Regency Olympia Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Olympia, Washington.
- Location
- 1811 East 22nd Avenue, Olympia, Washington 98501
- CMS Provider Number
- 505515
- Inspections on file
- 27
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Regency Olympia Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident admitted with a right hip fracture and cognitively intact status had physician transfer orders for an orthopedic follow‑up visit and staple removal within two weeks, but staff did not schedule or complete this follow‑up as ordered. The resident reported not seeing the orthopedic surgeon after admission and stated that the staples remained in for a long time before being removed, which was painful. Record review showed the staples were removed more than seven weeks after admission, and the DON acknowledged the transfer orders were not carried out due to an oversight, despite the administrator’s expectation that admission/transfer orders be completed as instructed.
A resident with a catheter and moderate cognitive impairment was observed multiple times in common areas with the drainage bag hanging under the wheelchair, uncovered, and urine visible. The resident’s orders and care plan called for the catheter system to be secured and covered with a privacy bag, and staff, including an LPN and the DON, stated catheter bags were expected to be covered for privacy.
Missing consent for psychotropic medications: Two residents received Seroquel without documented informed consent. One resident with severe cognitive impairment had an antipsychotic dose increased without consent documentation, and another resident with moderate cognitive impairment was given PRN Seroquel without consent documented in the EHR. Staff, including the RN, LPN, and DON, acknowledged the missing consent.
Psychotropic medication monitoring and documentation were deficient for three residents. A resident with anxiety received clonazepam without documented ASE monitoring, a cognitively impaired resident received PRN Seroquel without an AIMS test and PRN lorazepam without a 14-day stop date, and another resident with anxiety received repeated higher-dose PRN lorazepam without documentation of the behaviors supporting the dose given. Staff acknowledged missing monitoring and documentation in the records.
PASRR not updated after significant change in condition. A resident with moderate cognitive impairment and signs of physical and mental decline had a significant change in condition, but the EHR did not show that a new PASRR Level I was completed. Staff stated the resident had overall decline in food intake, cognition, mood, activity participation, ADL care, and behaviors including hallucinations and delusions, yet a new PASRR referral was not completed.
A resident with severe cognitive impairment had CBC and BMP labs ordered, but the BMP could not be resulted because the specimen had mild hemolysis and interference was noted. An LPN and the DON/RN stated the hemolysis should have been reported to the provider, and the DON/RN said the BMP should have been redrawn.
Digoxin Given Despite Low HR: A resident with chronic atrial fibrillation received Digoxin even when the HR was below 60 bpm on multiple occasions. The EMAR showed the medication was administered despite low HR readings, and the DON and an RN confirmed the drug should have been held and the provider notified.
A resident developed a pressure ulcer that was not properly identified or managed according to facility policy. Nursing staff documented a new skin condition but did not notify the physician or obtain treatment orders, and there was no evidence of ongoing assessment or investigation into the cause of the wound.
A resident with mild cognitive impairment experienced repeated verbal altercations and possible abuse from a roommate, which were documented by an LPN over several days. Despite facility policy requiring immediate reporting, the incidents were not promptly reported to authorities, and staff failed to intervene or interview those involved at the time. Leadership acknowledged the delay and lack of action as a breach of protocol.
Surveyors observed multiple failures in infection prevention and control, including staff not performing hand hygiene during wound care for two residents, improper PPE use during personal care for a resident on Enhanced Barrier Precautions, and incomplete protocols in the laundry area. The facility also lacked a documented infection control risk assessment and had an incomplete water management program.
Two residents with significant care needs reported incidents of potential abuse and neglect—one involving rough handling by a CNA resulting in a bruise, and another involving delayed toileting care after a NA refused assistance. Both allegations were handled as grievances and not reported to the State Survey Agency as required by facility policy and regulation.
The facility did not develop or document trauma trigger assessments for two residents with known trauma histories, despite care plans indicating the need to minimize such triggers. Staff interviews confirmed that specific trauma triggers were not identified or listed in the residents' records or care instructions, resulting in a lack of clear guidance for staff.
Surveyors found a treatment cart repeatedly left unlocked, containing various medications and wound care supplies, despite staff expectations that it should be secured. Additionally, a resident's Lisinopril order on the MAR did not match the medication bubble pack label, creating a risk for dosing errors. Staff confirmed both issues during the survey.
A facility failed to ensure that antibiotic initiation for UTIs was based on CDC-approved criteria. The Antibiotic Stewardship Policy did not specify which symptom criteria to use, and staff reported using an SBAR tool referencing McGeer's criteria for initiating antibiotics, contrary to federal regulations that require Loeb minimum criteria for this purpose.
A resident with a history of malnutrition and poor calorie intake reported outdated dentures and missing front teeth, which affected her ability to eat. Despite these issues being observed and documented in the care plan, the MDS assessment inaccurately recorded that there were no problems with the resident's dentures. The MDS Coordinator was unable to recall the resident's dental status.
Two residents with documented mental health diagnoses were admitted and had Level I PASARR screenings completed, but the facility did not make or document required Level II PASARR referrals as outlined in policy and regulation.
Two residents with complex medical needs did not have individualized care plans that addressed all aspects of their care, including assistance with repositioning and specific dietary and mobility instructions. Key care directives were either missing from or not reflected in the official care plan and Kardex, leading to inconsistent guidance for staff.
A resident did not receive care in accordance with physician orders for both heart and breathing medications. Nursing staff failed to notify the physician when the resident's pulse was below 60 prior to administering a heart medication, as required, and did not ensure the resident rinsed their mouth after using an inhaler, contrary to the prescribed instructions. The DON confirmed these lapses after reviewing the records.
A resident with cognitive impairment and significant assistance needs did not receive a prescribed restorative stretching program for the left lower extremity. Staff interviews revealed confusion and lack of documentation regarding the implementation of the restorative program, with nursing staff unaware or unable to confirm that the program was being carried out as ordered.
A resident with a history of stroke and moderate risk for pressure injury, who was dependent on staff for all activities of daily living, was not provided with timely pressure relieving devices or regular repositioning and toileting. The resident was observed for several hours in the same position in a wheelchair without staff intervention, and was later found with a red, blotchy rash. The DON confirmed the resident was not on a scheduled turning or toileting program, despite care plan requirements.
A resident with a history of stroke, paralysis, and aphasia was repeatedly observed in bed without music, radio, or television, despite documented preferences for these activities. Staff were unaware of the resident's interests, and the resident's representative was not consulted about activity preferences, resulting in a lack of meaningful engagement.
A resident with limited mobility and incontinence, identified as being at moderate risk for pressure injury, developed a Stage II pressure ulcer after staff failed to provide timely pressure-reducing devices and regular repositioning. The resident was observed for extended periods in bed and in a wheelchair without repositioning or bathroom assistance, and no pressure-relieving mattress was in use at the time the injury developed.
A resident with limited mobility due to a stroke was able to access and use a vape pen without proper supervision, as required by facility policy, and the device was not stored at the nurse's station. Additionally, a shower room containing a cabinet with potentially hazardous chemicals was left unlocked and accessible, with staff confirming the area was not secured as expected.
A resident was prescribed both Diclofenac and Eliquis upon admission, and the LTC pharmacy flagged a potential drug interaction. Despite this, the resident received Diclofenac before refusing further doses due to concerns. Nursing documentation and staff interviews confirmed that the pharmacy's warning was not promptly communicated to a provider for review or adjustment of the medication orders.
A facility failed to timely address abnormal urine characteristics in a resident with an indwelling catheter, leading to a kidney infection. Despite orders to monitor urine and collect a urinalysis if symptoms appeared, documentation was inconsistent, and no new medications were ordered. The resident was eventually hospitalized due to pain and urinary retention, where a kidney infection was diagnosed.
A tree fell on the facility's roof, causing damage, but the incident was not reported to the State Agency or logged in the Accident/Incident Log. The Maintenance Director confirmed no injuries occurred, and the building's integrity was intact. The Administrator acknowledged the oversight and planned to address it.
The facility failed to provide at least eight hours of RN supervision for 9 out of 30 days reviewed. The Director of Nursing acknowledged the shortage and mentioned active recruitment efforts, attributing the issue to a low hiring pool.
A facility failed to provide necessary equipment and exercises to prevent further avoidable reduction of ROM and mobility for a resident with hemiplegia and hemiparesis. The resident's care plan did not include the required interventions, and staff were unaware or untrained in providing the necessary care, placing the resident at risk for increased contractures and decreased quality of life.
Failure to Follow Physician Orders for Timely Post-Operative Staple Removal
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice by not carrying out a physician’s transfer order for a cognitively intact resident admitted with multiple diagnoses including a right hip fracture. The 5‑day MDS dated 02/20/2026 showed the resident was cognitively intact, and transfer orders dated 02/13/2026 directed staff to schedule a follow‑up appointment with the orthopedic provider for staple removal in two weeks. Interview and record review revealed that the resident reported not having been seen by the orthopedic surgeon since admission and stated that the staples had remained in for a long time before being removed, which was painful. The electronic health record showed the staples were not removed until 04/08/2026, 51 days after admission, and the DON/RN acknowledged that the transfer orders were not carried out due to an oversight, despite the expectation that admission/transfer orders be completed as instructed. This failure was cited under WAC 388-97-1060 (1)-(3) for not honoring each resident’s preferences, choices, values, and beliefs and for not providing care in accordance with professional standards of practice for one of three sampled residents reviewed for quality of life.
Uncovered catheter bag visible during resident observations
Penalty
Summary
The facility failed to provide care and services in a manner that promoted dignity for a resident with an indwelling urinary catheter. The facility policy titled, Indwelling Urinary Catheters, stated that residents with catheter bags would have them covered or use bags that provided dignity while in bed with visibility from the hallway, out of their room, or in the community. The resident was moderately cognitively impaired and had an indwelling catheter. Physician orders directed staff to ensure the catheter system was secured, the catheter strap was in place, and the privacy bag was used appropriately. The resident’s care plan also included maintaining dignity at all times with a leg strap and bag cover. During observations, the resident was seen sitting in a wheelchair in the dining room and later in the living room with the catheter drainage bag hanging under the wheelchair, uncovered, and urine visible in the bag. The resident was later observed in the hallway with a blue privacy bag bunched up under the wheelchair while the catheter drainage bag remained uncovered and visible. Staff interviews confirmed that catheter bags were supposed to be covered for privacy, and the DON stated it was her expectation that urinary catheter bags be covered for privacy.
Missing Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents and/or resident representatives were fully informed and gave consent before psychotropic medications were administered or increased for 2 of 6 sampled residents. The facility policy titled, Behavior Management/Psychotropic Medication Overview, stated that the resident or representative must be fully informed and consent obtained when psychotropic medications are initiated or when the dosage is increased. Resident 5 was severely cognitively impaired and was receiving Seroquel, an antipsychotic medication. Physician orders showed the dose was increased from 25 mg at bedtime to 25 mg twice daily, and the EMAR showed the increased dose began the next day. The EHR did not show documentation of informed consent for the increased dose. Resident 4 was moderately cognitively impaired and was prescribed Seroquel 25 mg, 0.5 tablet every 12 hours as needed. The EMAR showed the medication was administered, but the EHR did not show documentation of informed consent before the Seroquel was started. Staff interviews confirmed that consent should have been obtained and documented for these psychotropic medications.
Psychotropic Medication Monitoring and Documentation Deficiencies
Penalty
Summary
The facility failed to monitor for adverse side effects of antianxiety medication, failed to complete an AIMS test for antipsychotic medication, failed to place a 14-day stop date on PRN psychotropic medication, and failed to ensure resident-specific target behaviors were monitored before administering antianxiety medication for three residents reviewed for unnecessary medications. The facility policy titled, Behavior Management/Psychotropic Medication Overview, stated that psychotropic medications require adequate monitoring and reevaluation, including documentation in the eMAR every shift for a minimum of 14 days and use of the AIMS test for antipsychotic medication. Resident 3 had a diagnosis of anxiety disorder and was ordered clonazepam 0.5 mg three times daily for anxiety. Review of the March and April 2026 eMAR did not show documentation of facility monitoring for adverse side effects while the resident was receiving clonazepam. In interview, the DON/RN reviewed the record and stated there was no monitoring in place, and that monitoring for adverse side effects was expected while the resident received clonazepam. Resident 4, who was moderately cognitively impaired, was ordered Seroquel 12.5 mg every 12 hours as needed and received a dose on 04/06/2026, but the record did not show an AIMS test completed for the medication. Resident 4 was also ordered lorazepam concentrate 1 mg every 6 hours as needed for anxiety and received it on 04/08/2026, but the physician orders did not include a 14-day stop date. Resident 25, who had multiple diagnoses including anxiety disorder and was alert and oriented, had PRN lorazepam orders for 1 mg or 2 mg every 6 hours as needed; the April 2026 eMAR showed repeated administration of 2 tablets on several dates, but the record did not document the symptoms or behaviors that justified giving 2 tablets instead of 1. Staff stated that nurses used judgment and clinical observations, but they were unable to provide documentation of the behaviors supporting the higher dose.
PASRR not updated after significant change in condition
Penalty
Summary
The facility failed to ensure that a PASRR Level I screening was requested when Resident 7 experienced a significant change of condition. The facility policy titled, Pre-admission Screening and Resident Review WA (PASRR), revised June 2024, stated that the PASRR would be reviewed and updated as indicated with significant changes in a resident's physical or mental condition, and that the state mental health authority would be notified of changes affecting the resident's physical or mental condition. Resident 7 was admitted to the facility and later had a Significant Change MDS dated 01/28/2026 showing moderate cognitive impairment and signs of physical and mental decline. The resident's Level I PASRR dated 01/28/2026 documented that a Level II PASRR was not required, and the EHR showed the resident was assessed for change of condition on 01/28/2026. However, the EHR did not show documentation that a new Level I PASRR was completed after the significant change of condition. Staff stated the resident had overall decline in food intake, cognition, mood, participation in activities, ADL care, and behaviors including hallucinations and delusions, and that although the resident's condition had changed significantly, a new PASRR referral was not completed.
Failure to Report Hemolyzed Lab Results
Penalty
Summary
The facility failed to fully address laboratory results for one resident who was admitted on [DATE] and later died on 03/08/2026. The resident’s 5-day MDS dated 02/27/2026 documented severe cognitive impairment. A physician’s order dated 03/05/2026 directed CBC with platelets and a BMP. Laboratory results dated 03/07/2026 showed mild hemolysis present, noted that some results may be affected by interference, and indicated the BMP panel could not be resulted; only BUN/creatinine were reported. During interview and record review, an LPN stated that when lab results were received, nurses were expected to review them and report them to the provider. The LPN reviewed the resident’s lab report and stated the mild hemolysis should have been reported to the provider but was not. The DON/RN also reviewed the report and stated the hemolysis finding should have been reported to the provider and the BMP should have been redrawn.
Digoxin Given Despite Low Heart Rate
Penalty
Summary
The facility failed to adequately monitor one resident’s heart rate before administering Digoxin. Resident 3 was admitted with a diagnosis of chronic atrial fibrillation and was alert and oriented on the 5-day MDS dated 03/13/2026. The physician’s order dated 03/09/2026 directed Digoxin 125 mcg orally each morning for atrial fibrillation. Record review showed Resident 3’s heart rate was 58 bpm on 03/13/2026, 56 bpm on 03/20/2026, 59 bpm on 03/23/2026, 57 bpm on 03/27/2026, and 51 bpm on 04/09/2026. The EMAR showed Digoxin was administered on each of those dates despite the heart rate being below 60 bpm. During a joint interview and record review on 04/10/2026, the DON/RN and another RN stated nurses were expected to assess the resident’s heart rate before giving Digoxin, hold the medication if the heart rate was below 60 bpm, and notify the provider. They reviewed the record and confirmed Digoxin had been given when the resident’s heart rate was below 60 bpm, and that it should not have been administered with the low heart rate.
Failure to Identify and Obtain Orders for Pressure Ulcer
Penalty
Summary
The facility failed to appropriately identify and manage a pressure ulcer for a resident who was admitted without any pressure ulcers. Upon admission, the resident's care plan did not indicate any open areas or non-blanchable redness to the sacrum or buttocks. However, a subsequent nursing note documented a new skin condition involving a small skin tear with non-blanchable redness to the sacrum/buttocks. The nurse cleansed the area and applied a zinc barrier cream with a bordered gauze, but there was no documentation that the physician was notified or that a treatment order was obtained for the new wound. Further review of the Treatment Administration Record showed no evidence of ongoing assessment, care, or monitoring for the identified wound. During a later observation, the resident was found to have a pressure ulcer measuring approximately 1.5 cm by 1.0 cm on the left medial sacrum. Interviews with nursing staff revealed that the nurse who initially identified the wound assumed the Resident Care Manager would notify the physician and obtain an order, but this did not occur. The Director of Nursing confirmed that there was no investigation into the cause of the injury and was unable to provide documentation of such an investigation.
Failure to Timely Report Alleged Abuse Between Residents
Penalty
Summary
The facility failed to ensure timely reporting of an allegation of abuse involving a resident who was admitted for rehabilitation and was mildly cognitively impaired. Documentation in the electronic health record showed repeated incidents where another resident was observed yelling, cursing, and arguing with the resident, including threats to leave and ongoing loud verbal altercations. These incidents were documented by an LPN in the progress notes over several days, with descriptions of the disruptive behavior and the staff's attempts to manage the situation by assisting the resident and closing the door for privacy. Despite these documented incidents, the allegation of potential verbal and possibly physical abuse was not immediately reported to the Abuse Hotline as required by facility policy. Interviews with facility staff, including Social Services, the DON, and the Administrator, confirmed that the night shift nurse did not intervene or interview the residents at the time of the incident and only left a note for the DON. The delay in reporting and lack of immediate intervention were acknowledged by facility leadership as contrary to established procedures for handling abuse allegations.
Infection Control and PPE Deficiencies in Resident Care and Facility Operations
Penalty
Summary
Multiple deficiencies in infection prevention and control were observed throughout the facility. During wound care for two residents, staff failed to perform hand hygiene at critical points, such as after removing soiled gloves and before donning clean gloves, and did not use barriers for clean dressing supplies. In one instance, a staff member handled wound packing material that touched a soiled bedsheet before being placed into a resident's wound, and clean dressing tools were placed directly on potentially contaminated surfaces. Staff involved in these procedures acknowledged that hand hygiene should occur between dirty and clean processes but did not consistently follow this protocol during observed dressing changes. In the laundry area, staff did not use appropriate personal protective equipment (PPE) when sorting and loading dirty linens, as they were not required to wear clothing protectors to prevent contamination. Additionally, staff did not consistently sanitize all necessary parts of the washing machine, such as the interior rim of the door, before removing clean laundry. Staff responsible for these tasks indicated a lack of clear procedures and expectations regarding PPE use and cleaning protocols. The facility also lacked a comprehensive infection control program, as there was no documented facility and community-based infection control risk assessment available. The water management program was incomplete, missing key components such as specific control measures, corrective actions, contingency responses, procedures for confirming program effectiveness, and communication protocols. Staff were unaware of certain infection control interventions, such as Enhanced Barrier Precautions, and did not consistently follow posted instructions for PPE use during resident care.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to identify and report potential allegations of abuse and neglect to the State Survey Agency as required by policy and regulation. For one resident with a history of stroke and depression, who required maximum assistance with activities of daily living, a grievance was filed alleging that a male CNA was rough while dressing the resident, resulting in a bruise on the resident's arm. This allegation was investigated as a grievance but was not logged or reported to the State Survey Agency as a potential abuse incident. Another resident, admitted with a spinal fracture and depression and dependent on staff for toileting, reported being left in a soiled brief after a nursing assistant refused to provide care, stating it was not their section and the assigned aide was on break. This allegation of neglect was also investigated as a grievance and not reported to the State Survey Agency. The Director of Nursing Services confirmed that neither incident was logged or reported as required.
Failure to Document Trauma Trigger Assessments for Residents with Trauma Histories
Penalty
Summary
The facility failed to develop and document trauma trigger assessments for two residents with known histories of trauma. For one resident with a diagnosis of PTSD, the care plan identified a potential alteration in psychosocial well-being related to surviving a traumatic event and set a goal to minimize trauma triggers. However, staff were unable to locate a specific list of trauma triggers in the resident's records or in the care instructions provided to nursing assistants. Similarly, another resident with a history of trauma and diagnoses including depression and hallucinations had a care plan goal to minimize trauma triggers, but no specific triggers were documented in the resident's records. Interviews with facility staff, including the Resident Care Manager and the Director of Nursing Services, confirmed that trauma triggers for both residents were not identified or listed in the care plans or supporting documentation. This lack of documentation meant that staff did not have clear guidance on how to avoid or minimize trauma triggers for these residents, as required by the facility's policies and regulatory standards.
Unlocked Treatment Cart and Medication Labeling Discrepancy
Penalty
Summary
Surveyors observed that Treatment Cart 1 was repeatedly left unlocked on multiple occasions, despite containing various medications such as antifungal powders and creams, hydrocortisone cream, lidocaine ointment, zinc oxide paste, estradiol vaginal cream, clobetasol propionate, and Thera-Honey gel, as well as wound care supplies. Staff, including a Registered Nurse and the Director of Nursing Services, confirmed that the expectation was for the treatment cart to be locked, but it was found unlocked during several observations. Additionally, a review of medication records for a resident revealed a discrepancy between the Medication Administration Record (MAR) and the medication bubble pack. The MAR indicated an order for Lisinopril 20 mg, with instructions to give half a tablet via PEG tube twice daily, while the medication bubble pack was labeled for Lisinopril 10 mg, instructing to give one tablet via tube twice daily. Staff acknowledged that the orders should match and recognized the potential for a dosing error due to this inconsistency.
Antibiotic Stewardship Deficiency: Inappropriate Criteria for UTI Antibiotic Initiation
Penalty
Summary
The facility failed to ensure that antibiotic initiation for urinary tract infections (UTIs) was based on CDC-approved criteria. The facility's Antibiotic Stewardship Policy, revised in April 2023, did not specify which symptom criteria should be used to determine if a resident's symptoms met the threshold for starting antibiotics. During an interview, the DON stated that nurses used an SBAR tool referencing McGeer's criteria to report UTI symptoms to providers. However, review of federal regulations indicated that Loeb minimum criteria should be used for antibiotic initiation, while McGeer criteria are intended for surveillance and tracking of infection rates. The lack of appropriate criteria in the policy and the use of McGeer criteria for antibiotic initiation led to the deficiency.
Inaccurate Dental Assessment on MDS
Penalty
Summary
The facility failed to accurately assess the dental status of a resident on the Minimum Data Set (MDS) assessment. The resident, who was admitted with diagnoses of failure to thrive, poor calorie intake, and malnutrition, reported that her dentures were outdated and that her two front teeth were missing, which affected her ability to eat and chew. Observation confirmed the resident's report regarding her dentures. The resident's care plan documented an oral hygiene performance deficit due to full upper and lower dentures. However, the MDS assessment indicated that there were no broken or loosely fitting full or partial dentures. The MDS Coordinator stated she did not recall if the resident had missing teeth or dentures.
Failure to Complete PASARR Level II Referrals for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that the Preadmission Screening and Resident Review (PASARR) Level I forms were completed accurately and that appropriate Level II PASARR referrals were made for two residents. Specifically, one resident was admitted with diagnoses of depression, anxiety disorder, and insomnia, and another with depression and insomnia. Both residents had their Level I PASARR forms completed, which documented their mental health diagnoses, but there was no evidence in their electronic health records that referrals for Level II evaluations were made as required by facility policy and regulatory standards. During a review of the medical records, the facility administrator confirmed that referrals for Level II evaluations should have been made for both residents. The facility's policy states that Level II PASARR evaluations are required for residents identified with indicators of serious mental illness or intellectual disabilities during Level I screening or at any time during their stay. The lack of documentation and failure to initiate Level II referrals constituted the deficiency identified by surveyors.
Failure to Ensure Person-Centered Care Plans Addressed All Resident Needs
Penalty
Summary
The facility failed to ensure that person-centered care plans were completed to address all aspects of care, including individualized goals and approaches for eating and assistance with turning and repositioning, for two residents. For one resident with a history of stroke, hemiparesis, and aphasia, the care plan included an intervention to encourage frequent repositioning for pressure relief. However, the DON acknowledged that this resident could not perform this action independently, indicating the care plan did not accurately reflect the resident's needs or abilities. Another resident with dysphagia and a history of stroke required a mechanically altered diet and specific adaptive equipment for eating and drinking. Observations revealed that instructions for care, such as the use of a knobbed cup, prohibition of straws, and a preferred schedule for getting out of bed, were posted in the resident's room but were not included in the care plan or the Kardex, which nursing assistants use to guide care. Staff confirmed that these directives were missing from the official care documentation, resulting in a lack of consistent and comprehensive guidance for staff providing care.
Failure to Follow Physician Orders for Heart and Breathing Medications
Penalty
Summary
The facility failed to implement physician's orders for both a heart medication and a breathing medication for one resident. During medication administration, a registered nurse identified that the resident's apical pulse was 45 beats per minute, which was below the threshold of 60 as specified in the physician's order for the heart medication. The order required the medication to be held and the physician to be notified if the pulse was below 60, but there was no documentation that the physician was notified on multiple occasions when the resident's pulse was below the specified threshold, as evidenced by the Medication Administration Records for April and May. Additionally, the same resident was observed receiving a breathing medication via inhaler, with physician's orders to rinse the mouth with water and spit it out after administration. The nurse administering the medication did not have the resident rinse their mouth as ordered. The Director of Nursing Services confirmed that the expectation was to follow physician's orders and acknowledged that there was no documentation of physician notification when the resident's pulse was below 60.
Failure to Provide Restorative Nursing Services for ADL Maintenance
Penalty
Summary
The facility failed to provide restorative nursing services, specifically a restorative stretching program, for a resident who was identified as needing such interventions to maintain activities of daily living. The resident was cognitively impaired and required substantial to maximum assistance with bed mobility and transfers. Documentation indicated a referral for a stretching program for the resident's left lower extremity, with specific instructions to straighten the leg while in a chair and hold the stretch for a set duration, to be repeated up to five times or to the resident's maximum tolerance. Interviews with facility staff revealed inconsistencies and a lack of awareness regarding the implementation of the restorative program. The DON stated that nursing assistants were responsible for the restorative program, overseen by the charge nurse, while a registered nurse reported that there was no restorative nursing program in place. The rehab director confirmed a referral had been made, but nursing assistants described only basic care for the resident's left arm, such as washing, drying, and applying a splint, with no mention of the prescribed leg stretching program. The corporate regional nurse was unable to provide documentation of the restorative program for the resident's left lower leg.
Failure to Provide Repositioning, Toileting, and Pressure Relief for Dependent Resident
Penalty
Summary
A resident with a history of stroke and identified as a moderate risk for pressure injury, as indicated by a Braden Scale score of 14, was admitted to the facility and required staff assistance for all activities of daily living, including bed mobility, transfers, eating, and toileting. The resident's care plan included the use of pressure relieving devices in bed and/or wheelchair to prevent skin impairment. Despite these documented needs and interventions, the resident was observed without an air mattress or other pressure relieving device on the bed, and a provider order for an air mattress was not placed until 24 days after the risk was identified. Additionally, the resident was observed in a wheelchair for an extended period without being repositioned or offered toileting assistance. Over a span of several hours, no staff were seen providing these necessary services, and the resident remained in the same position. When eventually returned to bed and provided personal care, the resident was found to have a red, blotchy, non-raised rash on the lower abdomen and mid-to-lower back. The Director of Nursing Services confirmed that the resident was not on a scheduled turning or toileting check and change program, despite expectations for such care at least every two hours.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide an ongoing activity program of meaningful engagement tailored to individual resident needs for one resident reviewed for activities. The resident, who had a history of stroke, muscle weakness, paralysis, aphasia, and reduced mobility, was admitted with documented preferences for listening to music and watching certain television shows. The resident's Minimum Data Set assessment indicated that the family or significant other had communicated these preferences to the facility. Despite this information, multiple observations over several days showed the resident remained in bed without access to music, radio, or television. Interviews revealed that the resident's representative was not consulted about specific activity preferences, and the activity assistant was unaware of the resident's interests. This lack of individualized engagement resulted in the resident not receiving activities aligned with her documented preferences.
Failure to Provide Pressure Ulcer Prevention and Repositioning
Penalty
Summary
A resident with a history of diabetes, stroke, and decreased mobility in all limbs was admitted to the facility and assessed as being at moderate risk for pressure injury development, as indicated by a Braden Scale score of 14. The resident required total staff assistance for bed mobility, transfers, and positioning, and was incontinent of bowel and bladder. Despite these risk factors and documentation of redness in the peri area and buttocks, the resident did not have a pressure injury at admission. However, 24 days after being identified as at moderate risk, the resident developed a facility-acquired Stage II pressure injury on the coccyx. At the time of the injury, no pressure-relieving device, such as an air mattress, was observed on the resident's bed. Observations on the day following the injury revealed the resident lying on her back in bed without any pressure-reducing device. Later, the resident was observed in a partially reclined wheelchair for several hours without being repositioned or offered bathroom assistance by staff, as confirmed by both direct observation and the resident's representative. These findings indicate that the facility failed to provide necessary pressure-reducing measures and regular repositioning, which contributed to the development of the pressure injury.
Failure to Secure Smoking Materials and Hazardous Chemicals
Penalty
Summary
The facility failed to secure electronic smoking materials for a resident who required supervision while vaping, as outlined in the facility's own Smoking/E-Cigarette Safety Program policy. The resident, who had a history of stroke resulting in limited movement in his right arm and leg, was observed in possession of a vape pen outside of supervised smoking times, with the device not stored at the nurse's station as required. Staff interviews confirmed that smoking supplies were supposed to be kept secured, but the resident retained access to the vape pen, contrary to policy and the resident's care plan. Additionally, the facility did not implement a system for securing and storing potentially toxic chemicals in a shower room. The shower room door was repeatedly observed to be unlocked and open, and an unlocked cabinet inside contained a bottle labeled as potentially hazardous. Multiple staff members acknowledged that the shower room door was left open and accessible to residents, despite the expectation that it should remain closed and locked. These lapses in securing both smoking materials and hazardous chemicals created accident hazards within the facility.
Failure to Ensure Adequate Indication and Review for Concurrent Medication Orders
Penalty
Summary
The facility failed to ensure that adequate indication for medication was provided for one resident. Upon admission, the resident, who was alert, oriented, and able to make needs known, was prescribed Diclofenac and Eliquis. The facility's pharmacy generated a potential drug interaction report noting that concurrent use of these medications should be approached with caution. Despite this, the resident was administered Diclofenac on the first night and subsequently refused further doses due to concerns about medication interactions. Nursing documentation confirmed the resident's refusal and concern about the medication combination. Staff interviews revealed that the pharmacy had notified the facility of the potential contraindication on the day of admission, but the facility did not notify the on-call provider or Medical Director to review or adjust the medication orders as recommended. This lack of timely provider notification and review led to the deficiency.
Failure to Monitor and Respond to Catheter-Related Changes
Penalty
Summary
The facility failed to take timely action when a resident's indwelling urinary catheter showed abnormal urine characteristics, indicating a potential infection. The resident, who was admitted with diagnoses including type 2 diabetes and urinary retention, was dependent on staff for catheter care. Despite physician orders to monitor urine characteristics and collect a urinalysis if symptoms appeared, documentation showed inconsistent monitoring and recording of urine characteristics over several weeks. On multiple occasions, urine characteristics such as dark yellow color, sediment, and strong odor were noted, which should have prompted further evaluation and notification of the provider according to the facility's policy. However, these changes were not consistently documented, and no new medications were ordered for urinary infections during this period. Eventually, the resident experienced pain, no urine output, and swelling, leading to a hospital transfer where a kidney infection was diagnosed. The lack of consistent documentation and timely response to changes in urine characteristics resulted in the resident experiencing harm, requiring hospitalization for a kidney infection. The facility's failure to adhere to its catheter care policy and procedures placed the resident at risk of catheter-associated infections and delayed care, ultimately affecting the resident's quality of life.
Failure to Report and Document Tree Damage Incident
Penalty
Summary
The facility failed to notify the State Agency and did not record an incident in their Accident/Incident Log when a tree uprooted and fell on the building, causing a puncture in the roof. This incident occurred in the early morning hours, and the fire department was called to the scene. The Maintenance Director confirmed that the structural integrity of the building remained intact, and no injuries to residents or staff were reported. However, the incident was not reported to the State Agency Hotline, nor was it logged in the facility's records, which is a requirement. Observations during the survey revealed that a tarp was covering part of the roof and the outside wall of the facility, with signs indicating danger. Staff interviews confirmed that the tree fell on the roof weeks prior to the survey, and repairs were ongoing. The Administrator acknowledged that the incident had not been reported or logged and stated that she would address this oversight by contacting the necessary parties. This failure to report and document the incident placed residents at risk for an unsafe living environment and diminished quality of life.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide at least eight hours of Registered Nurse (RN) supervision for 9 out of 30 days reviewed. This deficiency was identified through the facility's Staffing Pattern Form, which documented the absence of RN coverage on specific dates. During an interview, the Director of Nursing Services and Registered Nurse acknowledged the shortage and mentioned that the facility was actively recruiting and had hired two RN staff. The shortage was attributed to a low hiring pool, resulting in insufficient RN coverage on the specified dates.
Failure to Provide Necessary ROM Equipment and Exercises
Penalty
Summary
The facility failed to ensure equipment was provided to prevent further avoidable reduction of range of motion (ROM) and mobility for a resident with hemiplegia and hemiparesis affecting the right side and an unspecified hand contracture. The resident's care plan did not include the intervention of a resting hand and elbow extension splint, despite a restorative program referral indicating the need for these interventions. Observations over multiple days confirmed that the resident was not wearing the splints, and staff interviews revealed a lack of awareness and training regarding the resident's need for passive range of motion (PROM) exercises and splint placement. Staff members, including CNAs and nurses, indicated that they were either unaware of the need for the splints or had not been trained to provide the necessary care. The Director of Nursing Services acknowledged that the PROM exercises and splint placement should have been included in the resident's care plan following the restorative program referral. The failure to implement these interventions placed the resident at risk for increased contractures and decreased quality of life.
Latest citations in Washington
Inaccurate PASARR screening affected two residents. One resident with vascular dementia, depression, and adjustment disorder had a PASARR level one that did not reflect mental health diagnoses, and staff stated it was inaccurate. Another resident with PTSD had a PASARR level one that did not include the PTSD diagnosis, with no additional PASARR level one or level two found in the EHR; staff stated the screening was not accurate and should have been repeated.
Undated open meds were found on 2 medication carts, including an open insulin vial and multiple open eye drop bottles with no dates. An LPN and an RN both stated the items should have been dated when opened, and the DON stated open multidose vials or bottles found without a date should be discarded immediately.
A resident with respiratory failure, HTN, and anxiety became SOB and diaphoretic, received a breathing tx, and was sent by EMS to the hospital. The facility could not locate the required SNF/NF to Hospital Transfer form or other transfer records showing what information was communicated to the receiving provider.
Care plans for two residents were not updated to match their current status and care needs. One resident had PTSD and generalized anxiety disorder and was receiving a psychotropic medication, but the care plan listed monitoring for antipsychotic and anticonvulsant meds that were not prescribed and did not include the anxiety diagnosis or related behaviors and interventions. Another resident had new upper and lower dentures, but the oral/dental care plan only noted edentulous status and difficulty chewing, with no mention of dentures or denture-related interventions.
Failure to Provide Individualized Activities: A resident with anxiety, depression, and weakness was cognitively intact but said they could not attend group activities because of leg problems and wanted more in-room activities. The resident mostly stayed in bed watching TV, and staff documentation showed only limited room visits with no consistent activity documentation despite a care plan goal for participation two to three times per week.
Failure to maintain heel offloading for a resident with a reopened DFU. A resident with dementia and dependence for mobility had a left heel wound that had healed and then reopened; the wound care provider recommended heel floating and pressure relieving boots at all times, but observations showed the resident in bed with heels on the mattress and later reclined in a wheelchair with the heel resting on the footrest strap and no boots in place. Staff stated the resident had not refused the boots or heel floating, and the care plan was not updated after the wound reopened.
Failure to Address Hearing and Vision Services for a Resident: A resident with dementia, bilateral hearing loss, and impaired vision was observed without eyeglasses or a hearing device, despite records showing admission with eyeglasses and a personal sound amplifier. The care plan addressed vision only and did not include hearing-related interventions, while staff interviews confirmed the resident’s hearing was strained and that the resident’s device use and vision needs were not fully reflected in the plan of care.
Respiratory care was not provided consistently for two residents receiving O2. One resident with COPD and chronic respiratory failure had an O2 order missing the indication for use and Sats parameters, no MAR documentation of O2 therapy, and inconsistent Sats charting. Another resident with respiratory failure was observed on continuous O2 via NC, but provider orders for O2 therapy and tubing changes were not present after readmission, despite the care plan stating the resident was dependent on O2.
A resident with dementia, hearing loss, and missing lower teeth had an MDS showing obvious or likely cavities or broken natural teeth, and the care plan identified oral/dental health problems with an intervention to coordinate dental care and transportation. Staff stated the resident’s dental needs were captured on the MDS, but no referral was made for dental services or follow-up with the dentist, and the DON said the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation: A resident with DM, dysphagia, and protein-calorie malnutrition was observed eating less than 25% of a meal, but the POC documented 76-100% intake. The CNA said the resident usually ate only 25-50% of meals and that intake was sometimes documented based on what a coworker reported. The LPN/RCM and DON stated meal intake should be documented accurately.
Inaccurate PASARR Screening for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were screened for additional mental health supports through the PASARR process. Resident 97 was admitted with diagnoses including vascular dementia, depression, and adjustment disorder, and was able to make needs known. Review of the PASARR level one dated 04/10/2026 showed no mental health diagnoses and no need for a PASARR level two, even though the resident’s record included mental health diagnoses. During interview, the Regional Social Services staff and the Administrator stated the PASARR was inaccurate, needed modifications, and did not meet expectations. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. Review of the PASARR level one dated 03/30/2026 showed no serious mental illness indicators marked and no PASARR level two indicated, and the EHR contained no other documented PASARR level one or level two. The Social Services Director stated the hospital-provided PASARR was reviewed for accuracy and, if inaccurate, another level one would be completed, and stated this resident’s PASARR did not include PTSD and should have had another level one completed. The Administrator also stated the PASARR was not accurate and another level one needed to be conducted, but none could be located in the EHR.
Undated Open Medications on Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications for 2 of 3 sampled medication carts reviewed for medication storage and labeling, including carts on the 400 and 500 halls. On the 500 hall medication cart, an open vial of insulin and an open bottle of eye drops were observed with no dates. During interview, an LPN stated that when an insulin vial or bottle of eye drops is opened, it should be dated immediately and said both items should have been dated upon opening; the LPN stated they would dispose of the undated vial and bottle. On the 400 hall medication cart, two open bottles of eye drops were observed with no dates. During interview, an RN stated both bottles should have been dated as soon as they were opened and said they would get new eye drops and dispose of the undated bottles. The DNS/RN stated that if an eye drop was opened it should have been dated immediately and that any open multidose vial or bottle found without a date should be discarded immediately.
Missing Hospital Transfer Documentation
Penalty
Summary
The facility failed to ensure hospital transfer documentation was completed for one resident who was transferred to the hospital after complaining of not being able to breathe and appearing diaphoretic. The resident had diagnoses of respiratory failure, high blood pressure, and anxiety disorder, and was able to make needs known. A breathing treatment was provided, and the provider agreed to send the resident out for further evaluation, after which emergency transportation took the resident to the hospital. Record review found no documentation showing what information was provided or communicated to the receiving facility for the transfer. Staff stated that transfer documentation should have included a SNF/NF to Hospital Transfer form, the resident's face sheet, and the medication and treatment administration records, but they were unable to locate documentation showing these items were completed or sent for the resident's hospital transfer.
Care plans did not reflect current diagnoses, medications, or denture status
Penalty
Summary
The facility failed to ensure that care plans were revised and accurately reflected residents’ current status and care needs for 2 of 21 sampled residents. Resident 6 was admitted with diagnoses including heart failure, respiratory failure, and PTSD, and was able to make needs known. The EHR showed Resident 6 also had generalized anxiety disorder and was receiving a psychotropic medication, but the current care plan dated 05/05/2026 documented monitoring for side effects of antipsychotic and anticonvulsant medications even though Resident 6 was not prescribed those medications. The care plan also identified PTSD but did not include generalized anxiety disorder or behaviors to monitor and interventions related to PTSD or anxiety disorder. Staff F, LPN/CC, stated the care plan did not accurately reflect the resident’s current status or prescribed medications, and Staff B, DNS, stated it did not meet expectations because it did not address the anxiety disorder or target behaviors and interventions. Resident 71 was admitted with diagnoses including PTSD, high blood pressure, and depression and was able to make needs known. Observation on 05/06/2026 showed a denture cup by the sink with the resident’s name on the lid and new upper and lower dentures dated 01/12/26. The resident stated the lower dentures did not fit well and that denture adhesive had been provided, but the dentures still did not fit right and the resident had not told staff yet. The focused oral/dental care plan, initiated on 06/23/2026, identified the resident as edentulous and having difficulty chewing, but did not show that the resident had dentures or include interventions related to denture use or maintenance. Staff E, CNA, stated they had not seen the resident wear dentures and were unaware of the new dentures, Staff C, LPN/CC, stated the care plan should have been updated when the dentures were obtained, and Staff B, DNS, stated the care plan should have reflected the dentures and interventions.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities for Resident 5, who was admitted with diagnoses including anxiety disorder, depression, and weakness. The admission MDS dated 01/14/2026 showed the resident was cognitively intact. During interviews on 05/03/2026 and 05/06/2026, Resident 5 stated they could not attend in-person activities because of their legs, wanted more activities to occupy them, mostly stayed in bed watching TV, and did not remember the last time activities staff visited to offer activities. The resident also stated activities staff would need to offer something they were able to do because they had difficulty doing some activities. The activities care plan dated 12/26/2026 showed a goal for Resident 5 to participate in activities two to three times per week. Progress notes documented one visit on 12/22/2026 to provide a welcome packet and encourage participation in daily activities, but no further activity documentation was found in the progress notes. Staff H stated room visits should include puzzles, arts and crafts, visiting, and chatting, and that documentation was placed in tasks, but the task record showed no documentation of activities for the past 30 days. Staff J stated paper documentation existed for room visits and that Resident 5 was on a list for room visits every Monday and Wednesday, while the room visit documentation showed only four visits on 01/26/2026, 02/06/2026, 03/10/2026, and 04/08/2026.
Failure to Maintain Heel Offloading for Reopened DFU
Penalty
Summary
The facility failed to consistently implement pressure reducing strategies for a resident with a left heel diabetic foot ulcer that had reopened. The resident was admitted with diagnoses including left hip fracture with surgical repair, a blood clot of the left lower leg, and dementia, and was dependent on staff for mobility and unable to make needs known. The baseline care plan and care plan both included heel offloading interventions, and the wound care provider initially recommended heel floating with pillows or wedge and pressure relieving boots. The wound later resolved, but a weekly skin assessment documented that the left heel wound reopened and was very painful to touch. After the wound reopened, the contracted wound care provider documented that the DFU to the left heel had reopened and recommended the resident wear pressure relieving boots at all times. The current care plan reviewed after the wound reopened did not include new interventions related to the reopened wound. Observations showed the resident seated in a reclined wheelchair with the left foot/heel resting on the footrest strap and no pressure relieving boots in place, and later lying in bed with both heels directly on the mattress without being floated and without boots. Staff interviews indicated the resident had not refused the boots or heel floating, and the LPN/CC and DON stated the resident should have been assessed and the plan of care updated when the wound reopened.
Failure to Address Resident Hearing and Vision Needs
Penalty
Summary
The facility failed to address one resident’s hearing and vision needs. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears, and was able to make needs known. The record showed the resident lost their glasses and was given readers, but the resident did not wear them because they were concerned that wearing glasses that were not their prescription would further degrade their vision. Observation did not show glasses in the resident’s room, and the resident stated they did not use a hearing aid. The resident was observed to be hard of hearing, requiring an elevated voice and repeated questions to understand. The admission MDS dated [DATE] documented adequate hearing with hearing aid and adequate vision with corrective lenses, while the significant change MDS dated [DATE] documented moderate difficulty hearing without a hearing aid and impaired vision without corrective lenses. The care plan initiated 02/24/2026 addressed impaired vision with interventions to arrange consultation with eye care practitioners as needed and remind the resident to wear glasses, but it did not include a focus area or interventions for hearing loss or use of hearing aids. A resident clothing list showed the resident admitted with one pair of eyeglasses and one Super Ear headset personal sound amplifier, yet observation and interview showed the resident in bed without eyeglasses or a hearing device, with the amplifier stored in the bedside table drawer. Staff interviews confirmed the resident’s hearing was strained, that the hearing device and glasses were not being used, and that the resident’s hearing device use should have been included in the plan of care and the resident should have been referred for eye care assessment.
Respiratory Care Orders and Documentation Not Maintained
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice for two residents receiving oxygen therapy. One resident with COPD and chronic respiratory failure with hypoxia was observed multiple times lying in bed receiving oxygen at 2 L via nasal cannula. The resident’s oxygen order, dated 02/15/2026, allowed 1 to 4 L per minute continuously via nasal cannula, but it did not include an indication for use or oxygen saturation parameters. The April and May 2026 MARs did not show documentation of oxygen therapy being provided, and the TARs showed only an order to change oxygen tubing if damaged or visibly soiled, not an order for oxygen therapy. Oxygen saturations were not documented consistently daily from 04/01/2026 through 05/04/2026. A second resident with respiratory failure, high blood pressure, and anxiety disorder was observed in the room receiving oxygen at 6 L via nasal cannula on multiple occasions. The resident stated they needed oxygen therapy to breathe, and the care plan identified the resident as dependent on oxygen and to receive oxygen per provider orders. However, provider orders reviewed on 05/04/2026 showed no orders for oxygen therapy or for changing oxygen tubing. Staff stated the oxygen and tubing-change orders had been discontinued when the resident went to the hospital and were not added back to the MAR or TAR when the resident readmitted to the facility.
Failure to Refer Resident With Identified Dental Needs
Penalty
Summary
The facility failed to ensure that Resident 112 received needed dental care. Resident 112 was admitted with diagnoses including a leg fracture, dementia, and hearing loss in both ears. Observation on 05/03/2026 showed the resident had missing lower teeth. The admission MDS, dated [DATE], documented obvious or likely cavities or broken natural teeth, and the care plan dated 02/24/2026 identified oral/dental health problems related to likely cavities or broken teeth with an intervention to coordinate dental care and provide transportation. During interviews, Staff G, Regional Social Services, stated Resident 112's dental needs were captured on the 02/24/2026 MDS and the resident was not referred for dental services. Staff M, Social Services Director, stated residents with dental needs should be referred to social services to be scheduled for assessment by a dental care practitioner, and that Resident 112 should have been referred after the MDS assessment. Staff B, DON, stated residents with identified dental needs should be referred for follow-up with a dentist and that Resident 112 should have been referred to the in-house dental provider; Staff B stated the lack of referral did not meet expectations.
Inaccurate Meal Intake Documentation
Penalty
Summary
The facility failed to accurately document the amount of food eaten for Resident 13, who was admitted with diagnoses including diabetes mellitus, dysphagia, and protein-calorie malnutrition. The quarterly MDS dated 02/12/2026 showed the resident was moderately cognitively impaired. During observation on 05/05/2026 at 12:09 PM, a meal tray was delivered to the resident’s room, set up on a bedside table, and the resident was observed eating slowly, eating less than 25% of the meal, then laying back in bed and closing their eyes while the tray remained in the room. Staff later removed the tray, but the POC documentation for lunch on 05/05/2026 recorded that Resident 13 ate 76-100% of the meal. During interview, the CNA stated the resident typically ate 25-50% of meals and never ate all of the food, and that if they did not pick up a tray they would ask a coworker what the resident ate before documenting it. The CNA stated they were told the resident ate 75-100% of lunch, so that is what was entered. The LPN/RCM stated staff should document meal intake accurately in POC, and the RN/DNS stated it was their expectation that all staff document meal intake accurately.
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