Mission Palms Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Westminster, California.
- Location
- 240 Hospital Circle, Westminster, California 92683
- CMS Provider Number
- 056271
- Inspections on file
- 19
- Latest survey
- March 19, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Mission Palms Healthcare Center during CMS and state inspections, most recent first.
A resident with a high fall risk and a care plan requiring two-person assistance for transfers was assisted to the bathroom by only one CNA, with a family member present. The resident was unstable and nearly fell during the transfer, and it was later confirmed that the resident was not cleared to ambulate. The DON acknowledged these findings.
The facility failed to provide appropriate respiratory care for six residents, with incorrect oxygen administration and failure to adhere to infection control protocols. Residents received incorrect oxygen rates, and a nebulizer set-up was not changed weekly as required. Staff acknowledged these deficiencies during interviews.
The facility failed to maintain sanitary conditions in the kitchen, with improper hand hygiene and glove use by staff, unclean equipment, and inadequate calibration of thermometers. Personal belongings were improperly stored, and utensils were not air-dried as required. These deficiencies were confirmed through observations and interviews with staff.
The facility failed to maintain effective infection control, with issues such as improper disposal of gowns, inaccurate infection logs, and unsanitary storage of a resident's nasal cannula. Medication carts were not cleaned properly, and a resident with an ESBL infection was not placed under required precautions. Staff acknowledged these deficiencies, indicating lapses in infection control protocols.
A facility failed to complete the McGeer's Criteria for Infection Surveillance Checklist for a resident on antibiotics, risking unnecessary use and resistance. The IP also failed to identify many HAIs in infection logs and incorrectly documented residents with confusion as asymptomatic.
A resident with moderate cognitive impairment was found with several medications at her bedside, which she self-administered without proper assessment or physician's orders. Facility policy requires an assessment for self-administration and secure storage of medications, which was not followed in this case.
Two residents experienced falls, and their post-fall neurological assessments were inaccurately documented, with no interventions recorded for sluggish pupil reactions. The facility's policies for neurological assessments and falls management were not followed, leading to potential delays in care. The deficiencies were acknowledged by the facility's staff and administration.
A facility failed to implement and document necessary fall risk interventions for a resident identified as high risk for falls. The care plan included conducting rounds every two hours, placing a star sticker on the resident's room, and applying a colored arm band, but these were not consistently followed. Interviews with an LVN and the DON confirmed the lack of documentation and the absence of required interventions, putting the resident at risk for further falls and injuries.
A facility failed to adhere to a resident's physician-ordered fluid restriction of 1000 ml per day, resulting in the resident's fluid intake consistently exceeding the prescribed limits. The Intake and Output Records were inaccurate, and staff interviews revealed a lack of understanding and communication regarding the fluid restriction. There was no evidence that the physician was notified or that the resident was monitored for fluid overload.
Two residents in a facility were administered the anticoagulant apixaban without proper monitoring for bleeding signs, as required by the facility's policy. Resident 39, with a care plan for high bleeding risk, lacked documented assessments for bleeding symptoms. Similarly, Resident 84, with acute embolism and thrombosis, was not monitored for bleeding until weeks after starting the medication. Interviews revealed a lack of in-service training for staff on monitoring anticoagulant therapy, and the facility's administration acknowledged these deficiencies.
A facility failed to ensure a resident was free from unnecessary psychotropic medication by inaccurately monitoring meal intake and not completing a monthly behavior summary for mirtazapine use. Discrepancies in documentation between licensed nurses and CNAs were noted, and the medication was administered despite meal intake often being below the required threshold.
The facility failed to ensure safe medication storage, with an unlocked medication cart left unattended and improper storage of medications. A resident had vitamin A&D ointment at their bedside without a physician's order, and eye and rectal medications were stored together in a cart. Staff acknowledged these storage issues.
The facility did not adhere to menu guidelines for pureed diets, resulting in discrepancies in meal preparation. Pureed mixed vegetables lacked cauliflower and tofu present in the regular version, and pureed beef was served without the required sauce. These deviations were confirmed by the DSS, potentially affecting the nutritional adequacy for residents on pureed diets.
The facility failed to ensure safe handling and storage of food brought by family members or visitors, as their policies lacked guidelines for such practices. Interviews revealed that while residents could request kitchen storage for outside food, there was no separate refrigerator, and overnight storage was not permitted. This oversight posed a potential risk of foodborne illnesses to residents.
A resident was physically abused by a CNA who slapped them on the face, resulting in redness on the cheek. The incident was confirmed through interviews and document reviews, revealing the CNA's admission of the act as a reflexive response to being kicked and hit by the resident. The facility's policies on abuse prevention and resident rights were not upheld, leading to the CNA's termination.
Failure to Provide Required Two-Person Assistance During Transfer
Penalty
Summary
A deficiency occurred when a resident, identified as high risk for falls and dependent on staff for activities of daily living (ADL) care, was not provided with the required two-person assistance for transfers as outlined in their care plan. The resident's care plan specifically indicated the need for two-person assistance with transfers and positioning due to altered skin integrity and a history of falls. Despite these documented needs, the resident was assisted to the bathroom by only one certified nursing assistant (CNA), with a family member present, rather than the required two staff members. Interviews and medical record reviews confirmed that the CNA held the resident's arm while ambulating to the bathroom, and the family member reported that the resident was unstable and nearly fell during the transfer. Further, the family member contacted physical therapy and was informed that the resident was not cleared to ambulate. The Director of Nursing (DON) acknowledged these findings during a review of the incident.
Inadequate Respiratory Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate respiratory care for six residents, as evidenced by incorrect oxygen administration and failure to adhere to infection control protocols. Residents 11, 32, 37, 44, and 685 were not receiving the correct rate of oxygen as per their physician's orders. For instance, Resident 44 was observed using an oxygen concentrator set at 2.5 liters per minute, contrary to the physician's order of two liters per minute as needed for shortness of breath. Similarly, Resident 32 was receiving oxygen at three liters per minute, while the order specified two liters per minute as needed. Resident 37 was also receiving oxygen at three liters per minute, despite a physician's order for two liters per minute to maintain oxygen saturation above 92%. Resident 685 was found to be receiving less than one liter per minute, contrary to the order for two liters per minute continuously. Additionally, there was no physician's order for oxygen saturation monitoring for Resident 685, and documentation of oxygen saturation results was inconsistent. Resident 11 was observed receiving oxygen at three and four liters per minute on different occasions, while the order specified two liters per minute continuously. Furthermore, the facility failed to change Resident 28's nebulizer set-up weekly as per the facility's policy and procedure. The nebulizer mask and tubing were observed inside a set-up bag dated beyond the seven-day change requirement. This oversight in infection control practices could potentially affect the respiratory health and well-being of the residents. The facility's Director of Nursing and other staff members acknowledged these findings during interviews.
Sanitation and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by multiple observations of improper hand hygiene and glove use by Dietary Aide 1. The aide was seen not washing hands between glove changes and using bare hands to handle clean items after touching dirty areas. This was confirmed during an interview with Dietary Aide 1, who acknowledged the findings. The facility's policies on glove use and handwashing were not adhered to, increasing the risk of contamination. Additionally, the facility did not ensure that kitchen equipment and utensils were kept in a clean and sanitary condition. Observations revealed rusty steel racks stored with clean utensils, a microwave with a cracked and rusty interior, and a plate warmer with dirt and rust on its hinges. These conditions were verified by the Dietary Services Supervisor (DSS) and were in violation of the USDA Food Code, which requires equipment to be clean and free from debris. The facility also failed to properly calibrate kitchen thermometers and maintain sanitizing solutions. Thermometers were not calibrated according to the manufacturer's instructions, and there was no documentation of sanitizer solution test results. Furthermore, personal belongings were improperly stored in the kitchen area, and utensils were not air-dried as required, with staff using paper towels to dry them instead. These practices were confirmed through observations and interviews with kitchen staff, indicating a lack of adherence to established sanitation protocols.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies. Room A, designated for Enhanced Barrier Precautions, lacked a receptacle for disposing of used gowns, leading to improper disposal practices by staff. The infection surveillance logs were inaccurately maintained, with numerous healthcare-associated infections (HAIs) not correctly identified or documented. The mapping of infections also failed to accurately reflect all HAIs, and there was confusion regarding the categorization of infections, particularly those not meeting McGeer's criteria. Resident 44's nasal cannula was found on the floor without proper storage, posing a risk of infection. Despite having a physician's order for oxygen administration, the nasal cannula was not stored in a sanitary manner, and staff were observed attempting to reuse it without proper cleaning. Additionally, medication carts were observed with hardened medication residue, indicating a lack of proper cleaning and maintenance, which is crucial for infection prevention. Resident 688, diagnosed with an ESBL-resistant urinary tract infection, was not placed under Enhanced Barrier Precautions as per the physician's order. There was no signage indicating the need for such precautions, and staff were unaware of the resident's status. The facility's infection preventionist and other staff members acknowledged these deficiencies, indicating a lack of adherence to established infection control protocols.
Failure to Complete Infection Surveillance Checklist and Identify HAIs
Penalty
Summary
The facility failed to ensure the completion of the McGeer's Criteria for Infection Surveillance Checklist for a resident who was administered antibiotics. During an interview and medical record review, it was verified that the resident received two different antibiotics, azithromycin and cefepime, with an increased dose of cefepime, without the necessary follow-up using the McGeer's Criteria. This oversight posed a risk of unnecessary antibiotic use, potentially leading to adverse reactions and antibiotic resistance. Additionally, the facility's infection control program was found lacking in identifying and tracking healthcare-associated infections (HAIs). The Infection Preventionist (IP) categorized infections into community-acquired, HAIs, and those not meeting McGeer's criteria, but failed to identify a significant number of HAIs in the facility's infection surveillance logs for December 2024 and January 2025. Furthermore, residents with increased confusion were incorrectly documented as asymptomatic, and the IP was unable to explain this discrepancy.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 389, was safe to self-administer medications found at her bedside. During an initial tour, it was observed that Resident 389 had several medications, including ibuprofen, Advil, alpha-chymotrypsin, arthritis relief pain ointment, and dry eye relief eye drops, on her bedside table. Resident 389 stated she self-administered these medications for various ailments, but there was no assessment conducted to determine her capability to do so safely. The facility's policy requires that residents be assessed for their ability to self-administer medications, and that medications be stored securely if self-administration is permitted. Further review of Resident 389's medical records revealed that she had moderate cognitive impairment and impairments in both upper extremities. There were no physician's orders for the medications found at her bedside, nor was there any documentation indicating that she had been assessed for self-administration. Interviews with facility staff confirmed that Resident 389 had not been evaluated for self-administration, and that the medications should not have been at her bedside without proper authorization and assessment. This oversight had the potential to lead to inaccurate medication administration and adverse reactions, impacting Resident 389's well-being.
Inaccurate Neurological Assessments Post-Fall
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for two residents, specifically in the area of post-fall neurological assessments. Resident 685 experienced an unwitnessed fall, resulting in a bump and skin discoloration on the forehead. The neurological assessment conducted post-fall showed a sluggish reaction in the right pupil, but no interventions were documented to address this finding. Additionally, a section of the assessment was left blank, indicating incomplete documentation. These issues were acknowledged by the facility's RN and administration during interviews. Resident 7 also experienced a fall, and the subsequent neurological assessment contained inaccuracies. The assessment documented the right pupil size with a letter instead of a number, and the left pupil size was similarly documented incorrectly. Despite the sluggish reaction noted in the right pupil, no interventions were recorded to address this issue. The LVN responsible for the assessment and the RN reviewing it both verified these findings, and the DON confirmed the inaccuracies in the documentation. The facility's policies and procedures for neurological assessments and falls management were not adhered to, as evidenced by the incomplete and inaccurate documentation for both residents. The lack of proper documentation and follow-up interventions had the potential to delay necessary care for the residents involved. The facility's administration acknowledged these deficiencies during interviews with surveyors.
Failure to Implement Fall Risk Interventions
Penalty
Summary
The facility failed to implement necessary care plan interventions for a resident identified as high risk for falls. The resident's care plan included interventions such as conducting facility rounds every two hours, placing a star sticker on the resident's room, and applying a colored arm band to alert staff of the fall risk. However, the facility did not consistently document the required fall risk monitoring, with multiple instances of missing documentation on the Fall Risk Monitoring Table. Additionally, the resident did not have the star sticker or colored arm band as specified in the care plan. Interviews with the LVN and DON confirmed the lack of documentation and the absence of the required interventions. The LVN acknowledged that the post-fall monitoring should be completed and documented every two hours for three months, and the DON verified the missing documentation on the Fall Risk Monitoring Table. The resident, who had a fall in the restroom due to the wheelchair's brakes not being locked, was at risk for further falls and injuries due to the facility's failure to implement and document the care plan interventions.
Failure to Maintain Fluid Restriction for Resident
Penalty
Summary
The facility failed to maintain acceptable parameters for fluid intake for a resident who was under a physician-ordered fluid restriction of 1000 ml per day. The nursing and dietary departments were responsible for providing specific amounts of fluid throughout the day. However, the resident's fluid intake consistently exceeded the prescribed limits, with daily totals ranging from 910 ml to 1260 ml, as documented by the CNAs. The facility's Intake and Output Records did not accurately reflect the resident's total daily fluid intake, and there was a discrepancy between the fluid restriction breakdown printed on the resident's records and the physician's order. Interviews with facility staff revealed a lack of understanding and communication regarding the resident's fluid restriction. A CNA incorrectly believed the resident's fluid limit from meals was 1500 ml per day, and the LVN confirmed that the documentation did not match the physician's order. Additionally, there was no documented evidence that the physician was notified of the resident's non-compliance or that the resident was monitored for fluid overload. This failure had the potential to negatively impact the resident's well-being.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to adequately monitor two residents, identified as Residents 39 and 84, who were administered the anticoagulant medication apixaban (Eliquis) without proper monitoring for signs and symptoms of bleeding. This oversight was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility's policy on anticoagulation therapy required staff to assess for adverse drug reactions and signs of bleeding, but this was not documented for the residents in question. Resident 39, who was readmitted to the facility and had a care plan addressing the high risk of bleeding due to anticoagulation therapy, did not have documented evidence of monitoring for bleeding signs. Despite receiving apixaban as prescribed, there was no record of assessments for bleeding symptoms such as bruising, gum bleeding, or hematuria. An interview with RN 3 confirmed the lack of documentation and emphasized the importance of monitoring due to the potential for fatal injury. Similarly, Resident 84, who had a diagnosis of acute embolism and thrombosis, was administered Eliquis without a physician's order for monitoring bleeding signs until several weeks after starting the medication. The resident's care plan included interventions for monitoring bleeding, but there was no evidence of such monitoring until a later date. Interviews with LVN 4 and the DSD revealed a lack of in-service training for licensed nurses on monitoring anticoagulant medication, and the facility's administration acknowledged these findings.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication, specifically mirtazapine, which was prescribed for depression manifested by poor oral intake. The resident's meal intake was supposed to be monitored and recorded as part of the treatment plan. However, there were discrepancies between the meal intake documentation by licensed nurses and CNAs, indicating inaccurate monitoring. The resident's meal intake often fell below the threshold of 76%, which was the criterion for administering mirtazapine, yet the medication was consistently administered. Additionally, the facility did not complete the monthly behavior summary related to the use of mirtazapine for the resident. This lack of documentation and monitoring could lead to the unnecessary use of the psychotropic medication, potentially affecting the resident's well-being. An interview with an RN confirmed these findings, highlighting the facility's failure to adhere to proper monitoring and documentation protocols for the resident's medication and meal intake.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage of medications and supplies, as evidenced by several observations. Medication Cart F was found unlocked and unattended in the hallway, with staff, residents, and visitors passing by. The cart contained syringes with needles, sterile gauze, alcohol prep pads, specimen vials, and bleach wipes stored with tuberculin syringes. The Infection Preventionist (IP) admitted to leaving the cart unlocked after removing isolation signage. Additionally, a packet of vitamin A&D ointment was found on a resident's bedside table without a physician's order, and the resident was unaware of its presence. The ointment was reportedly used by CNAs for the resident's dry skin. Furthermore, the facility's medication storage practices were found to be inadequate. Eye medication (cyclosporine ophthalmic emulsion) was stored together with rectal medication (bisacodyl suppository) in the same drawer of Medication Cart A. This was confirmed by LVN 5, who acknowledged that these medications should not be stored together. The Director of Nursing (DON) also confirmed that the storage of these medications together was inappropriate.
Menu Deviations in Pureed Diets
Penalty
Summary
The facility failed to ensure that the menus were followed, which resulted in discrepancies in the preparation and serving of pureed diets. Specifically, the pureed mixed vegetables did not match the regular mixed vegetables, as the pureed version was prepared with broccoli, zucchini, and carrots, while the regular version included cauliflower and slices of fried tofu, but no zucchini. Additionally, the pureed beef was not served with a ladle of sauce as required by the recipe. These deviations were confirmed by the Dietary Services Supervisor (DSS) during observations of food preparation and trayline assembly. The facility's policy requires that any deviations from posted menus be recorded and archived, but this was not adhered to, potentially impacting the nutritional adequacy of meals for residents on pureed diets.
Deficiency in Safe Food Handling and Storage
Penalty
Summary
The facility failed to ensure the safe handling and storage of food brought in by family members or visitors for residents. This deficiency was identified through observations, interviews, and a review of facility policies and procedures (P&P). The facility's P&P on foods brought by residents, family members, and visitors did not include guidelines for safe food handling and storage in the reach-in refrigerator. Interviews with RN 3 and the Dietary Services Supervisor (DSS) revealed that while residents and their families could request the kitchen to store food items from outside sources, there was no separate refrigerator for these items, and the facility did not allow overnight storage. The DSS and Registered Dietitian (RD 1) confirmed that the facility's P&P lacked specific instructions for the safe handling and storage of food from outside sources. The absence of these guidelines posed a potential risk of foodborne illnesses to the medically vulnerable resident population. The facility's failure to incorporate safe food handling practices into their P&P, as required by CMS guidelines, was a significant oversight that could impact resident health and safety.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, specifically a Certified Nursing Assistant (CNA). The incident involved a resident who reported being slapped on the face by the CNA, resulting in redness on the right cheek. This incident was confirmed through interviews with the resident, staff, and a review of medical records and facility documents. The resident expressed fear and a desire to leave the facility due to feeling unsafe. The facility's policies and procedures, including the Abuse Prevention Program and Resident Rights, were reviewed and indicated that residents should be free from abuse and treated with respect and dignity. Despite these policies, the CNA admitted to slapping the resident, claiming it was a reflexive action after being kicked and hit by the resident. The CNA's behavior was acknowledged as physical abuse and deemed unacceptable by the facility's administration. The CNA involved had a history of disciplinary actions for inappropriate behavior, including using vulgar language and not following instructions. Following the incident, the CNA was terminated from employment. The facility conducted an investigation, which included interviews with the CNA and other staff members, confirming the occurrence of the abuse.
Latest citations in California
Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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