Brickyard Healthcare - Elkhart Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Elkhart, Indiana.
- Location
- 1001 W Hively Ave, Elkhart, Indiana 46517
- CMS Provider Number
- 155685
- Inspections on file
- 38
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 28
Citation history
Health deficiencies cited at Brickyard Healthcare - Elkhart Care Center during CMS and state inspections, most recent first.
A resident with CHF, CKD, DM2, COPD, and acute metabolic acidosis, who had identified it as very important to have family involved in care and had designated a granddaughter as emergency contact, experienced multiple new treatments and changes in condition without notification of the chosen representative. Nursing and physician documentation showed repeated new orders for labs, analgesics, hypoglycemics, insulin adjustments, antibiotics for UTI and cellulitis, IV and hypodermoclysis fluids for elevated BUN, diuretics for lower extremity fluid seepage, nitroglycerin for chest pain, and a chest X-ray, with no evidence that the representative was informed. Progress notes also described chronic confusion in the resident, while the facility’s own Notification of Change policy required notifying the resident’s representative of new treatments and significant health status changes, which did not occur, and the emergency contact confirmed she had not been updated on these changes.
A resident with CHF, CKD stage 3, DM2, and acute metabolic acidosis had a physician order for metoprolol 25 mg BID with instructions to hold the dose if SBP was below a specified threshold or if pulse was below 60 bpm. Review of the MAR showed that nursing staff administered metoprolol on several occasions despite SBP readings below the ordered hold parameter. During interview, the ADON stated that nursing staff should have followed the physician’s orders, and facility policy required provision of physician-ordered services according to professional standards of quality.
A resident with cognitive and physical impairments was involved in a verbal altercation with a CNA after the resident ran over the CNA's foot with a motorized wheelchair. The CNA raised her voice at the resident, and the resident alleged physical contact. Staff intervened to de-escalate the situation, and the incident was documented and reported. The facility failed to ensure the resident was free from verbal abuse as required by policy.
A resident reported an alleged abuse incident involving an employee who inappropriately used a room deodorizer. The resident informed another employee, who failed to report the allegation immediately as required by the facility's policy. The Administrator was only informed days later, leading to a delay in addressing the situation.
The facility failed to serve food at palatable temperatures, affecting 110 residents. Observations showed hot foods on the steam table were below required temperatures, and meals transported on non-insulated carts further cooled down. Staff and residents confirmed the issue, with residents expressing dissatisfaction over cold meals. The facility's policy requires maintaining hot foods at or above 135°F.
The facility failed to ensure proper food handling and storage, affecting 114 residents. Observations revealed undated and improperly stored food items, and staff were seen mishandling meal trays, compromising food safety. The facility lacked a policy on meal tray delivery.
The facility failed to provide residents with timely access to their personal funds, restricting withdrawals to weekdays and imposing an unauthorized five-dollar limit. Staff were unaware of these restrictions, which contradicted facility policy.
The facility did not ensure that the surety bond for the Resident Fund account was sufficient to cover the total funds held, which amounted to $286,128.00. This amount was unusually high due to a closed account with funds from a home sale. The surety bond was only set at $250,000, contrary to the facility's policy requiring the bond to match or exceed the total resident funds. The Executive Director was unaware of the reason for the insufficient bond coverage.
The facility failed to timely initiate and complete baseline care plans for four residents with specific medical needs, including dialysis, tube feeding, falls, and pressure ulcers. The care plans lacked necessary goals and interventions and were not completed within the required 48-hour timeframe, as confirmed by the DON and Executive Director.
The facility failed to create comprehensive person-centered care plans for several residents, resulting in deficiencies in addressing their medical and psychosocial needs. A resident with dementia lacked individualized interventions for antipsychotic use, while another with Alzheimer's had unaddressed vision issues. Additional residents experienced inadequate care planning for conditions like edema, UTI, and constipation, as confirmed by the DON.
The facility failed to accurately document the resuscitative wishes of two residents. One resident had conflicting documentation between a DNR order and a full code status in their care plan and physician's order. Another resident lacked documentation of their code status preferences entirely. These discrepancies were confirmed by staff interviews and violated the facility's policy on communication of code status.
A resident with significant medical conditions and unresponsiveness was not provided with preferred activities such as music and television, despite documented preferences and a facility policy emphasizing resident-centered activities. The Activity Director noted the absence of a television and lack of one-on-one visits since the resident's return from hospitalization.
The facility failed to monitor edema for a resident with significant bilateral edema and did not timely administer antibiotics for another resident with an infected toe. The care plans lacked specific monitoring for edema, and assessments were inconsistent. Additionally, a delay in administering Doxycycline for cellulitis occurred due to mishandled medication orders, with no policy on timely antibiotic administration.
A resident with a history of cerebral infarction and in a persistent vegetative state did not receive a prescribed range of motion (ROM) program to prevent contractures. Observations showed the resident's hands in a fist-like position and knees bent, with a cushioned boot not in use. Despite physician's orders for ROM exercises and splints, there was no documentation of the program being implemented, and the splints were discontinued due to anxiety. An LPN confirmed the resident's tight hands and knees, indicating a lack of proper ROM care.
A resident with a PICC line for IV medications had a dressing that was improperly maintained, exposing the insertion site. Despite a physician's order for weekly and as-needed dressing changes, the dressing remained compromised for several days. The resident's medical conditions required strict infection control, but the facility's policy was not followed.
A resident with a tracheostomy was observed with a misaligned oxygen collar, leading to low oxygen saturation levels. The facility lacked comprehensive physician's orders for tracheostomy care, and the resident's care plan was not followed, as evidenced by missing entries in the treatment records. Staff interviews confirmed the absence of necessary orders for complete tracheostomy care.
The facility did not verify controlled substance counts for a medication cart in the SW Unit. Missing signatures were found on the controlled medication log book for several dates, indicating a failure to complete the required verification by the oncoming and offgoing nurse or QMA. The facility's policy mandates that two licensed nurses account for all controlled substances and access keys at the end of each shift, which was not followed.
A resident was prescribed Zyprexa for dementia with agitation without an appropriate diagnosis, as noted in a psychiatric note lacking an approved diagnosis. Despite the medication being clinically contraindicated, it was continued due to perceived benefits outweighing risks. The DON confirmed the absence of an appropriate diagnosis, contrary to the facility's policy requiring documentation of adequate indications for medication use.
A resident was found on wet bed linens and expressed dissatisfaction with their care. A CNA failed to follow proper hand hygiene and glove-changing protocols during perineal care, using the same gloves throughout the process and not washing hands, contrary to the facility's policy.
Failure to Notify Resident’s Representative of New Orders and Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s chosen personal representative of new medical orders and changes in condition, despite the resident’s expressed preference and facility policy requirements. Resident B was admitted with multiple diagnoses, including congestive heart failure, chronic kidney disease stage 3, type 2 diabetes mellitus, and acute metabolic acidosis. An admission MDS assessment documented that the resident was cognitively intact, and a resident preferences evaluation indicated it was very important to the resident to have family or a close friend involved in their care. A Social Services note recorded that the resident wanted her granddaughter to be her emergency contact. However, multiple nursing progress notes over time documented that the resident exhibited chronic confusion. Record review showed that on numerous occasions the facility obtained new medical orders for Resident B without notifying the resident’s personal representative. On one date, new orders were obtained from the nurse practitioner for labs, melatonin, and acetaminophen at bedtime, with no documentation that the representative was notified. On another date, new orders were received for acetaminophen as needed for pain, metformin, lispro insulin, prednisone for COPD, and Robitussin DM for cough, again without notification of the representative. Subsequent physician and nursing notes documented an acute visit for dehydration related to elevated BUN, with orders for IV normal saline, followed by additional orders for IV fluids, Macrobid for a UTI, Keflex for cellulitis of the right leg, and hypodermoclysis for elevated BUN, all without documented notification of the personal representative. Further documentation showed additional new orders and a change in condition for Resident B without representative notification. Nursing notes indicated new orders for furosemide due to excessive fluid seeping from both lower extremities and an increase in Lantus insulin dosage, with no evidence that the personal representative was informed. When the resident complained of chest pain, a new order for nitroglycerin as needed was obtained and administered, and a subsequent order for a two-view chest X-ray was received; in both instances, there was no documentation that the personal representative was notified of the change in condition or the new orders. During interview, the resident’s emergency contact stated she had not been informed of her grandmother’s changes in condition or new orders and noted the resident had periods of confusion and would not understand the orders. The facility’s own Notification of Change policy required informing the resident, consulting the physician, and notifying the resident’s representative when treatment is altered, including new treatment, and specified that even competent residents’ representatives should be notified of significant health status changes, which did not occur in this case.
Failure to Follow Physician Orders for Antihypertensive Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s orders for administration of an antihypertensive medication for one resident. Record review showed that a cognitively intact resident with diagnoses including congestive heart failure, chronic kidney disease stage 3, type 2 diabetes mellitus, and acute metabolic acidosis had a physician’s order for metoprolol 25 mg twice daily for hypertension, with instructions to hold the medication if systolic blood pressure was less than 110 mm/Hg or pulse was less than 60 beats per minute. The Medication Administration Records for November and December 2025 documented that nursing staff administered metoprolol on multiple occasions when the resident’s systolic blood pressure was below the ordered hold parameter, including readings of 102/42 mm/Hg, 102/80 mm/Hg, and 104/73 mm/Hg. During interview, the Assistant Director of Nursing acknowledged that nursing staff should have followed the physician’s orders, and the facility’s policy on Provisions of Physician Ordered Services stated that physician-ordered services are to be provided according to professional standards of quality. This citation relates to Intake 27044933,1-37.
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
A resident with multiple diagnoses, including multiple sclerosis, mild cognitive impairment, depression, epilepsy, anxiety, and mood disorder, was involved in an incident where a certified nursing assistant (CNA) responded to the resident's call light. The resident, who used a motorized wheelchair independently but required assistance for transfers, toileting, and bathing, was reported to have run over the CNA's foot with her wheelchair. Following this, the CNA was observed and heard screaming as she exited the resident's room. A verbal altercation ensued between the CNA and the resident, requiring intervention from multiple staff members to de-escalate the situation. During the incident, the resident alleged that the CNA hit her in the throat and pushed her into her chair. A physical assessment of the resident revealed no visible injuries, though she complained of neck pain. The incident was documented in the clinical record and reported to the appropriate authorities, including the local police and state health department. The facility's policy prohibits all forms of abuse, including verbal abuse, but the CNA was found to have raised her voice at the resident during the altercation.
Failure to Report Alleged Abuse Timely
Penalty
Summary
The facility failed to adhere to its policy regarding the timely reporting of an allegation of abuse involving a resident, identified as Resident B. Resident B reported that during a night the previous week, an employee, referred to as Employee 3, entered her room to assist with changing her brief and made inappropriate comments about the odor. Employee 3 allegedly sprayed Resident B's buttocks with room deodorizer and then inserted the spray can into her rectum. Resident B reported this incident to another employee, Employee 6, on January 20, 2025, while in the facility's lobby. However, Employee 6 did not report the allegation to the Administrator immediately, as required by the facility's policy. The Administrator became aware of the allegation only on January 22, 2025, when informed by Employee 2. Upon learning of the incident, the Administrator suspended Employee 3, reported the allegation to the State Agency, and initiated an investigation. The facility's policy mandates that all allegations of abuse be reported to the Administrator and other relevant authorities within two hours if the events involve abuse or result in serious bodily injury. Employee 6 acknowledged the failure to report the allegation immediately, despite having been trained on the requirement to do so.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures, affecting 110 out of 120 residents who consumed meals from the main kitchen. During a meal observation, it was noted that the temperatures of hot foods on the steam table were below the required levels, with pureed corn at 105°F, cream corn at 123°F, pureed beef at 118°F, beef gravy at 128°F, and pepper steak at 123°F. The facility's policy requires hot foods to be maintained at or above 135°F. Additionally, when meals were transported to the 500 hall on non-insulated carts, the last tray served had significantly lower temperatures, with pepper steak at 80°F, sweet potatoes at 85°F, and whole corn at 85°F. Interviews with staff and residents further highlighted the issue. A staff member confirmed that hot food temperatures should be held at or above 140°F while on the steam table, and the Dietary Manager stated that hot foods should be checked and maintained at at least 135°F. Residents expressed dissatisfaction, indicating that the hot food was often served cold. The Administrator acknowledged that hot foods should be served at appropriate temperatures. The Director of Nursing provided the facility's policy, which emphasizes the importance of maintaining proper food temperatures throughout meal service.
Food Handling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper handling and storage of food, which had the potential to affect 114 out of 115 residents receiving meals from the kitchen. During an initial walkthrough of the kitchen, several issues were observed, including an opened and undated box of lasagna noodles, a gallon of vanilla with an opened date from over a year ago, an undated container of gravy, expired health shakes, and an opened and undated box of Cream of Wheat cereal. These observations indicate a lack of adherence to the facility's policy on date marking for food safety, which requires food to be clearly marked with the date it was opened and the date by which it should be consumed or discarded. Additionally, during meal observations, staff members were seen handling food and meal trays inappropriately. One CNA was observed with her thumb extending over the plate's rim onto the food surface while serving residents, and another CNA was seen carrying a meal tray on her shoulder, allowing her hair to touch the top of the tray. These actions demonstrate a failure to follow proper food handling procedures, which could compromise the safety and hygiene of the meals served to residents. The facility's inability to provide a policy on meal tray delivery further highlights the lack of proper guidelines and training for staff in this area.
Deficiency in Resident Fund Access
Penalty
Summary
The facility failed to ensure that resident funds were available on the same day of the request and for the desired amount for four residents whose personal funds were managed by the facility. Residents reported limited access to their funds, with availability restricted to weekdays between 9 A.M. and 4 P.M., and no access on weekends. Additionally, residents were informed of a five-dollar withdrawal limit, which was not in accordance with facility policy. Interviews with staff revealed a lack of awareness regarding the withdrawal limit imposed on residents. The Business Office Manager indicated that there should not be a five-dollar withdrawal limit, and the Executive Director was unaware that staff were communicating this limit to residents. The facility's policy stated that during non-business hours, the Business Office Manager or a designee should provide the Nurse Supervisor with a petty cash box for resident funds, but this procedure was not effectively implemented.
Insufficient Surety Bond Coverage for Resident Funds
Penalty
Summary
The facility failed to ensure that the surety bond covering the Resident Fund account was sufficient to cover the total amount of funds held. During a review of the Resident Fund accounts with the Business Office Manager and the Executive Director, it was found that the total amount in the accounts was $286,128.00, which was higher than usual due to a closed account with funds from a home sale. The facility's surety bond, however, was only set at $250,000, which was insufficient to cover the total amount. The Executive Director was unaware of why the Corporation had not increased the surety bond amount, despite the facility's policy requiring the bond to be equal to or greater than the total amount of residents' funds as of the most recent quarter.
Failure to Timely Initiate Baseline Care Plans for Residents
Penalty
Summary
The facility failed to ensure timely initiation and completion of baseline care plans for four residents with specific medical needs. Resident 36, who was receiving dialysis, had a baseline care plan that lacked goals, interventions, and special needs, despite being admitted with conditions such as end-stage renal disease and diabetes. The Director of Nursing acknowledged that the care plan did not include all necessary information from the resident's chart. Resident 107, who was on tube feeding due to conditions like cerebral infarction and diabetes, had a care plan that was not completed until several days after admission, contrary to the facility's policy of completing such plans within 48 hours. Similarly, Resident 14, who had a history of falls and multiple health issues including major depressive disorder and heart disease, had a baseline care plan completed late. The Director of Nursing confirmed that the care plan should have been completed within the required timeframe. Resident 99, admitted with a pressure ulcer and moderate cognitive impairment, also did not have a timely baseline care plan for wound care. The facility's policy, which mandates the development of a baseline care plan within 48 hours of admission, was not adhered to in these cases, as confirmed by the Executive Director.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their specific medical and psychosocial needs. Resident 28, diagnosed with conditions including hemiplegia, dementia, and anxiety disorder, was prescribed Zyprexa for agitation. However, the care plan lacked individualized interventions for managing behaviors associated with antipsychotic use. Interviews revealed that interventions were not tailored to the resident's needs, as they were standardized across all residents. Resident 10, with Alzheimer's disease and other cognitive impairments, reported impaired vision and issues with her eyeglasses. Despite this, her care plan did not address her vision needs, and the MDS inaccurately recorded her vision status. Observations confirmed the presence of prescription eyeglasses, which the resident was not using due to ineffectiveness. The MDS coordinator acknowledged the oversight in the care plan and MDS documentation. Other residents also experienced deficiencies in care planning. Resident 14, with edema in his lower extremities, lacked a specific care plan to monitor and manage this condition, despite being prescribed Lasix. Resident 66, diagnosed with a UTI, did not have a care plan addressing this infection. Similarly, Resident 215, who had not had a bowel movement in 14 days, lacked a care plan for constipation. The Director of Nursing confirmed the absence of necessary care plans for these conditions, contrary to the facility's policy on comprehensive care planning.
Failure to Accurately Document Resuscitative Wishes
Penalty
Summary
The facility failed to provide accurate orders for resuscitative wishes for two residents, leading to a deficiency in honoring residents' rights to formulate and have their advanced directives respected. For Resident 94, there was a discrepancy between the Physician Orders for Scope of Treatment (POST) form, which indicated a do not resuscitate (DNR) status, and the physician's order and care plan, which both indicated a full code status. This inconsistency was confirmed during an interview with an LPN, who acknowledged the conflict between the POST form and the other documents. For Resident 36, the facility failed to document the resident's code status preferences in the physician's orders for the specified period. An LPN confirmed that there should have been an order for the resident's code status. The facility's policy on communication of code status, which was provided by the Director of Nursing, requires that any orders related to a resident's advanced directives be clearly documented in designated sections of the medical record. However, this policy was not adhered to in the case of Resident 36, resulting in a lack of documentation for the resident's code status.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide resident-centered activities for a resident who was observed multiple times lying in bed without any music or television playing, despite documented preferences for easy listening music and specific television programs. The resident, who had diagnoses including unspecified sequelae of cerebral infarction, anoxic brain, and tracheostomy, was noted to be unresponsive, and her cognitive function could not be assessed. An Activity Participation Review and a Progress Note indicated that the resident's family had expressed preferences for music and television, which were not being met. The Activity Director acknowledged the absence of a television in the resident's room, which had been removed during a hospital stay, and confirmed that the resident had not received any one-on-one visits since returning from the hospital. The facility's policy on activities emphasized the importance of providing programs that support residents' choices based on their comprehensive assessment, care plan, and preferences. However, the facility did not adhere to this policy, as evidenced by the lack of activities provided to the resident, which were supposed to include television twice daily according to the Activity Tasks for the month.
Failure to Monitor Edema and Timely Administer Antibiotics
Penalty
Summary
The facility failed to monitor edema for a resident who was admitted with significant bilateral edema to his legs and stumps. Despite the resident's condition, the care plans did not include a specific plan to monitor the edema, and assessments did not document the presence of edema. The resident was prescribed Lasix, a diuretic, but there was no policy or procedure in place for monitoring edema, and the documentation was inconsistent. Interviews with staff revealed that the edema was not properly assessed or documented in the clinical records. Additionally, the facility failed to administer antibiotic medication timely for another resident with an infected toe. The resident was prescribed Doxycycline for cellulitis, but the medication order was mishandled, leading to a delay in administration. The first dose was not given until the morning after it was ordered. The facility lacked a policy on the timeliness of following antibiotic orders, and there was no documentation of the medications included in the facility's Emergency Drug Kit.
Failure to Implement Range of Motion Program for Resident
Penalty
Summary
The facility failed to provide a range of motion (ROM) program to prevent further contractures for a resident, identified as Resident 93, who was reviewed for ROM. During an observation, the resident was noted to have her hands in a fist-like position and her knees bent, indicating a lack of proper ROM exercises. A straight-legged, cushioned boot was observed at the end of the resident's bed, suggesting it was not in use. The resident's diagnoses included unspecified sequelae of cerebral infarction, anoxic brain, and tracheostomy, and she was in a persistent vegetative state. Past physician's orders had included the use of a resting hand splint, a foot brace, and passive ROM exercises for the resident's upper and lower extremities every shift. Despite these orders, there was no documentation to confirm that the passive ROM program was being implemented. An LPN indicated that the resident should have been receiving a passive ROM program and acknowledged that the resident's hands and knees were tight. The LPN also mentioned that the resident's splints were discontinued due to causing anxiety. The facility's policy on the prevention of decline in ROM emphasized the need for a systemic approach to prevent ROM decline, including assessment, care planning, and preventative care, which was not adhered to in this case.
Failure to Maintain PICC Line Dressing
Penalty
Summary
The facility failed to provide appropriate care for a peripherally inserted central catheter (PICC) for a resident, identified as Resident 266, who was receiving intravenous medications, vancomycin and piperacillin. On multiple occasions, the PICC line's transparent dressing was observed to be improperly maintained. On July 29, 2024, the dressing was folded in half, leaving the insertion site exposed, and this condition persisted throughout the day. By August 1, 2024, the dressing was not adhered along the lateral edges, and the resident reported that it had become wet during a shower the previous evening. The resident had significant medical conditions, including osteomyelitis, methicillin-susceptible staphylococcus aureus, and type 1 diabetes mellitus, which necessitated careful infection control practices. A physician's order dated July 26, 2024, required the PICC line dressing to be changed weekly and as needed during the night shift. However, an LPN acknowledged seeing the compromised dressing on July 29, 2024, and indicated it was not changed until the following night shift. The facility's policy, provided by the Director of Nursing, stipulated that dressings should be changed weekly or if soiled to minimize infection risk, but this was not adhered to in the case of Resident 266.
Inadequate Tracheostomy Care for Resident
Penalty
Summary
The facility failed to provide adequate tracheostomy care for a resident, identified as Resident 93, who required respiratory support. During observations, the resident's oxygen collar was repeatedly found misaligned, positioned to the left of the tracheostomy stoma site, which affected the resident's oxygen saturation levels. At one point, the oxygen saturation was recorded at 85-86 percent, which is below the physician's order to maintain levels above 90 percent. The resident's condition improved to 92 percent after repositioning, indicating the misalignment of the oxygen collar was impacting respiratory function. A review of the resident's records revealed that the physician's orders for tracheostomy care were incomplete, lacking instructions for changing suction canisters and tubing, tracheostomy ties, and routine tracheostomy care. Additionally, the Medication and Treatment Administration Record for July 2024 showed no entries for tracheostomy care, despite the resident's care plan indicating the need for daily tracheostomy care and monitoring. Interviews with staff confirmed that the necessary orders for comprehensive tracheostomy care were not in place, and the facility's policy emphasized the need for care consistent with professional standards and the resident's care plan.
Failure to Verify Controlled Substance Counts
Penalty
Summary
The facility failed to verify controlled substance counts for a medication cart in the SW Unit. During an observation, it was noted that the controlled medication log book had missing signatures for the count sheets on several dates in July. This indicates that the required verification by the oncoming and offgoing nurse or QMA was not completed. The Director of Nursing confirmed that all narcotic count sheets should be signed for verification of residents' medications. The facility's policy requires two licensed nurses to account for all controlled substances and access keys at the end of each shift, which was not adhered to in this instance.
Inappropriate Antipsychotic Prescription Without Diagnosis
Penalty
Summary
The facility failed to ensure an appropriate diagnosis for a resident who was prescribed an antipsychotic medication, Zyprexa (Olanzapine), for dementia with agitation. The resident's medical record, reviewed on July 31, 2024, included diagnoses such as hemiplegia, cerebral infarction, unspecified dementia, atrial fibrillation, cardiomegaly, hypertension, and anxiety disorder. However, the psychiatric note dated July 24, 2024, lacked an approved diagnosis for the use of Zyprexa and documented a plan to continue the medication despite it being clinically contraindicated, as the benefits were deemed to outweigh the risks. During an interview on August 2, 2024, the Director of Nursing (DON) acknowledged that the resident did not have an appropriate diagnosis for taking the antipsychotic. The facility's policy, titled 'Unnecessary Drugs - Without Adequate Indication for Use,' dated February 2023, was provided by the DON on August 5, 2024. This policy indicated that documentation should be provided in the resident's medical record to show adequate indications for the medication's use and the diagnosed condition for which it was prescribed. The failure to adhere to this policy resulted in the deficiency noted by the surveyors.
Inadequate Infection Control During Personal Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during personal care for a resident. During an observation, a resident was found lying on wet bed linens and expressed dissatisfaction with the cleanliness of their care. On another occasion, a CNA responded to the resident's call light and noted a strong urine smell in the room, indicating uncertainty about when the resident was last checked or changed. This suggests a lack of timely and adequate personal care for the resident. Further observation revealed that a CNA did not follow proper hand hygiene and glove-changing protocols while providing perineal care. The CNA used the same gloves throughout the process, including when handling soiled items and touching clean linens, without washing hands or changing gloves. The facility's hand hygiene policy, which requires hand hygiene before and after glove use, was not adhered to. The CNA acknowledged the failure to change gloves and wash hands during an interview.
Latest citations in Indiana
Surveyors observed that dietary staff repeatedly worked in kitchen and meal service areas with uncovered facial hair, despite facility policy and state sanitation requirements mandating effective hair restraints. Two dietary aides with short beards or mustaches were seen walking through food preparation areas, taking food temperatures, handling food, and plating meals at steamtables in dining rooms without any facial hair coverings, while the current policy required all hair, including facial hair, to be restrained to prevent contamination.
The facility failed to consistently provide and document required bed-hold policy notices when several residents were transferred to the hospital. In multiple cases, residents with dementia, psychotic disorders, COPD, chronic respiratory failure, altered mental status, and cerebral infarction were sent out for acute changes in condition, and while transfer notes reflected physician and family notifications, they lacked documentation that the bed-hold policy was discussed with the resident or responsible party. Notices of Transfer or Discharge often indicated a copy of the bed-hold policy was sent with the resident, but the records did not show signed and dated acknowledgment by the resident or appropriate representative, including in situations where a resident had moderate cognitive impairment, short-term memory issues, or a documented need for a proxy and a financial POA authorizing an agent for health care decisions.
Surveyors found that the facility failed to provide trauma‑informed and culturally competent care by not incorporating two residents’ extensive trauma histories and specific behavioral triggers into their care plans. One resident with documented homelessness, polysubstance abuse, severe accidents with multiple fractures, viral encephalitis with coma, physical and sexual abuse, loss of family contact, and a past suicide attempt had multiple behavior‑focused care plans that referenced identifying triggers but listed none and did not mention their physical, sexual, medical, or psychosocial trauma. Another resident with TBI from being struck by a truck, an 11‑month coma, long‑term state hospital residence, alleged shooting of a parent, and diagnoses including intermittent explosive disorder and borderline personality disorder had a PASRR identifying a specific trigger and notes of inappropriate sexual behavior, yet their care plans omitted these traumatic events, the identified trigger, and the sexual behavior. Staff interviews confirmed that residents were screened for trauma, but the trauma histories and triggers were not reflected in the individualized plans of care.
A resident with schizophrenia, post‑stroke hemiparesis, and mild cognitive impairment expressed feeling down and wanting to kill himself, but staff did not document asking about a specific plan, did not notify the physician or psychiatric NP as expected, and did not develop or update a care plan addressing depression or suicidal ideation. The SSD documented offering support and initiating 15‑minute checks once, but there was no further follow‑up or documentation of interventions after subsequent suicidal statements made in a care plan meeting with the resident’s father. The DON and Administrator reported that facility policy requires immediate notification of key staff, assessment for a plan and means of self‑harm, and thorough documentation, which were not carried out or reflected in the medical record for this resident.
A resident with schizophrenia, post-stroke hemiparesis, and mild cognitive impairment verbalized suicidal ideation, but the care plan did not address depression or suicidal thoughts, and required assessments and services were not accurately or timely documented. An SSD note recorded the resident saying he wanted to kill himself and referenced 15‑minute checks and a care plan update, yet the active care plan lacked depression/suicidal ideation interventions. Multiple late-entry Social Services notes were later added, describing follow-up visits and the resident denying suicidal ideation, but the SSD later reported she did not typically ask about a suicide plan and did not personally provide individual follow-up visits as described. These practices conflicted with the facility’s policy requiring factual, first-hand, and timely documentation of assessments and services.
A resident was observed with an Albuterol inhaler on an overbed table and later reported keeping the inhaler in a nightstand drawer, with no staff present during these observations. Record review showed the resident had no cognitive impairment on the admission MDS but lacked any documented self-medication administration assessment. The DON acknowledged that the required assessment had not been completed, despite facility policy requiring staff and the practitioner to evaluate each resident’s mental and physical abilities before allowing self-administration of medications.
Surveyors found that the facility submitted inaccurate direct care staffing data to CMS through the PBJ system over multiple days in a quarter. CASPER reports showed apparent gaps in 24-hour licensed nurse coverage, low weekend staffing, and a 1-star staffing rating, while internal staffing sheets documented that licensed nurses were present and the facility was fully staffed on those days. The Administrator reported that the discrepancies were due to PBJ data entry errors, despite a facility policy requiring all PBJ entries to be accurate, auditable, and verifiable against payroll, invoices, or contracts.
Surveyors found that the facility did not provide or document required written transfer/discharge notices and bed-hold policy information for four residents who were sent to the hospital, including individuals with conditions such as dementia, CHF, chronic respiratory failure, and CKD. In each case, progress notes showed that the resident was transferred for acute issues, but the clinical records lacked evidence that written notices were given to the residents or their representatives, and in one case lacked documentation that required information was sent to the receiving provider. Facility leadership, including the ADON, DON, and Administrator, acknowledged that the records did not contain the required documentation, despite a written policy requiring such notices and information exchange.
A resident with Alzheimer’s disease and depression, previously on an antidepressant, exhibited intermittent refusals of medications and care, occasional yelling at staff, and reports of unusual perceptions, such as believing men were in or near her room. Nursing notes over several months documented these refusals and complaints but did not show that the behaviors were evaluated or recorded as dangerous, non-redirectable, or causing significant distress, nor did they document specific non-pharmacological interventions attempted or their outcomes. Despite this, a psychiatric NP later added new diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder and ordered an antipsychotic (Seroquel) without a comprehensive evaluation in the record to support these diagnoses. The facility’s psychotropic medication policy, which requires identification and documentation of target behaviors, use of nonpharmacological interventions, and ongoing behavior monitoring, was not followed for this resident.
The facility failed to keep PASARR Level I screenings accurate and current for three residents when new mental health diagnoses and psychoactive medications were initiated. One resident’s PASARR omitted a PTSD diagnosis and an added antidepressant, despite documentation of PTSD on the MDS and care plan and a physician order for Pristiq. Another resident’s PASARR listed only depression and dementia, even after additional diagnoses such as borderline personality disorder, delusional disorder, and schizoaffective disorder were added and an antipsychotic (quetiapine) was ordered, with the MDS later reflecting psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident’s PASARR did not include a depression diagnosis or newly ordered escitalopram and lorazepam, although the admission MDS documented depression with antianxiety and antidepressant use. These omissions occurred despite facility policy requiring a new Level I review after significant mental status changes, including new mental health diagnoses or new psychotropic medications.
Uncovered Facial Hair During Food Preparation and Meal Service
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food was served in a sanitary and safe manner in accordance with professional standards and facility policy during multiple kitchen and meal service observations. During an initial kitchen observation, two dietary aides were seen walking through the kitchen food preparation area with uncovered facial hair. One aide had facial hair above and below the lip and along the jaw line, approximately one-fourth inch in length, and the other had a mustache of similar length; neither used any facial hair covering. These observations occurred while staff were present in the kitchen area where food was stored and prepared. During subsequent observations on the same day, the same two dietary aides were again observed with uncovered facial hair while directly involved in meal preparation and service. One aide walked through the kitchen while the noon meal was being prepared and placed into a transport cart for service in the south dining room, and later was observed plating the noon meal at the steamtable in that dining room, still without a facial hair covering. The other aide walked through the kitchen while the noon meal was being prepared and placed into the steamtable for the north dining room, took food temperatures, assisted with plating meals at the steamtable, and retrieved food items and supplies from the kitchen, all while having an uncovered mustache approximately one-fourth inch in length. The Dietary Manager stated that staff hair was to be covered when in the kitchen and during meal service, and the facility’s written policy and the cited Indiana Food Establishment Sanitation Requirements both required effective hair restraints, including for facial hair, to prevent contamination of food, equipment, and utensils.
Failure to Provide and Document Bed-Hold Policy at Time of Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that required bed-hold policy information was provided and documented for four residents transferred to the hospital. For a resident with dementia, psychotic disorder, and autistic disorder who had a BIMS score of 0 indicating severe cognitive impairment, progress notes documented physician notification and guardian notification when the resident was sent to the hospital, but there was no documentation that the bed-hold policy was provided to the responsible party. A Notice of Transfer or Discharge later indicated a copy of the bed-hold policy was sent with the resident. Another resident with COPD and chronic respiratory failure, cognitively intact with a BIMS score of 13, experienced a decline in condition and was transferred to the hospital by ambulance; progress notes documented family notification but did not document any discussion of the bed-hold policy, although a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident. A third resident with altered mental status and cerebral infarction, with a BIMS score of 10 indicating moderate cognitive impairment and documented short-term memory impairment, experienced changes in condition and was transferred to the hospital. Progress notes stated the resident was their own responsible party and that no other notification was completed, and transfer documentation did not include the bed-hold policy, although an untimed Notice of Transfer or Discharge indicated a copy of the bed-hold policy was signed by the resident. A financial power of attorney document in the record showed the resident had designated an agent to act in consent or refusal of health care. For a fourth resident with dementia and osteomyelitis, transfer documentation and a Notice of Transfer or Discharge indicated a copy of the bed-hold policy was sent with the resident, and the transfer form noted the resident required a proxy for decision making. The facility’s policy required that at the time of transfer to a hospital, written notice specifying the duration of the bed-hold policy and information on return to the next available bed be provided, and that a signed and dated copy of the bed-hold notice given to the resident or representative be kept in the resident file, which was not consistently documented for these residents.
Failure to Integrate Trauma Histories and Behavioral Triggers Into Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to identify and incorporate residents’ trauma histories and specific behavioral triggers into their care plans, despite documented histories of significant trauma and behavioral health issues. For one resident, extensive social service and progress notes documented homelessness, polysubstance abuse, major depressive and anxiety disorders, chronic pain, a history of severe car accidents with multiple fractures, viral encephalitis resulting in a three‑month coma, loss of child custody, multiple divorces, physical abuse by a spouse, the death of a fiancé who was struck by a car while in a wheelchair, lack of family contact, and a past suicide attempt by Valium overdose. Additional documentation noted a history of rape by a brother at age eight and prior placement under direct supervision and 15‑minute checks related to suicidal ideation. Despite these documented traumatic events and behavioral health concerns, the resident’s care plans did not identify a history of physical trauma, sexual trauma, homelessness, substance abuse, medical trauma, or attempted suicide. For this same resident, the MDS showed no cognitive deficit and identified behaviors such as verbal aggression and rejection of care, along with diagnoses including seizure disorder, depression, chronic pain syndrome, homelessness, and anxiety disorder. Multiple care plans addressed behaviors such as drug‑seeking, pretending to have seizures for attention or medication, making false allegations, verbal aggression when unable to smoke, and a desire for intimate relationships with consenting male residents. These care plans referenced goals such as effective coping skills, seeking staff support, and compliance with the smoking policy, and they called for identification and reduction of behavioral triggers. However, none of these care plans actually listed any specific triggers. The care plan addressing the resident’s right to consensual intimate relationships focused on assessment and education regarding consent but did not integrate the resident’s extensive trauma history. Staff interviews indicated the resident had displayed sexual behaviors since admission, including an incident where the resident expressed anger at another resident for not buying a soda after engaging in sexual acts. A second resident with a documented history of traumatic brain injury (TBI), dementia, seizure disorder, borderline personality disorder, anxiety, intermittent explosive disorder, tobacco use, and other behavioral/emotional disorders was also affected by the same deficiency. Social history and progress notes documented that this resident sustained a TBI after being hit by a semi‑truck while riding a bicycle at age 18, resulting in an 11‑month coma, followed by 13 years in a state hospital and subsequent residence in a group home. Additional documentation indicated the resident allegedly shot their father at age 26 after being sworn at and had a PASRR identifying TBI, intermittent explosive disorder, and borderline personality disorder, with a specific trigger of hearing the name of the current U.S. President. Progress notes also described inappropriate sexual behavior toward staff, including touching themselves intimately during personal care and refusing to stop when redirected. Despite this, the resident’s care plans, which addressed explosive disorder and history of altercations, risk for decreased psychosocial well‑being, and refusal to bathe or shower, did not list any specific behavioral triggers, did not reference the traumatic events such as being hit by a truck or shooting their father, and did not document the inappropriate sexual behavior. The Administrator and Social Service Director acknowledged that residents were to be screened for trauma and that trauma responses and PTSD should be added to care plans, but the specific trauma histories and triggers for these two residents were not incorporated into their plans of care.
Failure to Assess and Care Plan for Resident Suicidal Ideation
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, investigate, and care plan for a resident’s suicidal ideation in accordance with its own policy and staff expectations. The resident had diagnoses including schizophrenia, cerebral edema, and hemiparesis/hemiplegia following a cerebral infarction, and a current MDS showed mild cognitive impairment (BIMS score 12). A progress note documented that the resident told the Social Services Director (SSD) he was feeling down and wanted to kill himself; the SSD offered assistance, activities, and initiated 15‑minute checks, and the note stated the care plan was updated. However, the note did not indicate that the SSD asked whether the resident had a plan to kill himself, and there were no additional notes regarding suicidal ideation or follow‑up. Review of the current care plan showed no problem, goal, or interventions addressing depression or suicidal ideation, and progress notes over the following month contained no documentation of physician notification related to the suicidal statement. Further record and interview evidence showed that the care plan conference summary did not document interventions for suicidal ideation, and the SSD acknowledged she did not normally ask residents expressing suicidal ideation if they had a plan. The SSD reported that the resident had admission paperwork mentioning suicidal ideation related to depression after a stroke and that the resident again vocalized suicidal ideation during a care plan meeting with his father, after which emotional support was offered and the father took the resident out on a leave of absence; no further visits or follow‑up were done. The DON stated that, upon notification of suicidal verbalization, staff should assess the resident, ask if there is a plan, remove potential means of self‑harm, immediately notify the psychiatric NP, and document the occurrence, and that a detailed progress note and updated care plan were expected but not present for this resident. The Administrator similarly stated that staff should ask about a plan, document interventions, notify the physician and family, and update the care plan, and indicated the resident should have had a care plan addressing depression with suicidal ideation. The facility’s written policy required immediate notification of the DON, SSD, and physician, an interview including asking about a plan and assessing mood and means for self‑harm, and thorough documentation of mood, behavior, and all actions taken, which were not reflected in the resident’s record.
Incomplete and Inaccurate Documentation of Suicidal Ideation and Follow-Up
Penalty
Summary
The facility failed to ensure accurate, complete, and timely documentation of assessments and services for a resident who verbalized suicidal ideation. Resident 6, who had schizophrenia, cerebral edema, and right-sided hemiparesis/hemiplegia following a cerebral infarction, had a BIMS score of 12 indicating mild cognitive impairment. The resident’s admission paperwork mentioned suicidal ideation related to depression after a stroke, and a Social Services note on 3/11/2026 documented that the resident was feeling down and said he wanted to kill himself. The Social Services Director (SSD) documented that she talked with the resident, coordinated with Activities, advised the resident to contact SSD or nursing if he wanted to talk, and that the resident was scheduled for 15-minute checks and the care plan was updated. However, the current care plan initiated on 2/26/2026 did not address depression or suicidal ideation. Multiple Social Services progress notes were later entered as late entries in April, with effective dates in March, stating that the resident had no plan and no longer had suicidal ideation, that he felt much better after 1:1 time, and that he continued his daily routine and therapy. These late entries described follow-up visits and reassessments of suicidal ideation on several consecutive days, but in interviews the SSD stated she did not normally ask residents about having a plan when they verbalized suicidal ideation and did not recall any other occurrences beyond the initial event. She further indicated she did not personally provide individual follow-up visits with this resident regarding suicidal ideation, despite the late-entry notes describing such visits. The DON acknowledged that late entries had been added to address concern about suicidal verbalization, and the Administrator stated that upon suicidal statements staff should ask about a plan, notify the physician and family, and update the care plan, and that this resident should have had a care plan addressing depression with suicidal ideation. The facility’s documentation policy required factual, first-hand, timely documentation, which was not followed in this case.
Failure to Complete Required Self-Administration Assessment for Inhaler Kept at Bedside
Penalty
Summary
Surveyors identified that a resident was allowed to keep and access an Albuterol inhaler without the facility completing the required self-administration medication assessment. During an initial tour, the resident was observed sitting in a wheelchair with a handheld Albuterol inhaler on the overbed table and no staff present in the room or hallway. On a subsequent observation, the resident again was in a wheelchair and reported that the Albuterol inhaler was stored in the top drawer of the nightstand, where it was found. Review of the clinical record showed an admission MDS indicating no cognitive impairment, but there was no documentation of a self-medication administration assessment. In an interview, the DON confirmed that the resident did not have the required self-medication assessment, despite the facility’s policy stating that staff and the practitioner must assess each resident’s mental and physical abilities to determine whether self-administering medications is clinically appropriate. This failure to complete and document a self-administration medication assessment for a resident who had an Albuterol inhaler kept at bedside constituted noncompliance with the facility’s own policy and with 410 IAC 16.2-3.1-11(a).
Inaccurate PBJ Staffing Data Submission to CMS
Penalty
Summary
The deficiency involves the facility’s failure to electronically submit complete and accurate direct care staffing information to CMS through the Payroll-Based Journal (PBJ) system for 22 days in a fiscal quarter. A CASPER report review on 4/6/26 showed that, according to PBJ data, the facility did not have licensed nursing coverage 24 hours per day on multiple specific dates across three months, had low weekend staffing, and held a 1-star staffing rating. However, review of the facility’s internal staffing sheets for that quarter indicated the facility was fully staffed and had licensed nurse coverage on all of the dates in question. During an interview, the Administrator stated that the PBJ information must have contained data entry errors, as she had verified licensed staff coverage on the timesheets. The facility’s PBJ policy in effect stated that all staffing data entered into the PBJ system would be auditable and verifiable through payroll, invoices, or contracts, but the submitted PBJ data did not accurately reflect the facility’s actual licensed nurse staffing as documented on internal records. No specific residents or clinical conditions were mentioned in the report, and the deficiency centers solely on inaccurate staffing data submission rather than direct resident care events.
Failure to Provide and Document Required Transfer/Discharge and Bed-Hold Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide and document required written notices of transfer/discharge and bed-hold policies, as well as required information to receiving providers, for four residents who were transferred or discharged to the hospital. For a resident with generalized anxiety disorder, major depressive disorder, and dementia, progress notes showed that the resident was sent to the hospital via 911 for chest pain, lower back pain, and shortness of breath and later returned to the facility, but the clinical record lacked documentation that a written Notice of Transfer/Discharge and the bed-hold policy were provided to the resident or representative, and lacked documentation that required information was conveyed to the receiving facility. The ADON and the Administrator both confirmed there was no documentation that these written notices were provided. For a resident with congestive heart failure and muscle weakness who was sent to the emergency room for painful urination and bloody urine, the clinical record lacked documentation that a Notice of Transfer/Discharge or bed-hold policy was given to the resident or representative, which the DON confirmed. Another resident with chronic respiratory failure and diabetes was discharged to the hospital for respiratory failure, and a resident with chronic kidney disease and dementia was discharged to the hospital, but in both cases there was no documentation that a written notice of transfer/discharge or bed-hold policy was provided to the residents or their representatives. Review of the facility’s Transfer and Discharge policy, dated 1/15/26, showed that the policy required the facility to provide written transfer/discharge notices and bed-hold information to residents and representatives and to provide specified information to receiving providers, but the records for these four residents did not contain the required documentation.
Failure to Document Target Behaviors and Non-Pharmacological Interventions Before Initiating Antipsychotic
Penalty
Summary
The deficiency involves the facility’s failure to document how a resident’s behaviors presented danger or distress to self or others, and failure to document non-pharmacological interventions attempted prior to initiating an antipsychotic medication. Resident 6 had documented diagnoses of Alzheimer’s disease, depression, and severe cognitive impairment, and was receiving sertraline for depression. A PASSAR identified only depression and dementia, and the admission MDS listed Alzheimer’s disease and depression as active diagnoses. Over several months, nursing progress notes documented that the resident intermittently reported unusual perceptions, such as believing there were men causing trouble, a man in her room, or a man wanting to marry her and yelling through the walls, but there was no documentation that these episodes caused danger to the resident or others or that they resulted in unmanageable distress. From late April through mid-July, nursing notes primarily described the resident’s frequent refusals of evening and morning medications, blood sugar checks, blood pressure checks, insulin administration, hygiene care, and showers. Staff documented that the resident sometimes yelled at staff, said “Get out!”, was visibly upset by a room move, was leery of staff and asked to see name badges, and became upset about a pillow under her head until it was removed, after which she calmed down. The notes also recorded instances where the resident believed housekeeping had not cleaned her room or that she had not received medications when she had. However, there were no progress notes or assessments indicating that these behaviors were evaluated as dangerous, non-redirectable, or causing significant distress or functional impairment, and no detailed behavior monitoring logs were present as required by facility policy. On a psychiatric NP visit for initial psychotropic medication management, new mental health diagnoses of schizoaffective disorder, borderline personality disorder, and delusional disorder were added, and Seroquel 25 mg, an antipsychotic, was ordered. The clinical record did not contain a comprehensive evaluation to support these new diagnoses, and there was no documentation of target behaviors meeting the facility’s policy criteria for psychotropic use, such as behaviors representing danger to self or others, causing distress and impairment in functional abilities, or clearly attributable to psychosis or mania. The resident’s representative reported that the resident had no prior history of mental health disorders or psychiatric hospitalization and was unaware of the new diagnoses. The facility’s own psychotropic medication policy required identification and documentation of specific target behaviors, use and documentation of nonpharmacological interventions, and ongoing monitoring of behaviors and interventions, which were not reflected in the record for this resident.
Failure to Update PASARR Screens for New Mental Health Diagnoses and Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that Preadmission Screening and Resident Review (PASARR) Level I screenings were accurate and updated when new mental health diagnoses and psychoactive medications were initiated for multiple residents. For one resident with dementia, anxiety, depression, and post-traumatic stress disorder (PTSD), the PASARR completed on admission listed anxiety, depression, and dementia with sertraline and quetiapine, but did not include the PTSD diagnosis or the antidepressant Pristiq, despite the admission MDS and care plan documenting PTSD and a subsequent physician’s order for Pristiq. For another resident with Alzheimer’s disease, borderline personality disorder, delusional disorder, schizoaffective disorder, and depression, the PASARR only reflected depression and dementia with sertraline, even though additional mental health diagnoses were added later and an antipsychotic (quetiapine) was ordered for borderline personality disorder, and the quarterly MDS documented psychotic disorder, schizophrenia, and depression with antipsychotic and antidepressant use. A third resident had diagnoses including Alzheimer’s disease, depression, anxiety disorder, irritability and anger, and nonrheumatic aortic valve stenosis. The PASARR for this resident listed dementia and anxiety with Risperdal but omitted the diagnosis of depression and the medications escitalopram and lorazepam, although physician’s orders were in place for escitalopram for depression and lorazepam for anxiety, and the admission MDS documented depression with antianxiety and antidepressant use. Interviews with the Assistant Director of Nursing confirmed that new Level I PASARR screens should have been completed when new mental health diagnoses and psychoactive medications were added, and that the PASARR for one resident, completed prior to arrival, should have included all mental health diagnoses and medications. The facility’s own policy required notification of the state mental health authority within 14 days after a significant change in mental condition and specified that a new Level I screen is required for new mental health diagnoses or newly prescribed psychotropic medications, which was not followed in these cases.
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