Vista Pacifica Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Jurupa Valley, California.
- Location
- 3674 Pacific Avenue, Jurupa Valley, California 92509
- CMS Provider Number
- 05A264
- Inspections on file
- 30
- Latest survey
- May 6, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Vista Pacifica Center during CMS and state inspections, most recent first.
Dietary staff were unable to correctly prepare sanitizer solutions, failed to wear gloves during table sanitization, and did not properly test dish sanitization, as confirmed by interviews and observations. These failures were inconsistent with facility protocols and manufacturer instructions, and were acknowledged by the Registered Dietitian and Director of Dietary Services.
Three cutting boards in the kitchen were found with deep indentations and rough surfaces, making them difficult to clean and sanitize. The Director of Dietary Services acknowledged that the boards should have smooth surfaces to prevent microorganism growth, and their condition did not meet professional food service safety standards.
A resident with cognitive impairment, legal blindness, and an upper limb amputation was not offered a smoking apron during a supervised smoking break, despite care plan and facility policy requirements. Staff acknowledged the omission and the importance of the apron in preventing accidental burns or injuries.
A resident with schizophrenia received long-acting injectable antipsychotic medication earlier than prescribed, contrary to physician orders and manufacturer guidelines, with no supporting clinical evidence for the altered schedule. Additionally, an Oral Emergency Kit was found to have an incorrect expiration date on its label, not matching the actual expiration of its contents, as confirmed by an LVN. Facility policies regarding medication administration and emergency kit labeling were not followed.
Four unit dose vials of ipratropium/albuterol inhalation solution belonging to a resident were found stored outside the manufacturer's protective foil pouch, contrary to manufacturer instructions and facility policy. An LVN confirmed the vials should have remained in the pouch to protect them from light, creating the potential for the resident to receive ineffective medication therapy.
A resident with severe protein-calorie malnutrition and diabetes, who was cognitively intact, requested cottage cheese as a bedtime snack but was only provided fruit cups. Despite documentation of this preference in the nutritional assessment and no clinical contraindications, the dietary staff did not honor the request, and all snack labels listed only fruit. Both the DM and RD confirmed the resident's preference should have been accommodated according to facility policy.
A Laundry Aide did not properly clean the lint trap in a dryer, resulting in a thick accumulation of lint. The cleaning log was inaccurately completed, with entries signed ahead of scheduled times rather than after the task was performed. Facility policy requires lint removal every two hours, but this was not followed, creating a potential fire hazard.
A resident with schizophrenia and moderate cognitive impairment was found with contraband (a metal fork) in their room. Although staff retrieved the item and counseled the resident, the resident's representative was not notified of the incident, contrary to facility policy. Multiple staff members acknowledged the oversight, and documentation confirmed the lack of notification.
A resident with schizophrenia and moderate cognitive impairment was found with a metal fork, considered contraband, under the mattress. Although staff discussed new interventions such as using plastic utensils and searching the resident for contraband after meals, these were not added to the care plan, and some staff were unaware of the need for such measures. The care plan was not revised as required following the incident.
A resident with schizoaffective disorder and osteoarthritis was not treated with dignity and respect during a smoke break when a Mental Health Worker (MHW) kicked a dropped cigarette out of reach, causing the resident to fall from the wheelchair. The MHW did not assist the resident back into the wheelchair or offer another cigarette, leading to the resident's agitation. Another staff member intervened to help the resident, but the MHW's actions were confirmed as inappropriate through security footage, resulting in the MHW's termination.
A resident with schizoaffective disorder and osteoarthritis was neglected when a Mental Health Worker left them on the ground after a fall during a smoke break. The incident was observed by an LVN and reported to the DON, but the report to CDPH was delayed beyond the required two-hour timeframe, violating facility policy.
The facility failed to implement an effective infection surveillance system for suspected scabies among six residents. A resident reported having scabies for a month before treatment began, and other residents were treated prophylactically. The Infection Preventionist and Director of Nursing were unaware of a specific surveillance process, and no tracing was conducted to track potential exposure. The facility's policies on infection prevention and control were not effectively implemented, leading to a delay in care and potential spread of infection.
The facility failed to ensure the designated Infection Preventionist (IP) completed the required specialized training for certification. During an unannounced visit, it was found that the IP was not certified, and there was confusion about oversight responsibilities. The facility's policies require the IP to be qualified by education, training, experience, or certification, and to have completed specialized training, which was not met.
A resident consumed cannabis-infused candy brought in by a staff member, leading to feelings of nausea and discomfort. The candy was mixed with regular candies given as rewards, and the incident was not documented or reported to the state. The facility lacked a policy on outside candy and did not follow protocols for drug testing or reporting changes in condition.
The facility failed to report an altercation between two residents to the CDPH within the required two-hour timeframe. The incident involved one resident spitting at and shoving another, which was not reported immediately by the staff who witnessed it. The delay in reporting violated the facility's abuse protocol.
Dietary Staff Lacked Proper Sanitization Procedures and Training
Penalty
Summary
The facility failed to ensure that dietary staff were able to safely and effectively carry out food and nutrition services. Two dietary staff members were unable to demonstrate the correct concentration for the red bucket sanitizer solution, with one staff member preparing a solution with only half the required water and another preparing a solution with less than the required one gallon. The Registered Dietitian confirmed the correct ratio and stated that improper concentration could result in foodborne illness. Additionally, the facility's Red Sanitizer Bucket Log Checklist and FDA Food Code were reviewed, both specifying the importance of correct sanitizer concentration. One dietary staff member did not wear gloves while sanitizing the food preparation table, admitting to forgetting and acknowledging the need for gloves for safety and contamination prevention. Furthermore, four dietary staff members could not demonstrate the proper procedure for testing dish sanitization, as they only tested the water compartment rather than also testing the surface of cleaned dishes, contrary to the dish machine owner's manual. The Director of Dietary Services confirmed the correct procedure and was unable to provide a written policy supporting the staff's method.
Unsanitary Cutting Boards Found in Kitchen
Penalty
Summary
Surveyors observed that three cutting boards in the facility's kitchen, identified as brown, green, and red and each measuring 24 inches by 18 inches, had deep indentations and rough surfaces. During a concurrent interview, the Director of Dietary Services confirmed that the cutting boards should have smooth surfaces to prevent the growth of microorganisms in the grooves. The presence of these damaged cutting boards was not in accordance with professional standards for food service safety, as outlined in the U.S. FDA Food Code 2022, which states that scratched and scored cutting surfaces may be difficult to clean and sanitize, potentially allowing pathogenic microorganisms to accumulate. No specific residents or their medical histories were mentioned in relation to this deficiency.
Failure to Provide Smoking Apron During Supervised Smoking Break
Penalty
Summary
A deficiency occurred when the facility failed to provide a safe, accident-free environment for a resident during a smoking break. The resident in question had multiple diagnoses, including schizoaffective disorder, legal blindness, and an acquired absence of an upper limb below the elbow. The resident's Minimum Data Set assessment indicated cognitive impairment, and the resident's smoking assessment and care plan both specified the need for a smoking apron to be offered during smoking breaks to reduce the risk of injury. On the observed date, a Mental Health Counselor lit a cigarette for the resident on the smoking patio, but did not offer or provide a smoking apron, contrary to the resident's care plan and facility policy. During an interview, the staff member acknowledged that the apron should have been offered and recognized its role in preventing accidental burns or injuries. Facility policy also indicated that smoking aprons should be used when appropriate to ensure resident safety.
Failure to Administer Medications as Prescribed and Inaccurate Emergency Kit Labeling
Penalty
Summary
The facility failed to ensure that medications were administered as prescribed and used appropriately to meet the needs of the residents. Specifically, a resident with schizophrenia was prescribed two long-acting injectable antipsychotic medications, Invega Sustenna and Haldol Decanoate, with orders for Invega Sustenna to be administered every 28 days. However, the medication administration record showed that Invega Sustenna was given earlier than prescribed: one dose was administered 21 days after the previous dose, and another was given 22 days after the prior dose. Interviews with the pharmacist, DON, and Medical Director confirmed that the medication was administered sooner than recommended by both the physician's order and the manufacturer's prescribing information. There was no physician order to alter the dosing interval, and no clinical evidence supported the practice of staggering the two antipsychotics two weeks apart. Additionally, during an inspection of the Emergency Kits, it was observed that the expiration date written on the outside of the Oral Emergency Kit did not match the actual expiration date of the medication inside. The kit was labeled with an expiration date of July, but it contained doxycycline tablets that expired in June. This discrepancy was confirmed by a licensed vocational nurse, who acknowledged that the expiration date on the outside of the kit was not correct. The facility's policies required medications and treatments to be administered as prescribed and for Emergency Kits to be inventoried monthly, with the earliest expiring medication's date noted on the outside of the kit. These policies were not followed, resulting in the administration of medication outside the prescribed schedule and inaccurate labeling of emergency medication expiration dates.
Improper Storage of Light-Sensitive Medication
Penalty
Summary
During an inspection of Medication Cart A at the Southside Nursing Station, four unit dose vials of ipratropium/albuterol inhalation solution, prescribed for one resident, were found stored outside of their original manufacturer's foil pouch. This storage practice was not in accordance with the manufacturer's instructions, which specify that the vials must be protected from light by remaining in the foil pouch until use. A licensed vocational nurse confirmed that the vials should have been kept in the pouch, and the facility's own policy also requires medications to be stored according to manufacturer recommendations. The improper storage had the potential to result in the resident receiving ineffective medication therapy.
Failure to Honor Resident Food Preference for Snack
Penalty
Summary
The facility failed to honor a resident's stated food preference, resulting in the resident not receiving her requested snack of cottage cheese. Despite the resident informing the dietitian of her preference for cottage cheese as a bedtime snack, she was only provided with fruit cups. Review of the resident's nutritional assessment and care plan confirmed that cottage cheese was listed as a food request, but all snack labels indicated only soft canned fruit. Both the Dietary Manager and Registered Dietitian acknowledged that there were no contraindications to providing cottage cheese and that the resident's preference should have been accommodated. The resident involved had a diagnosis of severe protein-calorie malnutrition and type 2 diabetes mellitus without complications, and was assessed as having intact cognitive function. The care plan and diet order supported the provision of a consistent carbohydrate diet with regular texture, and there was no clinical reason to deny the requested snack. Facility policy also required staff to accommodate resident food preferences and document them in the care plan, but this was not followed in the resident's case.
Failure to Clean Dryer Lint Trap as Required
Penalty
Summary
The facility failed to provide a safe environment when the Laundry Aide (LA) did not properly clean the lint trap in Dryer #3, resulting in a thick accumulation of lint. During an observation and interview in the laundry room, the LA stated that she cleaned the dryer lint trap every two hours, as required by facility policy. However, upon inspection, a thick layer of lint was found covering the entire trap. A review of the Laundry Lint Cleaning Log revealed that entries were signed ahead of the scheduled cleaning times, rather than after the task was completed, indicating inaccurate documentation of the cleaning process. Further interviews with the LA confirmed that the log should only be signed after the lint was actually removed, and the LA acknowledged that the amount of lint present could become a fire hazard if not addressed. The Housekeeping Supervisor also confirmed that the LA should have followed the policy requiring lint removal every two hours. The facility's policy and procedure, dated March 8, 2013, specifies that all lint must be removed from dryers every two hours and at the end of each shift.
Failure to Notify Resident's Representative After Contraband Incident
Penalty
Summary
The facility failed to notify a resident's representative after an incident involving contraband was discovered in the resident's room. The resident, who had a diagnosis of unspecified schizophrenia and moderate cognitive impairment, was found with a metal fork, considered contraband per unit policy. Staff retrieved the item and counseled the resident, but there was no documentation that the resident's representative was informed of the incident. Multiple staff members, including two program counselors and an LVN, acknowledged during interviews that they did not notify the representative, each assuming another staff member would do so or not realizing the incident was new. Facility policy required prompt notification of a resident's representative in the event of changes in the resident's condition or status, including significant changes in mental or psychosocial status. Despite this, the incident was not communicated to the representative, as confirmed by the Director of Nursing. The lack of notification was documented in the resident's progress notes and corroborated by staff interviews.
Failure to Revise Care Plan After Contraband Incident
Penalty
Summary
The facility failed to revise the care plan and implement appropriate interventions after a resident with a diagnosis of unspecified schizophrenia and moderate cognitive impairment was found with contraband, specifically a metal fork, under his mattress. Staff discovered the fork during a routine room check and removed it, subsequently informing the resident of the unit rules regarding unauthorized items. The incident was documented, and the assigned Program Counselor and other staff were notified. However, although there was discussion among staff about initiating new interventions, such as checking the resident for contraband after meals, these interventions were not added to the resident's care plan. The care plan, which was updated to reflect the incident of inappropriate behavior, did not include any new behavioral interventions to prevent the resident from taking contraband from the dining room. Interviews with staff, including the Program Counselor and the DON, confirmed that no new interventions were added to the care plan following the incident, despite facility policy requiring care plans to be revised as changes in the resident's condition dictate. Additionally, some staff members were unaware of the need to search the resident for contraband after meals, indicating a lack of communication and implementation of appropriate interventions.
Resident Dignity and Respect Violation by MHW
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect, as evidenced by an incident involving a Mental Health Worker (MHW 1) and a resident with schizoaffective disorder and osteoarthritis of the knee. During a smoke break, the resident accidentally dropped a cigarette, and MHW 1 kicked it out of reach, causing the resident to fall from his wheelchair. MHW 1 did not assist the resident back into the wheelchair or offer another cigarette, leading to the resident becoming angry and agitated. Interviews and record reviews revealed that MHW 1's actions were unprofessional and did not align with the facility's expectations for staff to assist residents with tasks they could not perform themselves. Another staff member, MHW 2, intervened by helping the resident back into the wheelchair and retrieving the cigarette, which temporarily settled the situation. However, MHW 1's continued antagonistic behavior, including kicking another cigarette away, further escalated the resident's agitation. The Director of Nursing (DON) and other staff members reviewed security footage, confirming MHW 1's inappropriate conduct. The footage showed MHW 1 antagonizing the resident and failing to provide necessary assistance, which violated the resident's rights to dignity and respect. The incident was reported to the DON, who took immediate action by sending MHW 1 home pending investigation, ultimately leading to the termination of MHW 1's employment.
Failure to Timely Report Resident Neglect
Penalty
Summary
The facility failed to report an incident of neglect involving a resident to the California Department of Public Health (CDPH) within the required two-hour timeframe. The incident involved a resident with schizoaffective disorder and osteoarthritis of the knee, who was left on the ground by a Mental Health Worker (MHW) after falling from his wheelchair during a smoke break. The MHW had antagonized the resident by withholding a cigarette and later kicked a cigarette away, causing the resident to fall. Another staff member assisted the resident back into his wheelchair, but the neglect was not reported promptly. The Licensed Vocational Nurse (LVN) observed the incident on security footage and reported it to the Director of Nursing (DON) at approximately 8:50 p.m. The Director of Staff Development (DSD) was informed at 9:30 p.m., but the report to CDPH was not made until 11:20 p.m., exceeding the two-hour reporting requirement. The facility's policy mandates that all suspected abuse or neglect be reported within two hours, but this was not adhered to, resulting in a delay in notifying the appropriate authorities.
Failure in Infection Surveillance for Scabies
Penalty
Summary
The facility failed to develop and implement an ongoing infection surveillance monitoring system for suspected scabies among six residents. During an unannounced visit, it was observed that Resident 1 had a rash on his lower extremities and reported having scabies for a month, with treatment only recently initiated. The facility's records indicated that Resident 1 had been monitored for redness and rash since early August, but no new orders were given until the end of the month when scabies treatment was ordered. Other residents, including Residents 2, 3, 4, 5, and 6, were also monitored for rashes and treated prophylactically for scabies, although not all exhibited symptoms. The designated Infection Preventionist (IP) and the Director of Nursing (DON) were not aware of a specific surveillance process for scabies, and no tracing or surveillance was conducted to track other residents who might have been affected. The IP only became aware of the scabies issue on September 2, 2024, and initiated contact isolation at that time. The DON was informed on September 3, 2024, and stated that the residents were placed on contact isolation, but there was no system in place to verify, assess, monitor, or track if other residents were affected by scabies. The facility's policies on infection prevention and control, as well as surveillance of infections, were not effectively implemented. The Administrator admitted to not being aware of a current surveillance process for scabies and acknowledged the need for a system to track residents who develop rashes and evaluate for possible scabies. The lack of a structured surveillance program led to a delay in care and treatment, with potential for the spread of infection throughout the facility.
Infection Preventionist Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) completed the required specialized training for the IP certification program. During an unannounced visit, it was revealed through interviews and record reviews that the designated IP was not certified at the time of the survey. The IP herself confirmed that she did not have the certification, and the Director of Nursing (DON) acknowledged that the IP was not certified but believed that certification was not necessary if the IP was in the process of obtaining it. Further interviews with the DON and the Administrator (ADM) revealed a lack of oversight and clarity regarding the IP's certification status. The DON was not overseeing the IP and was unaware of who was responsible for this oversight. The ADM stated that both he and the DON were overseeing the IP, who was still waiting to complete her certification class. The facility's job description for the IP position and its policy documents indicated that the IP must be qualified by education, training, experience, or certification and must have completed specialized training in infection prevention and control, which was not the case at the time of the survey.
Resident Consumes Cannabis-Infused Candy Due to Lack of Policy
Penalty
Summary
The facility failed to prevent a resident from consuming cannabis-infused candy, which was brought into the facility by a staff member. The incident involved Resident A, who was given the candy as a reward for participating in group activities. The candy was mixed with regular candies donated by staff, and Resident A reported feeling unwell after consuming it. The label on the candy package indicated it contained cannabis, and Resident A had no prior history of drug use. Interviews with staff revealed that there was no policy regarding the introduction of outside candy into the facility. The Program Counselor and Assistant Program Director confirmed that the cannabis-infused candy was inadvertently brought in by a counselor who was unaware of its contents. Despite Resident A's report of feeling nauseous and sweaty, no immediate medical evaluation was conducted, and there was no documentation of the incident in Resident A's medical record. The Director of Nursing acknowledged that the incident was not reported to the state, as required by the facility's policy on unusual occurrences. Although Resident A's vital signs were monitored, there was no formal protocol in place for handling residents under the influence of illegal substances. The facility's policies on drug testing and reporting changes in condition were not followed, as there was no documentation or incident report completed for Resident A.
Failure to Timely Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report an allegation of physical abuse between two residents to the California Department of Public Health (CDPH) within the required timeframe. The incident occurred on July 13, 2023, when Resident A and Resident B were involved in an altercation. Resident B spit at Resident A's face and shoved him after being told to stop spitting on the floor. The altercation was witnessed by another resident and a Mental Health Worker (MHW 1), who intervened but did not report the incident immediately. The Director of Nursing (DON) was informed of the incident the following morning, on July 14, 2023, but the report to the state agency was delayed beyond the mandated two-hour window. Interviews with the involved residents and staff revealed that the incident was not documented or reported promptly. Resident A and Resident B both confirmed the altercation, with Resident B stating that he reported the incident to MHW 1 on the night it occurred. However, MHW 1 admitted to getting busy and not reporting the incident to the Charge Nurse until later that night. The Licensed Vocational Nurse (LVN 1) also confirmed that she was not aware of the full details of the altercation until the following morning. The facility's policy requires that all abuse incidents be reported to the state agency within two hours, which was not adhered to in this case. The facility's failure to report the incident immediately resulted in a delay in the implementation of appropriate actions and protections for the residents involved. The DON acknowledged that the incident was not reported within the required timeframe and that this was a violation of the facility's abuse protocol. The facility's policy on abuse reporting clearly states that any suspected or known instances of abuse must be reported by telephone immediately or as soon as practically possible, which was not followed in this instance.
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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