. External responders (EMS and police) documented that staff did not know how long the resident had been pinned, that the bed’s corded control was found under the resident, and that the fall alert system and call light were not positioned to protect or assist the resident. These combined findings formed the basis for the cited deficiency at F689 for failure to prevent accidents and maintain an environment free of accident hazards.
Failure to Consistently Implement Safety Measures After Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from physical abuse by another resident on two separate occasions. One resident, admitted with chronic kidney disease, essential hypertension, and type 2 diabetes mellitus, had a quarterly MDS BIMS score of 15, indicating intact cognition. Another resident, admitted with aphasia, cognitive communication deficit, chronic kidney disease, and non-Hodgkin lymphoma, had a quarterly MDS BIMS score of 3, indicating severe cognitive impairment. On one date, nursing documentation showed staff were called to the room and observed a CNA removing the cognitively impaired resident from the cognitively intact resident’s room after the latter reported being hit three times on the left arm. A same-day skin assessment documented slight redness above the antecubital area. Following this first incident, the cognitively intact resident’s care plan was revised to include a stop sign on the door as an intervention. Despite this, a second incident occurred when a nurse at the nurse’s station heard yelling in the hall and then observed the cognitively impaired resident exiting the same resident’s room. When questioned, the cognitively intact resident reported that she had asked the other resident to leave and was then hit. The facility’s investigation documented that the residents were separated and that a skin assessment revealed redness to the left upper breast and left index finger knuckle, with no open areas or swelling and the resident denying pain. A later skin assessment the same evening documented no areas of concern. Surveyor observations and interviews showed that the stop sign intervention was not consistently implemented, contributing to the recurrence of resident-to-resident physical contact. An employee warning form documented that a staff member failed to reattach the stop sign across the doorway after returning the resident from an appointment. During surveyor observation, the stop sign was again not in place outside the resident’s room, and no staff were in sight while the resident sat on the side of the bed. The resident reported that the other resident had come into her room on two occasions and struck her and stated that staff did not keep the stop sign up much. An LPN acknowledged that the stop sign was supposed to be in place and admitted forgetting to put it back up after exiting the room. The DON confirmed that physical contact occurred on both dates when the cognitively impaired resident struck the cognitively intact resident, although neither resident sustained injuries.
Failure to Implement Care Plan Intervention for Door Stop Sign
Penalty
Summary
The deficiency involves the facility’s failure to implement a comprehensive, person-centered care plan intervention for one resident as required by facility policy. The facility’s care plan policy, revised March 2022, states that comprehensive care plans must include measurable objectives and interventions derived from a thorough analysis of information to meet residents’ physical, psychosocial, and functional needs. Resident #15 was admitted with chronic kidney disease, essential hypertension, and type 2 diabetes mellitus, and a quarterly MDS showed the resident was cognitively intact with a BIMS score of 15. The resident’s comprehensive care plan, revised 4/21/2025, included an intervention for a stop sign to be placed on the resident’s door, with staff to assist as needed to keep the stop sign in place. On 4/14/2026 at 8:24 AM, surveyors observed that the stop sign outside Resident #15’s room was not in place, and no staff were in sight of the room while the resident was sitting on the side of the bed. During an interview at 8:25 AM, the resident stated that staff did not keep the stop sign up much anymore. At 8:27 AM, an LPN acknowledged that the stop sign was supposed to be in place and admitted it was their fault, explaining they had forgotten to put the stop sign back up after exiting the resident’s room. At 8:40 AM, the DON, upon interview and medical record review, confirmed that the care plan intervention for the stop sign on the resident’s door had not been followed and stated she expected the stop sign to be in place for this resident.
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