Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harrison Terrace during CMS and state inspections, most recent first.
A resident with dementia and delusional disorder physically assaulted another cognitively impaired resident after accusing her of taking clothing. The resident first scratched an RN, then later punched the other resident in the eye during a dining room altercation, with a CNA witnessing the resident standing over the other resident, yelling threats, and striking her twice in the face.
A resident with dementia and psychotic and mood disturbance had behavior care plans for aggression, combative behavior, threatening statements, foul language, delusional thinking, and requests for kisses by female staff, with care in pairs listed as an intervention. During observation, a CNA provided care alone and later stated she did not ask another staff member for help, despite the care-in-pairs requirement.
Surveyors found that the facility was not kept clean or in good repair, with strong urine odors in multiple units, sticky and stained floors, and resident rooms with chipped door frames, damaged walls, and worn linens. Staff and residents confirmed these issues, and used gloves and dirty items were observed on the floor.
Hand hygiene was not followed during meal service in the Mapleton dining room. An AD was observed handling silverware, touching his face, eyeglasses, and pants without observed hand hygiene, and a CNA touched her hair, a resident's clothing and napkin, then served meals and assisted a resident before using sanitizer. Sixteen residents were present, and the facility policy required hand hygiene after touching a resident, the resident's environment, self, or clothing during meal service.
A resident with dementia and osteomyelitis, who required extensive ADL assistance, was repeatedly observed unshaved and with food and dry skin on his face and beard. Despite a care plan specifying the need for help with grooming and hygiene, staff did not ensure regular face washing or shaving, and interviews indicated the resident did not refuse these services during the observed period.
A resident with dementia and severe cognitive impairment began exhibiting new behaviors involving physical contact with peers, including grabbing other residents. Despite multiple documented incidents, medication changes, and room moves, the facility did not timely develop or implement an individualized care plan addressing these behaviors, the use of psychotropic medication, or the resident's anxiety and agitation. Direct care staff were not informed of the resident's behavioral history, and the required care planning was not completed as per facility policy.
The facility failed to follow physician orders and insulin manufacturer instructions for multiple residents. One resident with dementia and osteomyelitis did not receive all ordered Cipro doses as documented, another resident with dementia and diabetes had missing blood sugar checks and lispro documentation, and an LPN was observed priming Humalog pens incorrectly before giving reduced insulin doses to two residents.
Failure to Implement Fall Interventions: A resident with dementia, repeated falls, and poor safety awareness had care-planned fall interventions after two separate falls, including keeping the wheelchair out of sight when not in use and replacing an adjustable recliner. During survey observations, the wheelchair remained visible in the room and the same adjustable recliner with a remote control was still present, despite the resident's history of attempting self-transfers and sliding from the chair while adjusting a fan.
A resident with dementia and urinary retention had an order for catheter care and for urinary output to be recorded every shift, but the MAR did not show the output each shift. Instead, output was entered in the EHR under vital signs as large, medium, or in mL amounts. An LPN stated catheter output should be documented in mL and was unsure why it was not appearing on the MAR.
Inadequate Privacy Curtains in Shared Room: Two residents in a shared room did not have privacy curtains that extended fully around the bed. An LPN and the ADON were observed providing catheter care for one resident while the curtain did not block view from the walkway, and the other resident's curtain also did not provide total visual privacy. The LPN said the wrong size curtains may have been hung, and the ADON stated the curtains should go all the way around the bed.
The facility failed to maintain cleanliness in the kitchen and on the Meridian unit, affecting all residents consuming food from the kitchen and those on the unit. Observations revealed a black substance under the dishwasher and gray substance on ceiling vents. The ice machine had a black substance inside, dust, and drainage issues. The Culinary Manager and Maintenance Supervisor acknowledged the issues, but documentation of cleaning was lacking.
The facility failed to properly contain trash for all residents. During a kitchen tour, an open dumpster with visible trash bags was observed, and the surrounding area was littered with debris, medication cups, and gloves. The Culinary Manager stated that the maintenance department is responsible for the area, while the Maintenance Supervisor admitted to not regularly checking the dumpster area.
The facility's kitchen was found to have flying insects in the dishwasher and storage areas, with a red bucket of soiled rags attracting more insects. The Culinary Manager admitted the issue had persisted for two weeks. An exterminator had previously noted small flies and recommended cleaning around drains, but a later visit reported no pest activity.
A facility failed to notify a medical provider of high blood sugar readings for a resident with diabetes and dementia. Despite a care plan and physician order requiring notification for blood sugar levels over 300, multiple instances in August 2024 showed readings above this threshold without documentation of notification. The DON confirmed the absence of such documentation.
A facility failed to complete orthostatic blood pressure measurements as ordered for a resident with hypertension, who was receiving doxazosin. The order required daily checks in lying, sitting, and standing positions, but records showed only one reading per day without position indication. The Director of Nursing confirmed the expectation for complete documentation, but the facility lacked a policy on conducting these measurements.
A resident with a history of constipation and ileus did not receive effective monitoring and care for constipation. Despite physician orders for Miralax and Dulcolax, these were not administered as needed, and abdominal assessments were not performed when the resident went without a bowel movement for several days. Facility staff showed inconsistencies in monitoring bowel movements, and the facility's Bowel Elimination policy was not followed, leading to inadequate management of the resident's condition.
A resident receiving dialysis services was not provided the therapeutic diet as ordered, including the omission of ice cream and the provision of orange juice instead of cranberry juice. The CNA assisting the resident was unaware of the dietary restrictions, and the dietary staff failed to deliver the prescribed ice cream.
Failure to Protect Resident from Physical Assault by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident F had diagnoses including dementia and delusional disorder and was documented as cognitively impaired, though she was ambulatory with a walker and had no upper or lower extremity impairments. Resident G also had dementia and was documented as cognitively impaired. Both residents were involved in an incident in the dining room when Resident F accused Resident G of stealing her clothing. According to the record, Resident F first became physically aggressive toward an RN earlier the same day by scratching the RN on the neck after asking about her clothing. Later, while Resident G was eating lunch in the dining room, Resident F approached her and accused her of taking her dress. During the altercation, Resident F punched Resident G in the left eye with a closed fist. A CNA who witnessed the event stated that Resident F was standing over Resident G, yelling that she would hit her in the mouth, and then hit Resident G twice in the face before staff intervened. Resident G was later observed in her room and stated that a girl hit her in the eye and that she had been wearing the blouse without knowing it. The investigation materials also reflected that Resident F had previously been confused about clothing in the closet and had false beliefs that the clothing belonged to her. The incident was reported as physical contact between residents, and the report identified that Resident F had exhibited physical assault toward Resident G.
Failure to Implement Care-in-Pairs Behavior Intervention
Penalty
Summary
The facility failed to ensure that a care-in-pairs intervention was implemented for a resident with dementia and psychotic and mood disturbance who had behavior care plans addressing aggression, combative behavior, threatening statements, foul language, delusional thinking, and requests for kisses by female staff. The resident’s admission MDS indicated cognitive impairment, and the behavior care plans dated 4/13/26 and 4/21/26 both included care in pairs as an intervention for behavior management. During observation on 6/2/26 at 2:33 p.m., a CNA was seen leaving a supply room, pushing the resident to his room, and closing the door; the CNA was the only staff member observed in the room with the resident. In interview at 2:40 p.m., the CNA stated she took the resident to his room to use the restroom and did not ask another staff member for assistance, even though she was supposed to provide care in pairs. She also stated the resident was always good with her and that she had not experienced the behaviors he sometimes exhibited.
Failure to Maintain Clean, Odor-Free, and Well-Repaired Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, odor-free, and well-repaired environment for residents, staff, and the public. During multiple tours and observations, strong urine odors were detected in the main entry, Meridian Hills Unit, and Mapleton Unit. The floors in the Meridian Hills Unit were found to be sticky, with a six-inch black spot present between the entrance and the nurse's station. The Mapleton Unit was also noted to have a persistent strong urine odor during several visits. Interviews with staff and residents confirmed the presence of these odors and described the floors as dirty and linens as worn with holes. Further inspection of resident rooms revealed additional deficiencies in the physical environment. Resident rooms had chipped and scratched door frames, scrapes and missing pieces on chair rails, and walls with missing paint. Used gloves and dirty items were found discarded on the floor, and bed linens were observed to have holes. The maintenance supervisor indicated that repairs were made on an as-needed basis, and work orders were submitted by staff or families when issues were noticed. The facility did not have a policy in place for maintaining a homelike environment.
Hand Hygiene Not Followed During Meal Service
Penalty
Summary
The facility failed to ensure staff were using infection control practices with hand hygiene during a dining observation in the Mapleton Dining Room. During lunch meal service, the Activities Director was observed passing out silverware by reaching inside a container and placing utensils on napkins, then touching his face and eyeglasses without any observed hand hygiene afterward. He was later observed passing out meal trays and assisting residents with beverages, and during that time he pulled up his pants without any observed hand hygiene after touching his clothing. During the same observation, a CNA was observed touching her hair braids and then touching Resident 68's shirt and cloth napkin. The CNA then touched her hair again, served a meal tray to Resident 43, placed dishes on the table, removed the coverings from the dishes, returned the tray to the meal cart, and then used hand sanitizer. The CNA later sat down with Resident 68, placed the cloth napkin she had touched earlier on the resident's chest like a bib, and assisted the resident with the meal. There were 16 residents in the dining room at the time of the observation. The Regional Director of Operations stated staff should use hand hygiene if they touch their hair and/or body prior to continuing meal service. The facility's Hand Hygiene policy stated personnel should use an alcohol-based hand rub or wash with soap and water after touching a resident or the resident's immediate environment and after touching self or clothing during meal service.
Failure to Provide Adequate ADL Assistance for Resident with Dementia
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia and acute osteomyelitis did not receive adequate assistance with activities of daily living (ADL), specifically related to face washing and shaving. The resident's care plan indicated a need for assistance with bathing, dressing, grooming, and hygiene, and noted impaired decision-making and a tendency to refuse some care. Despite this, multiple observations over several days found the resident unshaved, with dry, flaky skin and food debris on his face and beard. The resident was also noted to have red corners of the mouth and skin flakes on his shirt collar. Interviews with staff confirmed that the resident required extensive assistance with ADLs and was usually shaved on shower days, but there was no indication that he refused face washing or shaving during the observed period. Staff interviews revealed that while the resident sometimes refused certain aspects of care, such as deodorant or showers, he was not known to refuse face washing or shaving. Observations consistently showed the resident in an unkempt state, with visible hygiene concerns that were not addressed until a later intervention by the Director of Nursing Services. The failure to provide regular and necessary grooming and hygiene assistance as outlined in the care plan led to the identified deficiency.
Failure to Timely Develop and Implement Individualized Care Plan for Resident with Dementia and New Behavioral Symptoms
Penalty
Summary
The facility failed to timely develop and implement an individualized plan of care for a resident diagnosed with dementia who began displaying new behaviors involving physical contact with peers. Specifically, a resident with severe cognitive impairment and a history of anxiety and insomnia exhibited behaviors such as grabbing other residents in the dining area and in his room. These incidents were documented in the clinical record and included multiple room changes due to incompatibility with roommates, as well as episodes of overstimulation and confusion in common areas. Despite these documented behaviors and the initiation of new medications to address anxiety and agitation, the clinical record did not contain a care plan addressing the new behaviors, the use of psychotropic medication, or the resident's anxiety and agitation. The deficiency was further evidenced by the lack of communication and education among direct care staff regarding the resident's history of making physical contact with peers. Interviews with CNAs revealed that they were not informed about the resident's behavioral history, even after several incidents had occurred. The facility's own policy required that care plans be initiated for any problematic or distressing behavioral expression and when a resident is receiving psychotropic medication for mood or behavior. However, the care plan for the resident did not address the new behaviors, the use of lorazepam, or the risk of agitation and aggression with roommates. Additionally, the facility's interdisciplinary team (IDT) met and reviewed the resident's behaviors, but failed to ensure that a care plan was promptly developed and implemented to address the specific behavioral issues. The lack of a timely and individualized care plan resulted in continued incidents involving physical contact with peers, room changes, and increased supervision, without a documented, proactive approach to managing the resident's behavioral health needs as required by facility policy.
Missed antibiotic doses, incomplete diabetes documentation, and improper insulin pen use
Penalty
Summary
The facility failed to provide treatment and care according to physician orders for a resident with dementia and acute osteomyelitis of the right ankle and foot. Resident F had a care plan for impaired skin integrity with a pressure injury to the sacrum and right heel, and the plan included obtaining labs as ordered, providing treatment as ordered, and notifying the physician of wound changes or signs of infection. A wound care note documented that the heel was painful and suspected osteomyelitis, and Cipro 500 mg every 12 hours for 14 days was ordered for the right heel infection. The August 2025 MAR showed that Resident F received Cipro on some scheduled doses, but one dose was documented as unavailable from the pharmacy, and later doses were either not signed as given or documented as not given because the medication was unavailable from the pharmacy. The DNS stated that the first two doses had been removed from the emergency drug cabinet, that the resident’s supply arrived on 8/29/25 at 5:03 a.m., and she was unsure why the medication did not arrive sooner or why a later dose was not administered even though the Cipro was in the building. The facility also failed to document and administer ordered diabetes care for a resident with dementia and diabetes. Resident K had orders for blood sugar checks with meals and at bedtime and lispro insulin 5 units subcutaneously three times daily, with the dose held if blood sugar was below 70. The August 2025 MAR lacked documentation of several blood sugar checks and several lispro doses. In addition, during observations, an LPN prepared Humalog insulin for two residents by priming the pen while it was held sideways with the cap still covering the needle, then administered reduced doses of 8 units and 4 units. RN 2 stated the pen should be cleaned and primed upright with the cap off so insulin could be seen at the needle tip, and the DNS stated the facility would follow the manufacturer’s guidelines.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to ensure that care-planned fall interventions were implemented appropriately for one resident who had a history of repeated falls, non-Alzheimer's dementia, and depression. The resident was cognitively intact, used a wheelchair, required staff supervision or touch assistance when walking, and had experienced two or more falls without injury and one fall with injury since the last assessment. After a fall in which the resident attempted to self-transfer from bed to wheelchair, the interdisciplinary team determined the root cause was the resident's impulsive behavior and poor safety awareness, and the care plan was updated to keep the wheelchair out of sight when not in use. After a later witnessed fall in which the resident slid to the floor while adjusting her fan from a recliner, the interdisciplinary team determined the root cause was the resident trying to adjust the fan. The care plan was updated to have the family bring in a recliner that could not be adjusted to the point that the resident could slide out. During observations, however, the resident's wheelchair remained visible in her room rather than being out of sight, and the same adjustable recliner with a remote control was still present in the room. A nurse confirmed the recliner had not been replaced and that the wheelchair was usually moved out of the room at night, then moved the wheelchair into the hallway.
Inaccurate Documentation of Urinary Output for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to accurately document urinary output for a resident with an indwelling urinary catheter. Resident 49 had diagnoses including dementia and retention of urine, and a quarterly MDS completed on 8/7/25 indicated severe cognitive impairment. A physician’s order dated 8/28/25 directed catheter care and required nursing staff to record urinary output every shift. Review of the August and September 2025 MAR showed no documentation of Resident 49’s urinary output each shift. Instead, urinary output was documented in the EHR under vital signs with entries such as large, medium, and specific milliliter amounts across multiple shifts from 8/29/25 through 9/8/25. During interview, an LPN stated urinary output from an indwelling catheter should be documented in milliliters and that the electronic MAR prompts the nurse to enter the output, but she was unsure why the output was not showing on the MAR. The Regional Nurse Consultant provided the facility’s Bowel and Bladder Program Policy, which stated urinary output from indwelling urinary catheters will be documented.
Inadequate Privacy Curtains in Shared Room
Penalty
Summary
The facility failed to provide privacy curtains that extended completely around the bed in a shared room for two residents observed for privacy. Resident 49 had diagnoses including dementia and retention of urine, and Resident 16 had a diagnosis including dementia. During observation, Licensed Practical Nurse 12 and the Assistant Director of Nursing were providing urinary catheter care for Resident 49 while the privacy curtain was drawn between the two residents, but Resident 49's curtain did not go around the entirety of the ceiling track and did not block view from the room walkway leading to the bathroom. Resident 16's privacy curtain also did not extend the full length of the track and did not provide total visual privacy for the bed. During interview, LPN 12 stated the wrong size privacy curtains may have been hung in the room, and the ADON stated the privacy curtains should go all the way around the bed. The Administrator provided a Privacy Curtains Policy stating that routine visual inspections should ensure curtains are hung properly and that the curtain shall provide adequate privacy to the resident.
Facility Fails to Maintain Cleanliness in Kitchen and Ice Machine
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen and on the Meridian unit, which had the potential to affect all residents consuming food from the kitchen and those residing on the Meridian unit. During observations, a black substance was found on the flooring under the dishwasher, and gray substance was noted on the ceiling vents in the food prep area. The Culinary Manager acknowledged the issue and mentioned the use of a power washer to address the black substance, but was unsure about the last cleaning of the ceiling vents. The cleaning schedules indicated regular cleaning tasks, but the Interim Administrator could not provide documentation of the last cleaning of the ceiling vents. Additionally, the ice machine on the Meridian unit was found with a black substance inside the ice bin, dust, and dried reddish droplets on its outer surfaces. A towel was placed on the floor due to drainage issues. The Maintenance Supervisor stated that the ice machine was last cleaned in July 2024 and was scheduled for quarterly maintenance. However, the machine's condition suggested more frequent cleaning might be necessary. The manufacturer's instructions recommended de-scaling and sanitizing every six months, but the current state of the machine indicated it might require more immediate attention.
Improper Trash Containment
Penalty
Summary
The facility failed to ensure proper containment of trash for all 70 residents. During a kitchen tour with the Culinary Manager, it was observed that one of the outside dumpsters had a sliding side door open, with trash bags visible inside. The area around the dumpsters and along the fence line in the parking lot was littered with paper, plastic debris, medication cups, and gloves. The Culinary Manager acknowledged that the sliding doors should be closed and stated that the maintenance department is responsible for maintaining the area around the dumpsters and the grass. An additional observation with the Maintenance Supervisor confirmed the presence of plastic bottles, paper product debris, medication cups, gloves, plastic silverware, food wrappers, and cups in the dumpster area and grass along the fence. The Maintenance Supervisor admitted that the maintenance department is responsible for the grounds but does not regularly check the area around the dumpsters.
Presence of Flying Insects in Kitchen Area
Penalty
Summary
The facility failed to maintain a pest-free kitchen environment, as evidenced by the presence of flying insects in the kitchen area. During an observation with the Culinary Manager, flying insects were noted in the dishwasher and storage areas. Additionally, a red bucket containing soiled rags was observed with flying insects on top, and when the Culinary Manager removed the rags, more insects were seen flying from the bucket. The Culinary Manager acknowledged that the insects had been present for at least two weeks and admitted that the rags should not have been left in the bucket. An exterminator service visit on 6/4/24 had previously noted small flies in the dishwasher area and recommended frequent cleaning around drains to prevent pest breeding sites. However, a subsequent exterminator visit on 8/5/24 reported no rodent or insect activity.
Failure to Notify Medical Provider of High Blood Sugar Readings
Penalty
Summary
The facility failed to notify the medical provider of blood sugar readings exceeding the specified parameters for a resident with diabetes mellitus and dementia. The care plan for the resident, dated March 15, 2021, indicated a risk for adverse effects of hyperglycemia or hypoglycemia due to glucose-lowering medication and insulin dependency. A physician order from May 20, 2021, required staff to notify the medical provider if the resident's blood sugar was greater than 300 or less than 70. Despite this, the Medication Administration Record for August 2024 showed multiple instances where the resident's blood sugar exceeded 300, specifically on August 1, 7, 10, and 11, without any documentation of the medical provider being notified. An interview with the Director of Nursing confirmed the lack of documentation for notifying the medical provider on these dates.
Failure to Complete Orthostatic Blood Pressure Measurements
Penalty
Summary
The facility failed to complete orthostatic blood pressure measurements as per the physician's order for a resident diagnosed with chronic kidney disease, generalized anxiety disorder, and hypertension. The resident was receiving doxazosin, a medication known to cause orthostatic hypotension in older adults, and there was a recommendation to consider discontinuing it. The physician's order required daily orthostatic blood pressure checks before medication administration for 14 days, with specific instructions to notify a medical professional if the systolic blood pressure was outside the specified range. However, the medication administration record showed only one blood pressure reading per day without indicating the position (lying, sitting, or standing) for several days. The clinical record lacked orthostatic blood pressure readings for certain days, and some entries were recorded as late entries. The Director of Nursing confirmed that the expectation was to perform and document blood pressure checks in all three positions, but the facility did not have a policy on conducting orthostatic blood pressures. This oversight in following the physician's order and documenting the required measurements led to the deficiency identified in the report.
Failure to Manage Constipation in Resident with History of Ileus
Penalty
Summary
The facility failed to provide effective monitoring, assessment, and care for a resident with a history of constipation, partial bowel obstruction, and ileus. Resident B, who was always incontinent of bowel and bladder, required maximum assistance for toileting. The resident had physician orders for Miralax and Dulcolax suppositories to be administered as needed for constipation, but the orders lacked specific frequency instructions. Despite a care plan indicating the need for abdominal assessments and physician notification if no bowel movement occurred after three days, these interventions were not consistently implemented. From early February to late March, Resident B experienced multiple episodes of constipation, with no bowel movements recorded for several consecutive days on multiple occasions. During these periods, the prescribed laxatives were not administered as per the physician's orders and the care plan. Additionally, there was no documentation of abdominal assessments or physician notifications when the resident went without a bowel movement for four or more days. Interviews with facility staff revealed inconsistencies in how bowel movements were monitored and reported, with some staff not counting small bowel movements in their assessments. The facility's Bowel Elimination policy outlined procedures for monitoring and addressing constipation, including administering laxatives after three days without a bowel movement and conducting abdominal assessments if no results were achieved by the fourth day. However, these procedures were not followed for Resident B, leading to a deficiency in the care provided. The lack of adherence to the policy and care plan resulted in inadequate management of the resident's constipation, as evidenced by the failure to administer prescribed medications and perform necessary assessments.
Failure to Provide Therapeutic Diet for Dialysis Resident
Penalty
Summary
The facility failed to provide a therapeutic diet as ordered for a resident receiving dialysis services, identified as Resident 31. The resident, who has diagnoses including dementia and end-stage renal disease, was observed during breakfast without the prescribed ice cream and was given orange juice instead of cranberry juice. The care plan for the resident, dated back to 2018, specified dietary restrictions including no orange juice and the inclusion of ice cream with every meal. However, during the observation, the Certified Nurse Aide (CNA) assisting the resident was unaware of these dietary requirements and allowed the resident to consume orange juice. Further investigation revealed that the dietary staff forgot to send the ice cream to the resident, as confirmed by the Culinary Manager. The Licensed Practical Nurse (LPN) on duty noted that the CNA was new to the unit and unaware of the resident's specific dietary needs. The facility's diet orders policy emphasizes the importance of providing liberalized diets tailored to each resident's medical condition, needs, and rights, but this was not adhered to in the case of Resident 31.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brickyard Healthcare - Brookview Care Center | 0.5 mi | ★★★★★ | 9 | 0 |
| Wildwood Healthcare Center | 0.6 mi | ★★★★★ | 11 | 0 |
| Arlington Place Health Campus | 1.8 mi | ★★★★★ | 11 | 0 |
| Miller's Merry Manor | 1.9 mi | ★★★★★ | 0 | 0 |
| Community Nursing And Rehabilitation Center | 2.2 mi | ★★★★★ | 17 | 0 |
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