La Bella Of Caseyville
Inspection history, citations, penalties and survey trends for this long-term care facility in Caseyville, Illinois.
- Location
- 601 West Lincoln Avenue, Caseyville, Illinois 62232
- CMS Provider Number
- 145585
- Inspections on file
- 39
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at La Bella Of Caseyville during CMS and state inspections, most recent first.
A resident with COPD and chronic respiratory failure, normally alert, sociable, and eating 75–100% of meals, became withdrawn over several days, stayed in her room, refused meals, reported feeling unwell, and received multiple PRN medications for cough, congestion, allergies, and pain. CNAs repeatedly reported that the resident was not at baseline, was staying in bed, refusing to eat, later developed nausea, vomiting, diarrhea, and new incontinence, and appeared drained and ashy in color. LPNs documented limited vital signs and PRN administrations but did not complete or document comprehensive assessments, did not consistently obtain full vitals including O2 saturation in response to respiratory symptoms, and did not notify the NP or physician of the resident’s change in condition. Only after another LPN and CNA raised concerns did the NP assess the resident, document fatigue, weakness, altered mental status, diarrhea, ashen/grey skin, poor intake, and that she was not at baseline, and arrange transfer to the ER, where the resident was admitted with RSV. The facility’s own policy required immediate assessment, full vitals, and provider notification for acute changes in condition, which were not followed in this case.
Multiple residents at high risk for falls experienced repeated unwitnessed falls resulting in injuries, as staff failed to consistently implement or update accident prevention interventions such as anti-slip devices, signage, and alarms. Care plans and fall risk assessments identified the need for these interventions, but observations and staff interviews revealed they were not reliably in place or known to staff, and new interventions were not added after changes in condition or additional falls.
The facility did not ensure an RN was on duty for at least eight hours per day on several occasions, with staffing records showing only LPNs and CNAs present during required RN shifts. The administrator acknowledged insufficient RN staffing, impacting all residents in the facility.
Three residents did not receive the required ABN and NOMNC forms when their Medicare Part A skilled services ended, as the responsible social worker was unaware of the need to issue both notices. In some cases, the NOMNC was provided after the end of coverage rather than in advance, contrary to facility policy.
The facility failed to prevent abuse in two residents, leading to one feeling scared and unsafe. One resident reported being grabbed by another, while another experienced verbal abuse from an agency CNA. The facility's abuse prevention policy was not effectively implemented, as evidenced by inadequate intervention and unaddressed aggressive behaviors.
The facility failed to administer oxygen therapy as prescribed and did not provide necessary signage for residents receiving oxygen therapy. A resident with COPD and Respiratory Failure was without an 'oxygen in use' sign and had an empty portable oxygen tank during lunch. Another resident with COPD had an oxygen concentrator with dusty filters and no humidification bottle. The facility's policy requires equipment to be in good working order, including signage.
A resident experienced a delay in receiving a stool DNA test kit due to the facility's failure to coordinate care and deliver mail promptly. The resident, who needed the test for a follow-up appointment, was upset by the delay. The facility staff did not effectively communicate or verify new medical orders, leading to a breakdown in care coordination.
The facility's infection control program was found lacking, with incomplete documentation of infection data, affecting all 88 residents. The infection control log and book were missing crucial information, such as dates and organisms. The Assistant DON, new to the role, admitted the surveillance and infection control processes were not up to standard.
The facility failed to respond to call lights in a timely manner, affecting several residents who reported average wait times of 30 minutes or more. Despite varying cognitive abilities, residents consistently experienced delays, which were discussed in resident council meetings and documented in grievances. The administrator acknowledged the issue but lacked a clear policy or recent audit results to address it, and the ombudsman confirmed ongoing complaints from residents and families.
The facility failed to manage resident clothing effectively, leading to missing laundry for several residents. Residents reported ongoing issues with lost clothing that was not found or replaced, and the facility's policy on discarding unclaimed clothing was not documented in the admission contract. The ombudsman noted numerous complaints, and observations revealed boxes of unlabeled clothing, highlighting a deficiency in maintaining a comfortable living environment.
The facility failed to prevent abuse among residents, with incidents involving resident-to-resident altercations. A resident with severe cognitive impairment and a history of substance abuse was involved in multiple altercations, including punching another resident. Another incident involved a cognitively intact resident in a physical altercation with a severely impaired resident who wandered into their room. Despite the facility's abuse prevention policy, these incidents indicate a deficiency in protecting residents from abuse.
The facility failed to ensure correct antibiotic use for two residents with UTIs, as no Culture and Sensitivity reports were available to confirm the appropriateness of the prescribed antibiotics. The newly hired Infection Control Preventionist acknowledged gaps in surveillance and infection control processes, contributing to the deficiency.
Failure to Assess and Notify Provider for Resident’s Change in Condition Leading to Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess and respond to a clear change in condition for one resident with significant respiratory and chronic health issues. The resident had diagnoses including acute and chronic respiratory failure with hypoxia, COPD, pneumonia, nasal congestion, and postnasal drip, and was normally alert, sociable, and ate 75–100% of meals in the main dining room while self-propelling in a wheelchair. Over a weekend period, nursing staff documented administration of multiple PRN medications for cough, congestion, sinus allergies, and pain, and recorded limited vital signs that often omitted temperature, respirations, and oxygen saturation. Despite these PRN administrations and the resident’s underlying COPD and respiratory history, there was no documented nursing assessment explaining why the PRNs were given, no documented lung assessment, and no comprehensive evaluation of the resident’s status. During this same timeframe, multiple CNAs observed and reported that the resident was not at her usual baseline. CNAs stated the resident refused to leave her room, refused meals, remained in bed, and repeatedly said she did not feel well. One CNA reported that the resident refused to eat all weekend and stayed in bed, and another CNA reported that the resident, who usually ate 75–100% of dinner in the dining room, refused to come out of her room and refused dinner on consecutive days. These concerns were reported to nursing staff, but there is no documentation that licensed nurses performed a head-to-toe assessment, obtained full sets of vital signs including oxygen saturation in response to these reports, or documented any change from baseline. The LPN primarily assigned to the resident over these days acknowledged that the resident was not her usual “jolly chipper self,” stayed in her room, was not eating well, and stated she felt “crappy,” yet the LPN did not notify the provider and could not explain why. On the following day, additional changes were observed and reported. A CNA assigned that morning noted the resident complained of nausea, refused breakfast, remained in bed past her usual time, had vomited on her blanket and clothes, and was incontinent of bowel and bladder despite usually being continent. These findings were reported to the LPN, but the CNA did not take vital signs because she was not asked to do so, and there is no corresponding nursing assessment documented in the record. Another LPN, while walking down the hall, was alerted by a CNA that the resident did not look good and was not herself; he observed that the resident appeared drained with an ashy facial color and reported this to the assigned LPN in the presence of the nurse practitioner. The nurse practitioner then assessed the resident, documented increased fatigue, weakness, diarrhea, altered mental status, ashen/grey skin color, lethargy, foul-smelling diarrhea, poor oral intake, and that the resident was not at her baseline, and arranged transfer to the emergency room. The resident was subsequently admitted to the hospital and diagnosed with RSV. Throughout the period leading up to this transfer, the facility’s own policy required licensed staff to perform appropriate physical assessments, obtain full vital signs, and notify the physician immediately upon recognition of an acute change in condition, but the record shows no such timely assessment or provider notification during the days when the resident’s condition and behavior had clearly changed. The DON stated that when a resident with COPD exhibits respiratory symptoms, she expects nurses to obtain full vital signs including oxygen saturation, assess lung sounds, and document these findings, and that when a normally sociable, good eater refuses to leave their room or refuses meals, this warrants a head-to-toe assessment and provider notification. The nurse practitioner similarly stated that for this resident with COPD, she expected staff to take full vital signs including oxygen saturation, assess lung sounds, document the assessment, and notify her of respiratory status so she could determine if additional treatment or transfer was needed. Both the DON and the nurse practitioner reported that they were not notified of the resident’s refusal of meals, persistent reports of not feeling well, administration of multiple PRN respiratory medications, vomiting, diarrhea, or other changes over the weekend. The facility’s written policy on notification of changes in condition required immediate physician notification and follow-up assessment with documentation of vital signs, pain, orientation, and changes from baseline for any acute change in condition, but the documentation and staff interviews show that these steps were not carried out for this resident during the period in question.
Failure to Implement and Revise Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that staff implemented existing accident prevention interventions and did not review or revise interventions after changes in residents' conditions, as evidenced by multiple incidents involving three residents at high risk for falls. One resident with a history of falls, cognitive impairment, and multiple comorbidities experienced several unwitnessed falls, resulting in significant injuries including a right ankle fracture and lacerations. Despite documented care plan interventions such as anti-slip tape, signage, and floor mats, these were not observed in the resident's room during inspection, and staff interviews revealed a lack of awareness or inconsistent application of these interventions. The resident's care plan and fall risk assessments consistently identified high fall risk, but interventions were not reliably maintained or updated following each incident. Another resident, also at high risk for falls due to severe cognitive impairment and muscle weakness, experienced an unwitnessed fall after sliding off the bed. The care plan was updated to include a non-slip cushion as an intervention, but during observation, the cushion was not present, and multiple staff members reported never having seen it in use. This indicates a failure to implement the planned intervention intended to prevent further falls for this resident. A third resident with severe cognitive impairment, a history of falls, and mobility deficits experienced multiple falls, some resulting in head injuries and lacerations. Documentation showed that after several of these falls, no root cause analysis was completed, and no new interventions were implemented or documented in the care plan. Staff interviews further revealed a lack of knowledge regarding fall interventions in place for this resident, and the only intervention consistently identified was a chair alarm. These failures demonstrate a lack of consistent implementation and review of fall prevention strategies for residents at high risk.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a registered nurse (RN) on duty for at least eight hours per day, as required. Review of the Daily Nursing Shift Assignment Sheets revealed that on multiple dates, including 6/12/25, 6/14/25, 6/15/25, 6/17/25, 6/18/25, 6/19/25, 6/20/25, 6/21/25, and 6/22/25, there was no designated RN present for the required duration. On 6/24/25, staffing consisted of four LPNs, nine CNAs, and an RN serving in the ADON/ICP role, but the administrator confirmed that there were not enough RNs to meet the requirement. The facility's own staffing summary states the goal to meet or exceed required nursing staff levels, yet this standard was not met, potentially affecting all 108 residents in the facility.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide required Medicare notifications to residents or their responsible parties when skilled services under Medicare Part A were ending. Specifically, three residents who were receiving skilled nursing facility (SNF) services did not receive the Advanced Beneficiary Notice (ABN) or the Notice of Medicare Non-Coverage (NOMNC) as mandated. In each case, the ABN was not issued because the social worker was unaware of the requirement, and the NOMNC was either not provided at all or was given after the end date of covered services, rather than at least two days prior as required by facility guidelines. Record reviews showed that for each of the three residents, the last covered Medicare A service date was documented, but the necessary notifications were either missing or provided late. Interviews with facility staff confirmed that the social worker responsible for issuing these notices was not aware of the need to provide both the ABN and NOMNC, having previously been told by prior administration that only the NOMNC was required. Facility policy states that both forms must be given in writing to the resident or their representative when Medicare Part A coverage ends due to no longer requiring daily skilled services, and that this notice must be delivered with at least two days' notice.
Failure to Prevent Abuse in Residents
Penalty
Summary
The facility failed to prevent abuse in two residents, resulting in one resident feeling scared and unsafe. One incident involved a resident who reported being grabbed by another resident, leaving bruises on her arm. The staff did not intervene immediately, and the resident expressed fear and a desire to be moved away from the other resident. The facility's administrator reviewed camera footage and did not observe the alleged grabbing, but acknowledged the other resident's daily behavioral issues, including yelling and screaming, which disturbed other residents. Another incident involved a resident who reported verbal abuse by an agency CNA. The resident, who is paraplegic and requires assistance with hygiene, stated that the CNA refused to clean him after a bowel movement and used foul language. The resident recorded the incident, which was later substantiated by the facility. The CNA was subsequently removed from the facility's schedule. The facility's abuse prevention policy prohibits mistreatment, neglect, and abuse, aiming to create a secure environment for residents. However, the incidents indicate a failure to protect residents from abuse, as evidenced by the lack of immediate intervention and the presence of aggressive behaviors that were not adequately addressed in the care plans.
Failure to Administer Oxygen Therapy and Provide Signage
Penalty
Summary
The facility failed to administer oxygen therapy as prescribed and did not provide necessary signage for residents receiving oxygen therapy. Resident 2, diagnosed with Chronic Obstructive Pulmonary Disease (COPD) and Respiratory Failure, was observed without an 'oxygen in use' sign on her door. She reported that her portable oxygen tank was empty during lunch, and when she informed the staff, she was advised by an unknown staff member to eat as much as she could without oxygen. The Assistant Director of Nursing acknowledged the importance of oxygen and stated that the CNA should have notified a nurse to refill the tank. Resident 3, also diagnosed with COPD, was observed with an oxygen concentrator that had filters completely covered in dust, and there was no humidification bottle present. The Director of Nursing admitted not seeing the filters but assumed their poor condition. The Maintenance Director did not have information on the concentrator, and a CNA confirmed the absence of 'oxygen in use' signs in both residents' rooms. The facility's policy on oxygen administration, dated October 2010, requires equipment to be in good working order, including the presence of a humidifier bottle and appropriate signage.
Failure to Coordinate Care and Deliver Medical Supplies
Penalty
Summary
The facility failed to ensure proper coordination of care for a resident, identified as R3, with their community-based physician, which resulted in a delay in preventative care. R3, who is cognitively intact, was admitted to the facility and later visited their primary physician, who recommended a non-invasive stool DNA test due to concerns about R3's breathing issues making a colonoscopy unsafe. The test kit was delivered to the facility on 5/24/2024, but R3 did not receive it until 6/7/2024, causing distress as R3 had a follow-up appointment scheduled and needed the test results. The delay in delivering the test kit was attributed to a lack of communication and coordination within the facility. The Director of Nursing was unaware of the delivery, and the Assistant Director of Nursing only became aware of the issue on 6/7/2024. The LPN responsible for handling R3's mail admitted to not recognizing the importance of the package, mistaking it for medication, and not prioritizing its delivery. Additionally, the facility's process for handling residents' medical appointments and paperwork was not effectively followed, as R3 returned from the doctor's appointment without the necessary documentation, and the facility staff did not verify new orders or follow-up appointments. The facility's failure to promptly deliver the test kit and ensure proper communication with R3's physician led to a delay in preventative care. The facility's policy requires that mail and deliveries be promptly given to residents, and that any new medical orders be verified and documented. However, these procedures were not adequately followed, resulting in a breakdown of care coordination for R3.
Inadequate Infection Control Program
Penalty
Summary
The facility failed to develop an ongoing infection control program that effectively collected and analyzed infection data, impacting all 88 residents. The infection control log provided was incomplete, lacking dates and organism documentation. The Assistant Director of Nursing, who recently assumed the role of infection control preventionist, acknowledged the deficiencies in the surveillance and infection control processes, noting that the necessary information was not adequately recorded. The infection control book, which was supposed to document infections and organisms, only listed residents' names, identified urinary tract infections, and the medications prescribed, but did not include any organism documentation. The facility's infection control program policy, last revised in 2017, outlined the need for monitoring laboratory reports and physician orders to prevent infections, but this was not effectively implemented, as evidenced by the incomplete documentation.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to ensure that call lights were being answered in a timely manner for five residents, as identified during interviews and record reviews. Residents reported that the average wait time for call lights to be answered was approximately 30 minutes, with some instances taking even longer. This issue was raised by residents R32, R36, R70, R77, and R82, who participated in a group meeting and expressed their concerns about the delays in response times. The residents' Minimum Data Set (MDS) assessments indicated varying levels of cognitive function, with some residents being cognitively intact and others moderately impaired. Despite these differences, all residents shared similar experiences of delayed responses to their call lights, which they had previously discussed in resident council meetings. The problem with call light response times had been ongoing, as documented in multiple resident council meeting minutes and a grievance filed by another resident, R190. The grievance highlighted that call lights were not being answered and that staff did not work together effectively. The facility's administrator, V1, acknowledged the issue and mentioned that in-services on call lights had been conducted, but was unsure about the results of any audits conducted to address the problem. Additionally, there was no existing policy on call lights, which further contributed to the deficiency. The ombudsman, V6, also confirmed receiving numerous complaints from residents and family members about the call light issue, indicating that the problem persisted despite assurances from the administrator that it would be addressed.
Deficiency in Laundry Services and Resident Clothing Management
Penalty
Summary
The facility failed to maintain, clean, and return resident clothing in a timely manner, affecting five out of seven residents reviewed for laundry services. During a group meeting, residents expressed concerns about missing laundry and the facility's lack of response. Specific residents, including those who were cognitively intact, reported ongoing issues with lost clothing that was neither found nor replaced. One resident mentioned that unidentified clothing was donated without prior notification, and another resident's family grievance highlighted missing clothing items. The facility's laundry supervisor stated that residents sign a contract requiring clothing to be labeled, and unclaimed clothing is discarded after 60 days. However, the admission contract did not document this policy. The ombudsman reported receiving numerous complaints about lost laundry, and the facility's policy emphasized the importance of safeguarding personal property. Observations in the laundry room revealed boxes of unlabeled clothing, contradicting the facility's stated commitment to maintaining a comfortable living environment for residents.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent abuse among residents, as evidenced by multiple incidents involving resident-to-resident altercations. One incident involved a resident with severe cognitive impairment and a history of substance abuse, who was observed standing over another resident and punching them near the head. Despite staff intervention, the altercation resulted in no injuries, but the facility's care plan for the resident did not address abuse prevention. Another incident involved the same resident attacking a different resident, who was also cognitively impaired and had a history of aggressive behavior. Both residents were separated, and no injuries were reported. In another case, a cognitively intact resident reported being involved in a physical altercation with a resident who was severely impaired and had a habit of wandering into other residents' rooms. The altercation occurred after the impaired resident was found going through the belongings of the intact resident's roommate. Although no injuries were noted, the incident highlighted the facility's failure to manage residents with wandering behaviors effectively. The facility's abuse prevention policy, revised in 2018, prohibits acts of mistreatment, neglect, and abuse, yet the incidents described indicate a lack of adherence to this policy. The facility's response to these altercations, including notifying family members and separating residents, did not prevent the occurrences, suggesting a deficiency in the facility's ability to protect residents from abuse.
Failure in Antibiotic Stewardship for Two Residents
Penalty
Summary
The facility failed to ensure that residents were given the correct antibiotics for the organism causing infection, as evidenced by the cases of two residents. Resident R40 was documented to have a urinary tract infection (UTI) in April 2024 and was prescribed Cephalexin. However, there was no Culture and Sensitivity (C&S) report available to confirm that Cephalexin was the appropriate antibiotic for the infection. The lack of a C&S report indicates that the facility did not verify the suitability of the prescribed antibiotic for R40's specific infection. Similarly, Resident R74 was documented with a UTI in May 2024 and was prescribed Levofloxacin and Cefepime HCL at different times. However, there was no C&S report available to confirm the appropriateness of these antibiotics for R74's infection. The Infection Control Preventionist, who was newly hired, acknowledged that the surveillance and infection control processes were not fully established, and C&S reports were not always obtained when residents were sent to the hospital. This lack of proper antibiotic stewardship and monitoring led to the deficiency in ensuring the correct antibiotics were used for the infections.
Latest citations in Illinois
A resident with end stage renal disease on dialysis, right below-knee amputation, osteoporosis, muscle weakness, dementia, and Alzheimer’s disease, who was care planned as high risk for falls, slid from a high-back wheelchair and sustained a left femur fracture. The care plan called for proper seating, posture reminders, and use of a non-skid/dycem pad in the wheelchair, but on the day of the fall the RN found the resident on the floor with the chair in an upright position and no non-slip pad in place. CNAs described differing routines for how the resident was transferred and positioned after dialysis and dinner, including expectations that the chair be slightly reclined and the resident monitored in a TV room, while the DON’s investigation did not confirm whether required fall-prevention devices were in use and acknowledged the resident had previously slid from his wheelchair.
A resident with hemiplegia, gait abnormalities, lack of coordination, and cognitive deficit, who required substantial assistance with ADLs including turning in bed, fell from bed during peri-care when a CNA asked the resident to turn onto her side and the resident’s legs went over the bed edge. Staff later reported that residents should be positioned in the middle of the bed before turning to prevent falls. An RN assessed the resident after the fall, and the resident was subsequently evaluated by an NP and sent to the hospital, where an intertrochanteric femur fracture associated with a traumatic event was diagnosed.
Two cognitively intact residents reported separate incidents in which CNAs used profane, disparaging, and humiliating language toward or about them during personal care. In one event, a male CNA providing incontinence care to a roommate refused to close the room door, argued with a resident about the request, and repeatedly used the term “mother f***er” in reference to that resident while care was being given. In another event, two CNAs entered a resident’s room after a recent hospice bath, with one CNA stating the resident “stinks” and that no one, including hospice, wanted to care for him because he always complained. Both residents had no documented history of making false abuse allegations, and the reported staff statements are inconsistent with the facility’s abuse policy defining mental and verbal abuse as including humiliation, harassment, and disparaging or derogatory terms.
A resident with ESRD on dialysis, right BKA, osteoporosis, dementia, and Alzheimer’s fell in his room and was assisted back to bed by an RN and CNA. The RN documented an assessment and later gave PRN tramadol, while the CNA reported the resident said “Oww” when his left leg was moved and screamed during care. The next day, a CNA reported that the resident screamed that his left leg hurt when being dressed and informed two RNs, and another CNA later heard the resident repeatedly say he was in pain but did not notify a nurse. Despite multiple pain complaints, documentation shows only one PRN tramadol dose and no thorough assessment of the left leg pain or MD notification for change in condition. The resident was later sent from dialysis to the ER for leg pain, where an X-ray showed a distal femur fracture requiring surgical repair, and the hospital record noted it was unclear if any evaluation had been done after the fall.
A resident had an active order for enhanced barrier precautions due to a PICC, with signage posted instructing staff to wear gloves and a gown during device care and use. A RN was observed performing PICC care and disconnecting the resident from IV antibiotic therapy while wearing gloves but no gown. The infection control nurse confirmed that enhanced barrier precautions require both gloves and a gown for PICC handling, and facility policy specified glove and gown use for high-contact device care activities.
A resident re-admitted after right femur fracture repair, with dementia and multiple comorbidities, had a PRN order for oxycodone 5 mg q4h for moderate to severe pain. Nursing documentation later that day described the resident yelling, screaming, and exhibiting severe pain, but the MAR shows no pain medication was given at that time, and only acetaminophen 325 mg was administered hours later. The RN and DON acknowledged that the resident was non-verbal, that oxycodone was ordered and available from the emergency supply, and that acetaminophen alone was not adequate for post-surgical pain, yet the narcotic was not administered until many hours after delivery from the pharmacy, contrary to the facility’s pain management policy.
Two residents experienced failures in required physician and family notification. For one resident on Lithium with multiple comorbidities, staff did not notify the psychiatrist of a documented high Lithium level and continued administering Lithium at the increased dose until the resident became lethargic and was later hospitalized with Lithium toxicity. For another resident with Parkinson’s disease and high fall risk who requires total assistance with ADLs, staff did not document physician or family notification after unwitnessed falls that resulted in bruising to the buttock, hip discoloration, and a head abrasion, despite internal policy requiring immediate notification for significant changes in condition and injuries.
Two residents experienced deficiencies in assessment and monitoring when staff did not adequately evaluate or document significant changes in condition and post-fall injuries. One resident with multiple chronic conditions and on lithium became markedly lethargic, unable to sit upright, and had difficulty swallowing, with CNAs repeatedly reporting these changes to an RN who documented only a bruise and no detailed assessment or frequent monitoring; a previously elevated lithium level had not been reported to the psychiatrist. Another resident with Parkinson’s disease and high fall risk had an unwitnessed fall and was later found by CNAs to have a large dark purple bruise covering most of the right buttock, but nursing staff either assessed only exposed skin or gave conflicting accounts of having noted the bruise, and documentation and post-fall assessments did not reflect this injury as required by facility policy.
A resident with multiple chronic conditions, moderate cognitive impairment, and independent ambulation was placed in a Geri-chair by a CNA who was not assigned to the resident, and a sheet was tied around the resident’s waist and the back of the chair, preventing the resident from getting up. The CNA stated she used the sheet as a seat belt and safety precaution because the resident was wandering into other residents’ rooms and disturbing them, acknowledging that tying a sheet in this way is considered a restraint and is not allowed. The resident, who does not use a wheelchair or Geri-chair and normally ambulates without assistive devices, remained in the chair until discovered by a day-shift CNA, who noted the resident could not get up as usual and saw the sheet restraining the resident. Facility leadership, including the administrator, DON, physician, and social services, confirmed that the Geri-chair and tied sheet constituted a physical restraint applied without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, contrary to facility policies prohibiting such use and requiring immediate reporting of potential abuse. A subsequent skin assessment documented discoloration/bruising to the resident’s upper and lower extremities.
Staff failed to follow the facility’s mandatory gait belt policy and individual transfer care plans for multiple cognitively impaired residents with conditions such as DM, CHF, Parkinson’s disease, dementia, cerebral infarction, and Alzheimer’s disease. CNAs repeatedly transferred residents between bed, wheelchair, and toilet without gait belts, instead lifting under the axillae, pulling on clothing, and moving wheelchairs into place while residents were partially supported. In one instance, a wheelchair was not locked during a transfer, causing a resident to end up on the edge of the bed and nearly fall. CNAs later acknowledged that gait belts are supposed to be used for transfers, and facility policy specifies that gait belts are mandatory for all physical assist transfers.
Failure to Implement Fall-Prevention Interventions for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain fall prevention interventions for a resident identified as high risk for falls, resulting in the resident sliding from a high-back wheelchair and sustaining a left femur fracture. The resident had multiple diagnoses, including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. The resident’s care plan identified him as high risk for falls and included interventions such as reminding him of good posture in the wheelchair, redirecting him to bed if slouching or fatigued, ensuring he was properly seated, and placing a non-skid mat/dycem non-slip pad in the wheelchair to prevent sliding. On the evening of the fall, the RN responded to the resident yelling and found him on the floor between his recliner (high-back wheelchair) and nearby furniture; the resident stated he had been sleeping in the recliner in front of the heater and slid down. The RN observed that the wheelchair was in the upright position rather than reclined as usual and that there was no non-slip pad on the chair. Interviews and record review showed inconsistent implementation of the resident’s fall-prevention plan and lack of clear follow-through on the circumstances of the fall. One CNA reported that on the day of the fall, the resident returned from dialysis already in his chair, likely transferred there by transport staff using a sheet, and that she did not transfer him into the chair herself. Another CNA, who routinely cared for the resident, stated that transport staff typically placed him in bed on return from dialysis and that staff would later transfer him to his high-back wheelchair with a mechanical lift before dinner, recline the chair slightly after dinner, and position him in the TV room so staff could monitor him and prevent him from falling asleep and sliding out. The DON, who investigated the fall, did not recall speaking with the RN or the CNA involved, did not know whether a non-slip pad was in place at the time of the fall, and acknowledged that the resident had slid out of his wheelchair in the past. The DON identified sliding from the wheelchair as the root cause of the fall and stated that the resident’s left leg fracture was from this fall.
Failure to Maintain Bed Safety During Peri-Care Resulting in Resident Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s safety during incontinence/peri-care, resulting in a fall from bed and a fracture. The resident had been readmitted with diagnoses including hemiplegia and hemiparesis affecting the right dominant side, multiple neoplasm sites, lack of coordination, and abnormalities of gait and mobility. A recent Minimum Data Set indicated the resident had a cognitive deficit and required partial to substantial assistance with ADLs such as turning in bed, bathing, toileting, dressing, and personal hygiene. During peri-care, a CNA reported completing cleaning of the resident’s front and then asking the resident to turn onto her side; the resident turned onto her right side, her legs went over the side of the bed, and she fell out of the bed. Another CNA stated that when providing peri-care, staff should ensure the resident is in the middle of the bed before turning them so they do not go too far and fall out. Following the fall, an RN reported being informed by the CNA that the resident had fallen out of bed while being cleaned and was asked to assess the resident. After the resident was returned to bed, the RN noted the resident nodded when asked if she had pain. A nurse practitioner later saw the resident in her wheelchair and noted she did not show signs of pain until her right hip and thigh were palpated, after which the resident’s power of attorney requested hospital transfer. Hospital records showed the resident was admitted with an intertrochanteric right femur fracture and was transferred to another hospital for surgery. The medical director stated that this type of fracture is associated with a traumatic event.
Failure to Protect Residents From Verbal and Mental Abuse by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from verbal and mental abuse by CNAs. One cognitively intact resident, R1, reported that on a morning the prior week, a Black male CNA entered the shared room around 5:55 AM to provide incontinence care to R2 and left the door open. When R1 told the CNA the door needed to be closed, the CNA replied that he does not close doors when working. After R1 stated he could make a complaint to the state, the CNA responded, “Do what you have to do mother f***er.” R1 then got out of bed, closed the door himself, and went to the bathroom. R1 reported this incident that morning to the Activity Director (V3), describing that an African American male CNA had used unkind words toward him related to his request to close the door. R2, who is also cognitively intact, corroborated the incident, stating that while he was receiving perineal care from a CNA, R1 and the CNA argued about the door being closed. R2 reported that during the care, while the CNA was wiping his perineal area, the CNA called R1 a “mother f***er.” After R1 closed the door and went to the bathroom, R2 stated that the CNA continued talking about R1 and referred to him as a “mother f***er” multiple times, with the term directed toward R1. The Administrator (V1) later interviewed the Black male CNAs and contacted an agency CNA (V10) who had worked that night; V10 admitted to swearing in the room while providing care to R2, stating he hit his foot and yelled out profanity, but denied swearing at residents. R1’s care plan and staff interviews indicated he had no history of making false abuse statements, and R2’s records similarly showed no history of false abuse allegations. A second incident of verbal and mental abuse involved R2 and two CNAs, V7 and V8. R2 stated that on a day shortly after a hospice aide had given him a bath, V7 and V8 entered his room to clean him and get him up. According to R2, V7 said, “You stink.” When R2 responded that he should not smell because he had just received a bath the day before, V7 allegedly stated, “Everyone in this place hates taking care of you.” R2 reported that these comments made him upset and feel bad about himself. R1, who was present in the room, stated that as soon as V7 entered, she told R2 that he stinks, and when R2 replied that he had just had a bath, V7 said, “No one want to take care of you, you are always complaining, not even hospice.” The facility’s abuse policy defines mental abuse as including humiliation and harassment, and verbal abuse as the willful use of disparaging and derogatory terms to residents or within hearing distance, which aligns with the language reported in both incidents.
Failure to Timely Assess and Treat Post-Fall Leg Pain Leading to Delayed Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received timely medical evaluation and treatment after a fall resulting in a fractured leg. The resident had multiple diagnoses including end stage renal disease with dialysis dependence, right below-knee amputation, osteoporosis, muscle weakness, lack of coordination, abnormal posture, anxiety, dementia, and Alzheimer’s disease. According to the fall incident note, the resident fell in his room and was found on the floor between his recliner and nearby furniture. The RN who responded reported performing a full assessment, including range of motion, and stated the resident could not move his left leg very much but considered this baseline and noted no pain complaints. She administered PRN tramadol later that night, documented for pain at a level 3, but stated she sometimes gives tramadol and melatonin to help him sleep and was unsure why pain was marked on the MAR. A CNA present after the fall reported that when the RN moved the resident’s left leg, he said “Oww” and began cussing, and that he screamed during incontinence care, though this was described as normal for him. On the following day shift, a CNA reported that when attempting to dress the resident, he screamed that his left leg hurt and stated he had fallen the previous day. The CNA immediately informed two RNs, who, according to the CNA, acknowledged the prior fall and said they were taking care of it; one RN later stated she did not recall being told about pain, and the other said she was leaving at end of shift after being told the resident had leg pain. Another CNA caring for the resident later that day and night reported the resident repeatedly said “don’t touch me, I’m in pain,” but she did not report this to a nurse because she believed it was normal for him to yell. Progress notes and records from this period show only one PRN tramadol dose given and no documented assessment of the resident’s left leg pain or notification of the physician regarding a change in condition between the fall and his transfer out. The next day, at the dialysis center, the resident appeared agitated and pointed to his left leg, prompting transfer to the ER, where imaging revealed a minimally displaced distal femur fracture requiring intramedullary nailing. The hospital history and physical noted it was unclear if any evaluation had been performed after the fall at the facility.
Failure to Use Required PPE During PICC Care Under Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when staff did not follow required personal protective equipment (PPE) use for a resident on enhanced barrier precautions. The resident (R4) had a physician order dated 3/31/26 for enhanced barrier precautions related to a peripherally inserted central catheter (PICC), with a start date of 3/26/26. An enhanced barrier precaution sign was posted on the resident’s bathroom door, instructing staff to wear gloves and a gown during device care and use. On 3/31/26 at 11:12 AM, a registered nurse (V16) was observed in the resident’s room handling the PICC line and disconnecting the resident from an antibiotic while wearing gloves but no gown. During an interview, the infection control nurse (V7) stated that enhanced barrier precautions are used to help limit infections and that staff are required to wear both gloves and a gown when handling a PICC. The facility’s Enhanced Barrier Precautions Protocol, revised 7/26/21, specified that gloves and gowns were to be used during high-contact care activities, including device care or use. This sequence of observations, interviews, and record review showed that despite existing orders, signage, and policy requiring both gloves and gowns for high-contact device care under enhanced barrier precautions, the registered nurse did not wear a gown while performing PICC care for the resident.
Failure to Administer Ordered PRN Narcotic for Severe Post-Surgical Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered pain medication to a resident following right femur fracture repair. The resident was re-admitted with diagnoses including peripheral vascular disease, late-onset Alzheimer’s disease, unspecified dementia, falls, diabetes, and osteoarthritis. Physician orders dated December 2025 included oxycodone 5 mg every 4 hours as needed for moderate or severe pain. On 12/27/25 at 1:38 PM, nursing notes documented the resident exhibiting yelling and screaming behaviors and severe pain, with interventions listed as scheduled pain medication and PRN medication administration. However, the Medication Administration Record for December 2025 shows no pain medication was administered at 1:38 PM, and instead acetaminophen 325 mg was given later at 3:34 PM. During interviews, the RN stated the resident was confused and non-verbal, with pain indicated by facial grimacing and behaviors, and confirmed the resident had scheduled acetaminophen and PRN oxycodone available, noting that if waiting for pharmacy delivery, narcotics could be pulled from the emergency supply. The DON reported that discharge instructions from the hospital included narcotic prescriptions and that oxycodone was available in the emergency supply box. The DON confirmed the resident arrived at 10:27 AM, that the nurse’s note at 1:38 PM documented severe pain, and that no pain medication was administered at that time despite an order for oxycodone 5 mg for moderate to severe pain. The DON also stated that acetaminophen alone would not be adequate for pain control following hip surgery and was unsure why nursing did not administer the narcotic. The controlled substance record shows oxycodone was delivered to the facility at 10:00 PM and first administered at 1:00 AM the following day. The facility’s pain management policy states that pain management will be provided to residents who require such services, consistent with professional standards of practice and the person-centered care plan.
Failure to Notify Physician and Family of Abnormal Labs and Post-Fall Injuries
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of an abnormal laboratory result for a resident receiving Lithium, as well as failure to notify a physician and family of injuries following unwitnessed falls for another resident. One resident, a 65-year-old with multiple medical diagnoses including paranoid schizophrenia, hypertension, hyperlipidemia, atherosclerotic heart disease, anxiety disorder, and restlessness/agitation, had a physician order for Lithium that was increased over time to 300 mg twice daily as of early March 2026. A laboratory result dated March 10, 2026, showed a Lithium level of 1.40 mmol/L, flagged as high, with no documentation that the physician was notified of this abnormal result. The MAR shows that staff continued to administer Lithium 300 mg twice daily from March 5 through March 15, 2026, without documented physician notification or dose adjustment in response to the elevated level. On March 15, 2026, progress notes document that this resident became very lethargic, unable to stand or transfer, and unable to answer questions, with continued lethargy and inability to respond even to simple questions later that evening. The notes indicate that the physician and DON were contacted at that time and that the resident was sent to the hospital via emergency services. Hospital records show the resident was admitted with a primary diagnosis of Lithium toxicity and that a subsequent Lithium level was critically high at 1.73. The resident’s psychiatrist later stated he was not aware of the elevated Lithium level obtained on March 10, 2026, and that facility staff were expected to notify him of high or low Lithium levels so that medication doses could be adjusted and the resident monitored for changes in condition. The deficiency also includes a second resident, a 64-year-old with multiple diagnoses including altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, and difficulty walking, for whom the facility failed to notify the physician and family of injuries after unwitnessed falls and subsequent bruising. This resident requires total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documents a fall by the nurses’ station with no initial injury noted and physician and family notification at that time; however, a large dark purple bruise covering most of the right buttock was later observed, and the post-fall follow-up assessment dated March 23, 2026, does not show documentation that the physician or family were notified of this bruise. Staff interviews show inconsistent accounts regarding when the bruise was noticed and who was informed, and a CNA reported that the bruise had been observed and reported to the nurse. Additionally, an earlier incident report dated February 23, 2026, documents an unwitnessed fall with yellow discoloration to the left hip and an abrasion to the posterior head, with no progress note documentation that the physician or family were notified of these injuries, despite facility policy requiring immediate notification of the physician and family for significant changes in condition or injuries.
Failure to Assess Change in Condition and Complete Post-Fall Body Assessment
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess and respond to a change in condition for one resident (R1) and to perform a complete post-fall body assessment for another resident (R5). R1, a 65-year-old with multiple medical diagnoses including hypotension, hypertension, coronary artery disease, paranoid schizophrenia, urinary retention, anxiety disorder, and restlessness/agitation, was documented on the MDS as alert and oriented and requiring substantial to maximum assistance with ADLs. On the morning of March 15, 2026, R1’s nurse (V5) observed her leaning to one side in her wheelchair after breakfast and instructed CNAs to put her to bed to prevent a fall. V5 noted a bruise on R1’s left shoulder but did not document any further assessment of her condition. Despite multiple CNAs (V8, V9, V10) recognizing that R1 was very lethargic, leaning forward and to the side, unable to sit upright, having difficulty swallowing food and water, gagging, and appearing in a daze, there was no detailed nursing assessment or frequent monitoring documented for R1 during the morning shift. Later that day, during shift change, another nurse (V7) observed R1 to be very lethargic, barely responsive to her name, and unable to stand or transfer. V7 had not been informed of any change in condition and was unfamiliar with R1’s baseline. After R1’s family expressed alarm at her condition, V7 confirmed with CNAs that R1 usually got up with assistance and used a bedside commode but was now unable to get up or sit on the commode even with assistance from three staff. V7 obtained vital signs, which were stable, but R1 remained lethargic. V7 notified the physician and the DON and arranged for R1 to be sent to the hospital via emergency services. Progress notes from the evening documented that R1 was very lethargic, moaning but unable to speak or answer even simple questions. Hospital records showed R1 was admitted with a primary diagnosis of lithium toxicity, with a critically high lithium level of 1.73 mmol/L. A prior lab result from March 10, 2026, showed an elevated lithium level of 1.40 mmol/L, with no documentation that the physician was notified. R1’s psychiatrist (V14) stated he was not aware of the elevated lithium level and that facility staff were expected to notify him of high or low lithium levels so that dosing and monitoring could be adjusted. The deficiency also includes the facility’s failure to conduct and document a complete post-fall body assessment for R5, a 64-year-old with altered mental status, Parkinson’s disease, lack of coordination, muscle wasting and atrophy, difficulty walking, dysphagia (oral phase), and cognitive communication deficit. R5 required total assistance for toileting, hygiene, and dressing. An incident report dated March 20, 2026, documented that R5 had an unwitnessed fall by the nurses’ station, was on a blood thinner, and was sent to the hospital, with no injury initially noted. Upon R5’s return from the hospital on March 22, 2026, a progress note stated that a full body assessment was conducted and no new skin issues were noted, and subsequent post-fall assessments through March 23, 2026, also documented no skin issues. However, CNAs (V16 and V17) later observed a large dark purple bruise covering almost the entire right buttock during a full body assessment on March 23, 2026. CNA V17 reported seeing this bruise the evening of March 22, 2026, when assisting R5 to the toilet and stated she immediately notified nurse V6. CNA V21 confirmed being informed of the bruise during shift change. Nurse V5, who cared for R5 on the morning of March 23, 2026, stated he only assessed exposed skin and did not see the bruise. V6 initially stated she was unaware of the bruise but later changed her statement to say she had done a complete body check on admission and noted the bruise. The ADON (V20) stated that when a bruise is found, staff must document its size, location, color, tenderness or pain, and notify the physician of injuries or changes in condition. The facility’s Accident and Incident Policy requires documentation of the extent of injury, assessment, and at least 72 hours of daily documentation after an incident, which was not reflected in R5’s records regarding the buttock bruise.
Resident Improperly Restrained in Geri-Chair With Sheet and No Medical Justification
Penalty
Summary
The deficiency involves a resident who was physically restrained in a Geri-chair using a sheet without a physician’s order, consent, or documented medical justification. The resident is an older adult with multiple medical diagnoses including type 2 diabetes mellitus with hyperglycemia, COPD, hypertensive heart disease without heart failure, hyperlipidemia, urinary incontinence, edema of unspecified eye, and bipolar disorder. The MDS documented a BIMS score of 9, indicating moderate cognitive impairment, and showed the resident required only supervision or touching assistance for sit-to-stand and ambulation tasks, did not use a wheelchair or scooter, and was ambulatory without assistive devices. The care plan documented the resident as an adult with chronic health conditions and co-morbidities living in LTC, with recognition that such circumstances may be viewed as a form of trauma, but did not document any history of being a perpetrator or recipient of mistreatment, abuse, neglect, or exploitation. On the night in question, a CNA who was not assigned to the resident placed the ambulatory resident into a Geri-chair on the third floor and tied a sheet around the resident’s waist and the back of the chair, using it as a seat belt. The CNA stated she did this around 3:30 a.m. because the resident was walking from room to room, entering other residents’ rooms, pulling on residents while they were sleeping, and other residents were getting upset. The CNA reported that the resident was awake, clapping, able to move arms and legs, but could not get out of the Geri-chair because it was reclined “like a couch.” The CNA acknowledged that wheelchairs do not come with seat belts, that tying a sheet over a resident who does not use a Geri-chair is considered a restraint, and that using a sheet in this way is not allowed, but stated she believed she was helping and using it as a safety precaution to keep the resident from falling out and to keep the resident with her while she went from room to room. The resident remained in the Geri-chair with the sheet tied until discovered by a day-shift CNA after 7:00 a.m., who found the resident in the dining room, noted that the resident could not get up as usual, and on closer inspection saw the sheet restraining the resident from getting out of the chair. The day-shift CNA reported the situation to a nurse and the resident was removed from the chair around 7:10–7:15 a.m. Subsequent review of security footage by the administrator and DON confirmed the resident sitting in the hallway in a Geri-chair with a sheet tied over the lap, and multiple staff, including the administrator, DON, attending physician, and social services director, identified the Geri-chair and tied sheet as a restraint, noting that the resident is ambulatory and does not utilize a Geri-chair. A skin/shower worksheet dated several days later documented skin discoloration/bruising to the resident’s upper and lower extremities. The facility’s written policies state that physical restraints are to be used only as a last resort after alternatives have been tried and failed, based on assessment and IDT determination, and that the facility prohibits abuse, neglect, exploitation, and mistreatment, with employees required to immediately report any incident, allegation, or suspicion of potential abuse or neglect to the administrator or an immediate supervisor who must immediately report it to the administrator. In this incident, the resident was restrained without assessment, IDT involvement, physician order, consent, or documented medical symptoms warranting restraint, and the restraint was applied solely at the CNA’s discretion. Additional staff interviews further described the circumstances and staff awareness. The DON confirmed that the resident is ambulatory, does not use assistive devices, does not utilize a Geri-chair, and is able to transfer independently, and stated that placing the resident in a Geri-chair and tying a sheet over the resident would be considered a restraint. The attending physician stated that someone took it upon themselves to place the resident in a Geri-chair and used a sheet to tie the resident down, described this as wrong and never okay, and characterized it as the aide’s misguided independent action. The social services director stated the resident ambulates independently with moderate cognitive impairment, does not require a wheelchair or Geri-chair, and that having something wrapped around the resident’s legs or thighs in this manner is technically a restraint. The administrator stated that the Geri-chair was considered a restraint because it was not assigned to the resident, and the sheet was also a restraint because it was tied over the resident’s lap, and confirmed that the resident is mobile and does not use a chair or other devices. The report also details staff knowledge and recognition of the restraint and the reporting chain. The CNA who discovered the resident in the morning stated she had received abuse prevention training and knew that use of restraints is prohibited and considered abuse, and that there are different levels of restraints. She reported the situation to a nurse but did not directly notify the administrator. The house supervisor LPN stated she was told by the CNA that the resident was in a Geri-chair and was wet, but she did not hear that the resident was tied with a sheet; she stated that if she had heard that the resident was restrained, she would have immediately assessed the resident and notified the administrator, acknowledging that restraints are not allowed and that the resident ambulates independently and does not use a Geri-chair. The night-shift LPN assigned to the resident stated he saw the resident in the Geri-chair, with hands visible and no distress, but did not see the sheet tied around the waist and was not aware the resident was restrained; he stated he had received abuse prevention and restraint education. Another CNA on orientation reported seeing the resident rolled into the dining room and giving the resident water but did not see the sheet being tied and acknowledged that such use would be considered a restraint. Facility documentation, including the final incident investigation report and policy excerpts, confirms that the resident was physically restrained in a Geri-chair using a sheet, without physician orders, consent, or medical justification, and that this constituted inappropriate use of a physical restraint and a failure to protect the resident from abuse and to follow facility policies on restraint use and abuse prevention.
Failure to Use Gait Belts and Follow Transfer Care Plans
Penalty
Summary
Surveyors identified a deficiency in which staff did not follow the facility’s mandatory gait belt transfer policy or residents’ care plans requiring gait belt use for physical assist transfers. One resident with Type 2 DM, CHF, severe cognitive impairment, and a care plan requiring a walker, gait belt, and one-person assist for transfers was observed being transferred from wheelchair to bed by a CNA who did not use a gait belt, instead pulling under the resident’s arm and by the waistband of his pants. Another resident with Parkinson’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker or sit-to-stand device with one-person assist for transfers was transferred to and from the toilet by a CNA without a gait belt or walker; the CNA used one hand to guide the resident’s hip and the other to pull the wheelchair into position behind the resident. A third resident with dementia, cerebral infarction, severe cognitive impairment, and a care plan requiring a gait belt, sit-to-stand device, and one-person assist for transfers was repeatedly transferred without a gait belt. The CNA lifted the resident under both axillae from bed to a high-back wheelchair, then into and out of the bathroom using the handrail and lifting under one axilla, again without a gait belt. During a subsequent transfer from wheelchair to bed, the CNA did not lock the wheelchair and did not apply a gait belt; as the resident grabbed the bed rail and the CNA lifted under the axilla, the wheelchair rolled away, leaving the resident sitting on the edge of the bed and nearly falling before the CNA was able, after several attempts, to get the resident’s legs and feet onto the bed. A fourth resident with Alzheimer’s disease, severe cognitive impairment, and a care plan requiring a gait belt and walker with one-person assist for transfers was transferred between wheelchair and toilet by a CNA who did not use a gait belt, instead pulling the resident up by her pants and under her arm and then holding onto the pants while pulling the wheelchair into position. Multiple CNAs later stated that gait belts are used for transferring residents, and the facility’s written policy states that use of a gait belt for all physical assist transfers is mandatory.
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