Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hemet Valley Healthcare Center during CMS and state inspections, most recent first.
A resident with significant physical and cognitive impairments was transferred from bed to a shower gurney by a CNA and RT when the gurney's brakes failed to lock, causing the gurney to slip and the resident to slide to the floor. Both staff members were aware of the malfunctioning brakes but proceeded with the transfer and did not report the equipment issue as required by facility policy.
Food Storage and Labeling Deficiencies: The kitchen had nine one-gallon BBQ sauce containers and one box of rice pilaf stored without expiration dates, and multiple prepared food items in refrigerator 3 were uncovered and open to air. The DFN stated the items had no expiration dates and that food dispensed onto trays the same day should be covered, while the DON stated all food items should be labeled and covered to prevent cross contamination.
Expired central line dressing change supplies and Prostat protein packets were found stored in medication areas and readily available for use. The RNS confirmed the items were expired and should have been removed from storage so they would not be used or given to residents.
The facility did not report a COVID-19 outbreak to CDPH as required and failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling devices, wounds, or colonized MDROs. Staff were observed providing care without proper PPE, lacked awareness of EBP, and the facility's infection control policy was outdated and not aligned with current guidelines.
Four residents with significant health conditions, including respiratory and kidney failure, tested positive for COVID-19, but no care plans were developed to address their infection. Staff interviews revealed confusion about care plan responsibilities and timing, and record reviews confirmed the absence of required care plans despite facility policy mandating timely updates after a change in condition.
A resident with complex medical needs was placed in the activity room for several days due to a Covid-19 outbreak and lack of available rooms. The room remained cluttered with furniture, supplies, and equipment, and staff continued to access the space for activities, with no privacy curtains provided. Facility staff confirmed the environment was not appropriate for residential care and did not meet the standard for a homelike setting.
The facility did not submit staffing information to the CMS database for the second fiscal quarter. The DON stated that the IP, responsible for the submission, was transitioning into their role and the facility faced staffing issues, leading to the delay. The DON acknowledged the data should have been submitted timely, as per CMS guidelines.
The facility failed to provide and document information on Advance Directives (AD) for two residents and did not have an AD readily available for another resident. One resident with severe cognitive impairment and another who was unresponsive did not have documented evidence of AD information being provided to their representatives. Additionally, an alert and oriented resident's AD was not found in their medical record, despite facility policy requiring such documentation.
The facility failed to document the rationale for extended use of lorazepam for a resident and did not consistently monitor the effectiveness of quetiapine for another resident. The lack of documentation and monitoring could lead to unnecessary use of psychotropic medications.
The facility failed to ensure food safety and sanitation in the kitchen, with unlabeled and improperly stored food items, cleanliness issues, and equipment not maintained according to standards. Observations included open and unlabeled food in refrigerators, wet-stacked pans, and ice buildup in freezers, risking foodborne illness.
The facility failed to implement proper infection control practices, including a nurse using a gloved finger to check water temperature for medication dilution, and two nurses not performing hand hygiene before administering eye drops. Additionally, a suction canister was found unlabeled and undated, contrary to facility policy.
A resident with severe cognitive impairment and skin conditions frequently refused showers, leading to recurring redness in various areas. Despite having physician's orders for antifungal and antibacterial treatments, the facility failed to implement interventions to address the resident's shower refusals. The Infection Preventionist acknowledged the refusals, but the care plans lacked necessary interventions, as confirmed by the DON.
The facility failed to develop and implement written policies and procedures for the monthly drug regimen review by a licensed pharmacist. During an interview and record review with the Director of Pharmacy (DOP), it was found that there was no documented evidence of such policies. The DOP confirmed the absence of a current policy, potentially delaying the identification of harmful drug interactions and side effects, impacting residents' well-being.
A survey found a medication error rate of 9.68% in an LTC facility. Errors included an LVN administering tobramycin eye drops to both eyes instead of just the right eye, and holding fludrocortisone based on incorrect blood pressure parameters. An RN also improperly diluted Phos-NaK powder for a resident's feeding tube. These actions led to medications not being given as per orders or specifications.
The facility failed to ensure a safe and sanitary environment, as air vents above the beds of two residents with respiratory failure were found stained with dark dust particles. This was confirmed by the DON and DRD during a survey. The facility's policy requires immediate correction of such hazards, which was not followed.
A resident with lower extremity contractures sustained a left hip fracture due to improper positioning during urine sample collection. Despite hearing an abnormal sound, the staff continued the procedure. Additionally, the facility failed to monitor and address a bluish discoloration on the resident's left eyelid, resulting in delayed treatment.
A resident with chronic respiratory failure and in a persistent vegetative state was found with a bruise on the left eyelid, which was not reported to CDPH within the required timeframe. The injury was documented on December 14, 2023, but not reported until March 15, 2024, 81 days later. The DON acknowledged the reporting delay, which could have delayed appropriate action and protection for the resident and others.
Failure to Ensure Shower Gurney Brakes Functioned Properly During Resident Transfer
Penalty
Summary
The facility failed to ensure that the shower gurney's wheel brakes were locking properly, resulting in an accident during the transfer and bathing of a resident who was dependent on staff for all transfers and showers. The resident, who had acute respiratory failure, contractures of both lower extremities, and no discernible consciousness, was being transferred from bed to a shower gurney by a CNA and a respiratory therapist. During the transfer, the gurney's brakes did not lock properly, causing the gurney to slip away and the resident to slide to the floor. Staff present managed to prevent the resident's head from hitting the floor, but the resident's buttocks and legs did make contact with the floor. Interviews with the CNA and respiratory therapist confirmed that they were aware the gurney's brakes were not functioning correctly at the time of use. The CNA acknowledged that she should not have used the malfunctioning equipment and should have reported the issue to the charge nurse. The DON stated that staff are expected to immediately report malfunctioning equipment and remove it from service, but was not informed of the issue until after the incident. Facility policy requires that any equipment suspected of malfunctioning be removed from service and reported, but this procedure was not followed in this case.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure food safety and sanitation were observed in the kitchen when nine one-gallon containers of BBQ sauce were found without expiration dates, one box of rice pilaf was found without an expiration date, and multiple prepared food items in refrigerator 3 were found uncovered and open to air. During the kitchen inspection, these items were observed stored in the dry storage area and refrigerator 3, and the Director of Food and Nutrition stated there were no expiration dates on the BBQ containers or the rice pilaf box and that food items dispensed onto trays the same day should be covered and not left open to air. The Director of Nursing stated that all food items should be labeled and covered to prevent cross contamination. The facility policy titled Food Storage stated that manufacturer expiration, use by, or sell by dates must be adhered to and that all foods prepared in operation must be covered and labeled as to contents and date of preparation prior to storage in refrigerators and freezers.
Expired medical supplies and nutrition products stored for use
Penalty
Summary
Expired medical food and dressing change supplies were found stored in the medication storage areas and were readily available for use. During a medication storage inspection with the Registered Nurse Supervisor (RNS), two sterile central line dressing change trays were observed to contain outdated components, including Medium Aloe Vinyl Examination gloves with an expiration date of 5/28/2025, a Stabilization PICC Statlock with an expiration date of 08/28/2025, and an Aegis CHG disk with an expiration date of 10/18/2025. The sticker label on the kits stated that upon opening the pack, the expired component should be removed and destroyed, while the remainder of the items were safe for use. In interview, the RNS stated the items were expired and should have been removed from storage so they would not be used on residents. The inspection also found 18 outdated Prostat concentrated liquid protein packets stored and readily available for use, with expiration dates of 10/10/2025, 8/13/2025, and 6/17/2025. In interview, the RNS stated the Prostat packets were expired and should have been removed from storage so they would not be given to residents. The facility policy titled, EXPIRED/RECALLED PRODUCTS, dated May 2024, stated that outdated or recalled nutrition products would not be provided to patients and that outdated or recalled products would be discarded immediately or returned to the manufacturer for credit.
Failure to Report COVID-19 Outbreak and Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection prevention and control practices, specifically by not reporting a COVID-19 outbreak to the California Department of Public Health (CDPH) when one staff member and four residents tested positive. The Infection Preventionist (IP) acknowledged the outbreak and reported it only to the county public health officer, omitting the required notification to CDPH. Facility policy and state guidance both require such outbreaks to be reported to both local and state health authorities, but this was not followed. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) as required by CDC and CDPH guidelines for residents with indwelling medical devices, wounds, or colonized multidrug-resistant organisms (MDROs). Observations revealed that staff were not using gowns and gloves during high-contact care activities for these residents, and there was no signage indicating EBP in the rooms of affected residents. Interviews with staff, including CNAs and LVNs, indicated a lack of awareness and training regarding EBP, and the Infection Preventionist and DON confirmed that EBP was not being practiced or included in facility policy. Record reviews showed that multiple residents with tracheostomies, feeding tubes, urinary catheters, and wounds did not have physician orders or care plans for EBP. The facility's infection control policy was outdated and did not reflect current EBP requirements. Staff interviews further confirmed that EBP was not being implemented, and staff were unclear about the appropriate use of PPE for residents at risk of MDRO transmission.
Removal Plan
- Members of the Governing Board and MEC (Medical Executive Committee) were notified of the findings by the COO (Chief Operating Officer).
- The DON identified all residents with colonized MDROs, those at increased risk to acquire MDRO infection, and those that require high contact care activities for which EBP should be used.
- The DON validated the facility had appropriate and adequate levels of PPE to use for EBP. The DON contacted central supply to ensure levels were justified and supplies were available at all times.
- All residents currently on the unit were evaluated by the DON to ensure no adverse effects occurred. EBP was implemented for all residents if applicable by the DON/designee.
- Appropriate signage for EBP was created by the DON and placed by the room entrances of residents for whom EBP should be used to aid in identifying and reminding staff to use EBP when providing high contact care activities to the residents.
- The DON rounded on all resident's rooms to ensure the appropriate signage for EBP is in place as per facility policy. Any missing signage was placed in applicable rooms.
- The Medical Director (MD) of the subacute unit was notified of the IJ and was advised of the findings. The MD will continue to collaborate with the leadership team to create and implement the appropriate infection control measure.
- The resident and/or resident representatives of all residents impacted by the deficiency were notified of the incident via phone by the DON/designee.
- The DON/RN Charge Nurse started staff education on EBP and hand hygiene using 1:1 education and group education during huddles. The staff will receive the education before the start of their next shift.
- Providers for the residents impacted by this deficiency were contacted and orders obtained to include the use of EBP. The care plans of the affected residents impacted by this deficiency were updated by the DON/RN to include the use EBP.
- The DON reviewed the policy on EBP and revised it to ensure compliance with current regulations and best practices. The policy reviewed and approved by the Medical Director of the subacute unit and Medical Director of infection control.
- All staff present were educated on the revised EBP policy by the DON/designee. Staff not present will be educated on the revised policy before the start of their next shift. All staff will be educated to the policy.
Failure to Develop Care Plans for Residents with COVID-19
Penalty
Summary
The facility failed to develop and implement care plans for four residents who tested positive for COVID-19. During an unannounced visit, it was found that these residents, who had significant diagnoses such as respiratory failure and kidney failure, did not have care plans addressing their COVID-19 infection. Interviews with staff revealed uncertainty about the process and timing for updating care plans, with the Infection Preventionist and a Registered Nurse both acknowledging that care plans should have been created or updated following the residents' positive COVID-19 diagnoses, but this was not done. Record reviews confirmed that, despite documentation of positive COVID-19 test results in the residents' progress notes, there were no corresponding care plans developed to address the infection. The facility's policy required that an individual plan of care be initiated within 24 hours of admission or a change in condition, and updated as needed, but this procedure was not followed for the affected residents.
Resident Placed in Activity Room Fails Homelike Environment Standard
Penalty
Summary
The facility failed to provide a homelike environment for one resident who was readmitted following a hospital stay. Upon readmission, the resident, who had diagnoses including acute-on-chronic respiratory failure, hydrocephalus, psychosis, and a tracheostomy, was placed in the activity room for five days due to a lack of available female rooms during a Covid-19 outbreak. The activity room was not cleared of its usual furniture and supplies, and staff continued to access the room for activity materials while the resident was present. No privacy curtains were provided, and the room contained multiple large tables, chairs, carts, bins, cabinets, and emergency oxygen tanks, creating a cluttered and non-homelike environment. Interviews with facility staff, including the Infection Preventionist, LVN, and DON, confirmed that the resident remained in the activity room for five days, and that the room was not adequately prepared for residential use. The DON was unaware of the extent of the clutter and the duration of the resident's stay in the activity room. Staff acknowledged that the environment was not appropriate for a resident, and that the resident was alert and aware of her surroundings, though she had unclear speech and communicated through nonverbal means. The facility's own policy on resident rights, which emphasizes the right to a dignified existence and a homelike environment, was not followed in this instance. The resident's placement in a cluttered, shared activity space without privacy or proper accommodation for personal belongings did not meet the standard for a safe, clean, and comfortable environment as required by facility policy.
Failure to Submit Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit staffing information based on payroll data to the CMS database for the second fiscal quarter of the year. This failure was identified through a review of the CMS PBJ Staffing Data Report CASPER for fiscal year quarter 2, which indicated that the data was not submitted for the quarter. During an interview, the Director of Nursing Services (DON) explained that the Infection Preventionist (IP), who was responsible for submitting the report, was transitioning into their role during the reporting period. The facility was also experiencing staffing issues, which contributed to the delay in submission. The DON acknowledged that the data should have been submitted in a timely manner, as required by CMS' Electronic Staffing Data Submission Payroll-Based Journal: Long-Term Care Facility Policy Manual.
Failure to Provide and Document Advance Directive Information
Penalty
Summary
The facility failed to ensure that information regarding the formulation of Advance Directives (AD) was provided to the Resident Representatives (RR) for two residents, and that another resident's AD was readily available in their medical record. For Resident 18, who had severe cognitive impairment and required high complexity medical decision-making, there was no documented evidence that information on formulating an AD was provided to the RR. The Infection Preventionist and Social Services Liaison confirmed that there was no documentation of such information being offered, and the Director of Nursing acknowledged that it should have been provided upon admission. Similarly, for Resident 7, who was unresponsive and unconscious with a history of chronic respiratory failure and anoxic brain injury, there was no documented evidence of recent attempts to provide information on formulating an AD to the RR. The RR had previously declined to complete an AD, and the facility staff could not state any frequency for follow-ups regarding AD formulation, confirming no recent attempts were made to discuss or provide information to the RR. For Resident 11, who was alert and oriented, there was no documented evidence that information on formulating an AD was provided, nor was there an AD filed in the resident's record. The Social Services Liaison and Director of Nursing were unable to locate the AD in both paper and electronic records, despite the resident having an AD in their chart upon initial admission. The facility's policy indicated that AD information should be documented and scanned into the patient's medical record, but this was not adhered to in Resident 11's case.
Failure to Document Rationale and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. For one resident, the facility did not have the prescriber-documented rationale for the extended use of as-needed lorazepam beyond 14 days. The resident's medical record showed multiple orders for lorazepam, but there was no documentation justifying the need for continued use. The Director of Nursing acknowledged the lack of documentation and stated that the expectation is for the physician to evaluate and document the rationale for extending such orders. For another resident, the facility did not consistently monitor the effectiveness of the antipsychotic medication quetiapine. The resident had a history of substance abuse, multiple injuries, and chronic respiratory failure, and was prescribed quetiapine to manage psychosis. However, the behavior monitoring documentation was inconsistent, with some days having less than the expected two entries per day. The Clinical Nurse Educator and Infection Preventionist confirmed the inconsistency, and the Director of Nursing noted issues with staff documentation practices.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to food safety requirements for food storage and sanitary food preparation in the kitchen. During an inspection, it was observed that multiple items in the walk-in refrigerator, freezer, and dry storage area were not labeled and/or left open to air. Specifically, bags of red grapes and heads of green leafy lettuce were stored without lids, a gallon of lime juice was opened and not labeled with an open date, and another gallon of lime juice was expired. Additionally, a large vacuum-sealed pork in the freezer was not labeled or dated, and containers of spices were not labeled with open dates. A bag of Cinnamon Strudel Topping Mix was left open to air, and stainless steel pans were stacked wet, risking cross-contamination. The kitchen also had cleanliness issues, with a used black rubber glove left on a cooking prep table, tattered oven mitts with exposed batting, and a stainless steel shelf with peeling plastic and loose particles. Freezers 2 and 3 had ice buildup on the floors, which was acknowledged as unacceptable by the Deputy Regional Director. The facility's policies and procedures for food storage, preventing disease transmission, and cleaning and sanitation were not followed, as confirmed by the Dietary Supervisor during interviews.
Infection Control Deficiencies in Medication Administration and Equipment Management
Penalty
Summary
The facility failed to implement proper infection control practices during medication administration and equipment management. One licensed nurse used her gloved finger to check the water temperature before using it to dilute medications and flush the feeding tube for a resident. This practice was confirmed by the nurse and identified as an infection control issue by both the Infection Preventionist and the Director of Nursing. Additionally, two nurses did not perform hand hygiene before administering eye drops to residents. One nurse used the same pair of gloves throughout the medication pass, including administering eye drops, due to a lack of gloves in the resident's room. Another nurse changed gloves but did not perform hand hygiene before administering eye drops, believing it was unnecessary unless hands were visibly soiled. The facility's policy required hand hygiene before clean/aseptic procedures, which was not followed. Furthermore, a suction canister for a resident with respiratory failure was found unlabeled and undated. The Respiratory Therapist confirmed the oversight, noting that suction canisters should be labeled and dated to ensure timely changes. The facility's policy required suction canisters to be changed every two weeks or as needed, which was not adhered to in this instance.
Failure to Address Resident's Shower Refusals and Skin Care
Penalty
Summary
The facility failed to implement interventions to address a resident's frequent refusals of showers, which could potentially delay the care and treatment of the resident's skin conditions. The resident, who was admitted with chronic respiratory failure and diabetes mellitus, had a BIMS score of zero, indicating severe cognitive impairment. The resident's Medication Administration Record included physician's orders for antifungal and antibacterial treatments for inflamed skin in various areas, including under the arms, breasts, and groin. Despite these orders, the resident frequently refused showers, leading to recurring redness in these areas. The Infection Preventionist, who also served as the Treatment Nurse, acknowledged the resident's frequent shower refusals and stated that bed baths were offered as an alternative. However, the resident's care plans did not include any interventions to address these refusals. The Director of Nursing confirmed that there should have been a plan of care or interventions developed to address the resident's skin issues related to shower refusals. The facility's policy on interdisciplinary care plans required individualized plans to be initiated upon admission and adjusted in response to identified problems, but this was not done in this case.
Lack of Policies for Monthly Drug Regimen Review
Penalty
Summary
The facility failed to develop and implement written policies and procedures for the monthly drug regimen review by a licensed pharmacist. This deficiency was identified during a concurrent interview and record review with the Director of Pharmacy (DOP) on July 31, 2024. The review revealed no documented evidence of such policies and procedures in place. During a subsequent interview, the DOP confirmed the absence of a current policy addressing the monthly drug regimen review. This lack of policy had the potential to delay the identification of harmful drug interactions, side effects, and inadequate monitoring, which could negatively impact residents' physical, mental, and psychosocial well-being.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility was found to have a medication error rate of 9.68% during a survey, with three medication errors occurring out of 31 opportunities. One error involved a Licensed Vocational Nurse (LVN) administering tobramycin eye drops incorrectly to a resident. The physician's order specified that the drops should be administered to the resident's right eye only, but the LVN administered them to both eyes. Additionally, the same LVN held a dose of fludrocortisone for the resident based on incorrect blood pressure parameters, contrary to the physician's order which specified holding the medication only if the systolic blood pressure was greater than 110. Another error involved a Registered Nurse (RN) administering Phos-NaK powder to a different resident via a feeding tube with insufficient dilution. The RN used only 40 ml of water instead of the required 75 ml per packet as indicated on the medication's labeling and in the drug information resource. The RN admitted to not having received training on the proper dilution of Phos-NaK for feeding tube administration. These errors resulted in medications not being administered according to the prescriber's orders and/or manufacturer's specifications, potentially affecting the therapeutic outcomes for the residents involved.
Failure to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by the presence of stained air vents with dark colored dust particles above the beds of two residents. This was observed during a survey conducted on July 30, 2024, at 10:30 a.m., with confirmation from the Director of Nursing and the Deputy Regional Director. The affected residents, identified as Resident 17 and Resident 170, both have diagnoses related to respiratory failure, which could be exacerbated by the dust particles. The Director of Facility acknowledged the issue and mentioned plans to place new covers on the vents. The facility's policy, revised in March 2021, requires that hazards posing imminent danger be corrected immediately, which was not adhered to in this instance.
Improper Positioning and Lack of Monitoring Lead to Resident Injury
Penalty
Summary
The facility failed to ensure proper positioning of a female resident with lower extremity contractures during urine sample collection using a straight catheter. The resident's hip and leg/thigh were lifted up six inches from the mattress, and despite hearing an abnormal sound from the resident's hip area, the licensed nurse continued to collect the urine sample. This improper positioning resulted in the resident sustaining a left hip fracture and being transferred to an acute hospital for a surgical procedure. Interviews with the staff involved revealed that they were aware of the resident's contractures and the abnormal sound but proceeded with the urine collection under the charge nurse's instructions. Additionally, the facility failed to assess, monitor, evaluate, and refer to the physician for appropriate treatment of a bluish discoloration to the resident's left eyelid. The discoloration was first noticed by the resident's family member and reported to the staff. Despite initiating a short-term care plan to monitor the discoloration, there was no documented evidence of further assessment, evaluation, or physician notification. The Director of Nursing acknowledged the lack of documentation and follow-up regarding the discoloration. The resident involved had a history of chronic respiratory failure, status post tracheostomy, and persistent vegetative state. The improper handling during the urine collection and the failure to monitor and address the discoloration on the resident's eyelid highlight significant deficiencies in the facility's care practices and adherence to protocols for resident safety and health monitoring.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for Resident A to the California Department of Public Health (CDPH) within the required timeframe. Resident A, who has a history of chronic respiratory failure and is in a persistent vegetative state, was found with a bruise on the left eyelid on December 14, 2023. Despite the bruise being documented and monitored, the facility did not report the injury to CDPH until March 15, 2024, which is 81 days after the initial identification. The Director of Nursing (DON) acknowledged that the injury should have been reported within 2 hours of its discovery, as per the facility's policy on abuse prevention and reporting procedures. The deficiency was identified during an announced visit on March 28, 2024, to investigate a facility-reported incident. Interviews with the DON revealed that the family of Resident A had noticed the bruise and believed it occurred during a shower given by the staff. The DON's assessment on December 25, 2023, indicated the bruise was old and healing, but neither the resident nor the staff could determine its cause. The facility's failure to report the injury promptly had the potential to delay appropriate action and protection for Resident A and other residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Hemet
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Devonshire Care Center | 0.1 mi | ★★★★★ | 6 | 0 |
| San Jacinto Valley Post Acute | 0.1 mi | ★★★★★ | 14 | 0 |
| Meadowbrook Post Acute | 1.5 mi | ★★★★★ | 34 | 0 |
| Ramona Rehabilitation And Post Acute Care Center | 1.8 mi | ★★★★★ | 16 | 1 |
| The Bradley Gardens | 2.2 mi | ★★★★★ | 21 | 0 |
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