Pinnacle Health & Rehab At Sanford
Inspection history, citations, penalties and survey trends for this long-term care facility in Sanford, Maine.
- Location
- 1142 Main St, Sanford, Maine 04073
- CMS Provider Number
- 205082
- Inspections on file
- 18
- Latest survey
- February 26, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Pinnacle Health & Rehab At Sanford during CMS and state inspections, most recent first.
The facility failed to develop comprehensive care plans for several residents, lacking specific interventions for ADLs such as eating, hygiene, and mobility. Changes in assessments and a new EMR system contributed to the oversight, as confirmed by staff interviews.
The facility failed to ensure that two authorized staff members signed the Shift Count page for controlled substances at shift changes, as required by policy. This deficiency was observed in both the Second and First Floor Medication Rooms, with missing signatures on multiple dates, indicating a lack of adherence to the established procedure for controlled substance counts.
The facility failed to store vaccines according to CDC guidelines, using a dormitory-style refrigerator in the First Floor Unit's Medication Room. This refrigerator, which is not recommended for vaccine storage, contained vials of purified protein derivative and unit dose syringes of pneumococcal and influenza vaccines. The issue was confirmed by the charge nurse and Infection Preventionist.
The facility was found to have environmental deficiencies, including a need for wall repair in a resident's room, tape hanging from the dining room ceiling, dark spots on ceiling strapping in a common area, and an unpainted repaired area in the Spa room on the first floor. Additionally, a stained ceiling tile was observed outside a resident's room on the second floor. These issues were noted during a survey and discussed with the Administrator.
A facility failed to maintain complete and accurate clinical records for a resident with Parkinson's disease, who requires total care for ADLs. The care plan specified oral hygiene after meals and toileting every 3-4 hours, but documentation showed these tasks were not consistently performed. Staff interviews confirmed the resident's dependency, and the administrator acknowledged the findings.
A facility failed to implement the care plan for a resident with Parkinson's disease, who is dependent on staff for all ADLs. The care plan included interventions such as assistance with ADLs, oral hygiene, toileting, and repositioning, but the clinical record lacked evidence of these being completed. A CNA confirmed the resident's need for total care and the protocol for refusals, while the administrator acknowledged the deficiency during a record review.
The facility failed to maintain a sanitary environment in a shared room, where personal hygiene items were found unlabeled and available for use on a shared sink. A resident confirmed using these items without knowing their ownership, while another resident's family retrieves items for them. An LPN and a surveyor confirmed the presence of these unlabeled items during an inspection.
Deficiency in Comprehensive Care Plans for ADLs
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for several residents, specifically in the area of Activities of Daily Living (ADLs). The care plans for six residents lacked specific interventions needed to assist them in various ADL areas such as eating, personal hygiene, transfers, dressing, bathing, toileting, bed mobility, and ambulating. This deficiency was identified during a review of the residents' care plans, which did not include personalized assistance required for each resident to attain or maintain their highest practicable quality of life. The issue was partly attributed to changes in the Minimum Data Set assessments for GG - Functional Abilities, which were not properly updated in the residents' care plans. Additionally, the transition to a new Electronic Medical Record system failed to automatically transfer necessary information, requiring manual updates that were not completed. These oversights were confirmed through interviews with the Licensed Practical Nurse Manager, the Director of Nursing, and the Unit Director, who acknowledged the deficiencies in the care plans.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs, as required by their Shift Count policy and procedure. The policy, dated 2/3/2000, mandates that all Schedule II-V medications be counted at the change of each shift by both the off-going and on-coming nurse, with both required to sign the shift count sheet if the count is correct. However, during a survey conducted on 2/11/25, it was observed that on multiple occasions, neither the nurse coming on duty nor the nurse going off duty signed the Shift Count page of the Controlled Substances Book, indicating that the controlled substances count was completed. This issue was identified on both the Second Floor and First Floor Medication Rooms. The surveyor confirmed these findings with the Unit Manager and Charge Nurse, noting that the lack of signatures occurred on several dates across both units. The specific dates where signatures were missing include 6/16/24, 9/13/24, 10/2/24, 10/3/24, 11/3/24, 11/6/24, 11/16/24, 11/23/24, 12/2/24, 12/12/24, 12/29/24, 1/3/25, 1/18/25, 1/24/25, 1/25/25, 1/26/25 (both units), 1/27/25, 2/9/25, and 2/10/25. This failure to adhere to the established procedure for controlled substance counts was confirmed through record reviews, observations, and interviews with facility staff.
Improper Vaccine Storage in Dormitory-Style Refrigerator
Penalty
Summary
The facility failed to ensure proper storage of vaccines in accordance with the Centers for Disease Control and Prevention (CDC) guidelines. During an observation of the First Floor Unit's Medication Room, a surveyor identified a dormitory-style refrigerator being used to store vaccines, which is against CDC recommendations. The refrigerator contained vials of purified protein derivative for tuberculosis testing and unit dose syringes of pneumococcal and influenza vaccines. This finding was confirmed by the charge nurse and the Infection Preventionist, and later discussed with the Administrator.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment on both the first and second floors. On the first floor, a resident's room had a wall behind a chair that required repair, and the main dining room had many pieces of tape hanging from the ceiling. Additionally, the first-floor common area had several dark spots on the ceiling strapping, and there was an unpainted repaired area on the wall in the Spa room. On the second floor, a stained ceiling tile was observed just outside a resident's room. These observations were made during a survey conducted on February 12, 2025, and were discussed with the facility's Administrator at approximately 10:00 a.m. on the same day.
Incomplete Clinical Records and ADL Care Deficiency
Penalty
Summary
The facility failed to ensure that clinical records for a resident were complete and contained accurate information, as required by professional standards. During a complaint investigation, it was found that the facility did not document the provision of oral hygiene and denture cleaning for a resident with Parkinson's disease, who is dependent on staff for all activities of daily living (ADLs). The care plan specified that oral hygiene should be performed after each meal and at bedtime, but there was a lack of documented evidence that this care was provided on numerous occasions throughout September 2024. Additionally, the facility did not adhere to the care plan's requirements for toileting and repositioning the resident. The care plan indicated that the resident should be toileted every 3-4 hours and turned or repositioned every two hours. However, records showed that the resident was toileted and repositioned far less frequently than required. Interviews with staff confirmed the resident's need for total care with ADLs, and the facility administrator acknowledged the findings during a review of the clinical record.
Failure to Implement ADL Care Plan for Resident with Parkinson's
Penalty
Summary
The facility failed to implement the interventions outlined in the care plan for a resident with Parkinson's disease who is dependent on staff for all Activities of Daily Living (ADL) needs. The resident's care plan, updated on August 27, 2024, included specific interventions such as staff assistance with ADLs, oral hygiene and denture cleaning after each meal and at bedtime, toileting or changing every 3-4 hours, and turning and repositioning every two hours. However, a review of the resident's clinical record revealed a lack of evidence that these interventions were completed as written. A complaint was received by the Department of Licensing on September 13, 2024, indicating that ADL care was not being provided as stated in the care plan. During an interview, a Certified Nursing Assistant (CNA) confirmed that the resident requires total care for all ADLs and mentioned the protocol for handling resident refusals, which includes reapproaching and documenting refusals. The facility's administrator confirmed the findings during a review of the resident's clinical record with a surveyor, highlighting the deficiency in implementing the care plan interventions.
Inadequate Labeling of Personal Hygiene Items in Shared Room
Penalty
Summary
The facility failed to maintain a sanitary environment in room [ROOM NUMBER], as observed during a survey. The shared sink in the room contained multiple personal hygiene items that were unlabeled and available for use, including deodorant bottles, body wash, mouthwash, shaving cream, an opened can of ginger ale, an electric razor, several razors held together with a rubber band, a soiled basin, and a toothbrush in a paper cup. Resident 3 confirmed that they use the items on the sink but are unsure of ownership due to the lack of labeling. Resident 2 mentioned that their family retrieves personal items for them from the shared sink. An LPN, along with a surveyor, confirmed the presence of these unlabeled items during an inspection. The deficiency was discussed with the Administrator.
Latest citations in Maine
Surveyors found a soiled utility closet with a malfunctioning keypad lock left unsecured on a unit where residents with cognitive impairment reside. Inside the closet, staff stored multiple hazardous chemical products, including disinfectants and moisture absorbers, whose SDS instructions call for immediate and specific first aid in cases of skin or eye contact or ingestion. CNAs on the unit acknowledged the door should have been locked due to the hazardous nature of the chemicals and the cognitive status of residents, but they were unsure how long the lock had been inoperable.
Two residents did not receive medications according to physician orders and facility expectations. One resident with PNA, COPD, and an upper respiratory infection lacked timely access to ordered Acetylcysteine and did not receive Ipratropium-Albuterol and Doxycycline doses as ordered, despite Doxycycline being available in the PIXUS automated dispensing system and the DON’s expectation that nurses use PIXUS when medications are needed before pharmacy delivery. Another resident with HTN received Metoprolol Tartrate even though the recorded BP was below the ordered hold parameter, and the DON confirmed the dose should have been held.
Staff failed to protect the confidentiality of resident health information when assignment sheets containing personal medical details were left face up and unattended on treatment and medication carts. On two separate occasions, assignment sheets listing multiple residents’ medical information were observed on unattended carts in a unit hallway, visible and easily accessible to residents, visitors, and other unauthorized individuals while various staff, ambulatory residents, and family members were nearby. An LPN later acknowledged that such assignment sheets should not be left in the open, and the issue was brought to the DON.
A resident was transferred and admitted to an acute hospital following a facility-initiated transfer/discharge, but the clinical record contained no written bed-hold notice or transfer/discharge notice to the resident or legal representative. This omission, affecting 1 of 3 sampled residents with such transfers, was confirmed by the DON during record review and interview.
A resident who experienced difficulty breathing was transferred to the ER and subsequently admitted to the hospital, but the clinical record contained no evidence that the physician was notified of this significant change in condition or of the transfer. Facility policy requires consultation with the healthcare provider and documentation of physician and family notification in the EHR when a decision is made to transfer or discharge a resident. The DON confirmed there was no documentation in the electronic record showing that the physician had been notified.
A resident with MDD, anxiety, PTSD, and intact cognition, who was primarily bedbound and usually received bed baths, experienced bowel incontinence and declined a shower, requesting a bed bath and to speak with the unit manager. The unit manager was not informed of this request. After the charge nurse confirmed with leadership that there were no contraindications to a shower, the charge nurse and a CNA used a mechanical lift to place the resident on a shower chair, covered the resident with bath blankets, and transported the resident to the shower room. Despite the resident expressing fear, stating they did not feel like a shower, and later reporting crying and repeatedly saying they did not want a shower, staff proceeded with the shower. This conflicted with the resident’s expressed wishes and the facility’s policy on the right to refuse treatment, dignity, and reasonable accommodation of individual needs and preferences.
A resident admitted with a fractured leg and chronic hip and knee pain reported requesting pain medication shortly after arrival, but staff stated they were waiting for pharmacy access to the Cubex machine and the resident did not receive ordered PRN oxycodone until about eight hours later, despite a documented pain score of 6. Record review showed an active hospital discharge order for oxycodone 5 mg PO q4h PRN, but there was no documentation that staff contacted a physician for alternative pain orders or implemented non-pharmacological pain interventions such as repositioning or distraction. The DON confirmed there was no evidence of these interventions or physician contact while waiting for Cubex access.
Surveyors found that the facility did not provide required written bed-hold and transfer/discharge notices to two residents or their legal representatives when the facility initiated transfers to an acute hospital, and did not complete required discharge summaries for two discharged residents. In multiple instances, records lacked any documentation of bed-hold notices or transfer/discharge notices, and for discharged residents, there was no recapitulation of stay, no documented discharge instructions, no medication reconciliation, and no recorded follow-up appointments or therapy recommendations.
The facility failed to keep provider orders current and organized by not discontinuing inactive or outdated orders for two residents. One resident was observed receiving O2 at 1.5 L/min via nasal cannula while the active orders still listed three separate O2 orders at 2 L/min, including PRN and continuous orders for SOB and to maintain O2 saturation at 90%. Another resident had been discharged from hospice and had the hospice care plan resolved, yet active orders still included a referral to a named hospice and a referral for evaluation and treatment for palliative care for pain management. These issues were confirmed on review by regional clinical leadership.
The facility did not investigate staff-reported allegations of abuse and neglect despite having a policy requiring investigation of all possible incidents. A staff member submitted a written statement to the DON reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and another unsigned statement reported that a resident appeared scared and that a staff member was rough and mean. In interviews, the DON and the Administrator acknowledged that no investigations were completed and no evidence of investigative activity could be produced regarding these allegations.
Unsecured Soiled Utility Closet Containing Hazardous Chemicals
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when, during an environmental tour, a soiled utility closet on the Somerset unit was found unlocked despite being equipped with a keypad locking mechanism. Inside the unlocked closet, surveyors observed multiple chemical products stored on a shelf, including Tropiclean, Virex TB Ready-To-Use Disinfectant Cleaner, Hang [NAME] Plus Clinging Disinfectant Bowl Cleaner, and Damp Rid Moisture Absorbers. Staff present at the time, including two CNAs, reported that the keypad lock had not been functioning properly and were unable to state how long it had been inoperable. They acknowledged that the door should have been secured because of the hazardous chemicals stored inside and the presence of residents with cognitive impairment on the unit. The Safety Data Sheets (SDS) for each of the chemicals in the unlocked closet described the need for immediate and specific first aid measures in the event of skin contact, eye contact, or ingestion, including flushing skin or eyes with water for extended periods, removing contaminated clothing, not inducing vomiting unless directed, and seeking medical or poison control advice. These documented properties of the chemicals, combined with the unsecured storage area and the known presence of cognitively impaired residents on the unit, formed the basis of the cited deficiency for failing to ensure hazardous chemicals were properly secured and the environment was free from accident hazards.
Failure to Provide Timely Respiratory Medications and Follow Cardiac Medication Parameters
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered respiratory and antibiotic medications in a timely manner and to follow physician orders for cardiovascular medication parameters. For one resident with pneumonia (PNA), COPD, and an upper respiratory infection, physician orders included Acetylcysteine inhalation solution as needed every 6 hours for PNA, Ipratropium-Albuterol solution four times daily for COPD, and Doxycycline Monohydrate capsules twice daily for an upper respiratory infection. Record review showed no evidence that Acetylcysteine was available or administered from the initial order date through the date it was discontinued and reordered, and that the Ipratropium-Albuterol solution was not administered per provider orders upon admission. The resident was sent to the emergency room for difficulty breathing and returned the next day. The MAR/TAR also showed that the noon dose of Ipratropium-Albuterol and the nighttime dose of Doxycycline were not given until after the resident’s return, despite Doxycycline 50 mg capsules being available in the facility’s PIXUS automated dispensing system. The DON stated that nurses are expected to use PIXUS when medications are needed before pharmacy delivery and acknowledged that two 50 mg capsules should have been used to provide the ordered evening dose. For another resident with hypertension (HTN), a physician ordered Metoprolol Tartrate 12.5 mg by mouth twice daily with instructions to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 60. Review of the MAR/TAR showed that on one evening the Metoprolol Tartrate was administered despite a recorded blood pressure of 95/56, which was outside the ordered parameters. In an interview, the DON confirmed that the Metoprolol should have been held in accordance with the physician’s order parameters.
Failure to Protect Confidentiality of Resident Health Information
Penalty
Summary
The facility failed to maintain the confidentiality of protected health information when staff assignment sheets containing residents’ personal medical information were left unattended and visible on treatment and medication carts. On 3/23/26 from 8:12 a.m. to 8:15 a.m., a surveyor observed an unattended treatment cart on the Pemaquid Unit with a staff member’s assignment sheet placed face up, displaying personal medical information for ten residents. The sheet was visible and easily accessible to residents, visitors, and unauthorized personnel, while Environmental Services staff and CNAs were nearby. A Licensed Practical Nurse later confirmed that the assignment sheet should not have been left in the open and should have been secured. Later that same day, from 3:35 p.m. to 3:41 p.m., a surveyor observed an unattended medication cart on the Pemaquid Unit with another staff member’s assignment sheet on it, also face up, containing personal medical information for four residents. This sheet was similarly visible and easily accessible to residents, visitors, and unauthorized personnel, with Environmental Services staff, CNAs, ambulatory residents, and residents’ family members in the area. The issue was subsequently discussed with the Director of Nursing.
Failure to Provide Required Written Bed-Hold and Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide required written bed-hold and transfer/discharge notices for a facility-initiated transfer of one resident to an acute hospital. Record review showed that the resident was transferred on 3/8/26 and subsequently admitted to the hospital, but the clinical record contained no evidence that a written bed-hold notice or a transfer/discharge notice was issued to the resident or the resident’s legal representative. This lack of documentation regarding the resident’s bed-hold rights and transfer/discharge information was confirmed with the Director of Nursing on 3/23/26 at 1:30 p.m. The deficiency centers on the absence of written notification related to the resident’s needs, appeal rights, or bed-hold policies at the time of the facility-initiated transfer/discharge to the acute care setting, as required by regulation, for 1 of 3 sampled residents who experienced such transfers.
Failure to Notify Physician of Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician of a significant change in condition for one resident receiving MD or ID services. Record review showed that this resident experienced difficulty breathing and was transferred to the emergency room on 3/8/26, where he/she was subsequently admitted to the hospital. Further review of the resident’s entire clinical record revealed no evidence that the physician was notified of the transfer to the hospital. The facility’s Change of Condition Policy and Procedure states that the facility must consult with the resident’s healthcare provider and notify the resident’s legal representative or family member when there is a decision to transfer or discharge the resident, and that physician/family notification must be documented in the electronic health record. On 3/23/26 at 1:30 p.m., the Director of Nursing confirmed there was no documentation in the resident’s electronic medical record indicating that a physician had been notified of the transfer.
Resident’s Refusal of Shower and Preference for Bed Bath Not Honored
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s right to refuse care and choose their preferred method of bathing. After an episode of bowel incontinence, staff asked the resident if they wanted a shower, and the resident declined, requesting a bed bath and to speak with the unit manager. The unit manager was in a clinical meeting and was not made aware of the resident’s request. The charge nurse interrupted the meeting, asked leadership if there was any reason the resident could not have a shower, and was told there were no known contraindications. The charge nurse then informed the resident that management was okay with the resident having a shower, and staff proceeded with preparations for a shower despite the resident’s prior refusal and request for alternative care. The resident, who had diagnoses including Major Depressive Disorder, Anxiety, and PTSD and a BIMS score indicating intact cognition, was primarily bedbound and typically received bed baths, with the care plan later revised to specify bed baths only per request. A CNA and the charge nurse used a mechanical lift to transfer the resident onto a shower chair, covered the resident with bath blankets, and transported the resident down the hall to the shower room. According to the CNA, the resident expressed fear and said not to push or take them down, and again said they did not feel like a shower, but the CNA encouraged the shower as being quick. The resident reported being placed naked on a sheet, transported down the hall, and bathed while crying, yelling, and repeatedly stating they did not want a shower, and later described hating the experience and continuing to have nightmares. The facility’s own policy states that residents have the right to refuse treatment, to have their dignity maintained, and to have their needs and preferences reasonably accommodated, which was not followed in this incident.
Failure to Provide Timely Pain Management for New Admission
Penalty
Summary
The facility failed to provide timely pain management for a resident admitted with a fractured left leg and chronic hip and knee pain. After discharge from the hospital, the resident arrived at the facility at approximately 2:50 p.m. and requested pain medication. The resident reported being told that their medications had not yet arrived from the pharmacy and that staff were waiting for a code from the pharmacy to access the Cubex automated medication dispensing machine for narcotics. Review of the hospital discharge orders showed an order for Oxycodone 5 mg by mouth every 4 hours as needed for pain for 14 days. The admission nurse’s note documented the resident’s pain level as 6 on a 1–10 scale. Review of the Medication Administration Record showed that the resident did not receive the ordered Oxycodone until 11:05 p.m., approximately eight hours after the initial request for pain medication, with a documented pain level of 6 at the time of administration. There was no documentation in the clinical record that staff attempted to contact a physician for alternative pain medication orders while waiting for access to the Cubex machine. Additionally, there was no documented evidence that non-pharmaceutical pain interventions, such as repositioning, distraction activities, or discussing prior effective pain relief methods with the resident, were attempted. In an interview, the DON confirmed there was no evidence of non-pharmaceutical interventions or attempts to contact a physician during this period.
Failure to Provide Bed-Hold Notices and Complete Discharge Summaries
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold and transfer/discharge notices for residents who experienced facility-initiated transfers to an acute hospital, as well as the failure to complete required discharge summaries. For one resident, the clinical record showed a transfer and subsequent admission to an acute hospital, but there was no evidence that a written bed-hold notice or transfer/discharge notice was issued to the resident or legal representative. For another resident who was transferred and admitted to an acute hospital on multiple occasions, the clinical record lacked evidence of written bed-hold and transfer/discharge notices for two of the transfers, and lacked evidence of a bed-hold notice for an additional transfer. These findings were confirmed with facility leadership, including the Regional Director of Operations and the Interim DON. The facility also failed to ensure that residents discharged from the facility had complete discharge summaries that included a recapitulation of the stay, diagnoses, course of illness/treatment or therapy, and reconciliation of all pre-discharge medications with post-discharge medications. One resident’s spouse reported that at the time of discharge, the resident did not receive discharge instructions, including pre- and post-discharge medication reconciliation, follow-up appointments, or referrals for home health services, and the clinical record lacked evidence of a recapitulation of stay or discharge instructions. Another discharged resident’s record similarly lacked a completed discharge summary, including recapitulation of stay, discharge instructions, discharge medications/instructions, follow-up appointments, and therapy recommendations. These documentation gaps were confirmed in interviews with the Administrator, Social Worker, Regional Director of Operations, and Director of Clinical Operations.
Failure to Discontinue Inactive Oxygen and Hospice-Related Provider Orders
Penalty
Summary
The facility failed to maintain organized and updated physician orders that reflected residents’ current needs by not discontinuing inactive or outdated orders for two residents. For one resident who was observed on two occasions receiving oxygen via nasal cannula at 1.5 L/min, the active provider orders still listed three separate oxygen orders, all written at 2 L/min: oxygen at 2 L/min PRN to maintain oxygen saturation at 90%, oxygen at 2 L/min PRN for shortness of breath with documentation of O2 saturations and start/stop times, and oxygen at 2 L/min continuous every shift for shortness of breath. These multiple active orders did not match the observed oxygen flow rate being delivered. For another resident, interview with the resident’s representative and record review showed the resident had been discharged from hospice services, with a social services note documenting hospice discharge and a hospice care plan that had been resolved. Despite this, the active provider orders still contained two hospice-related orders: a referral to a named hospice and a referral to the same entity for evaluation and treatment for palliative care for pain management. On review, the Regional Director of Clinical Operations confirmed that these outdated hospice-related orders and multiple oxygen orders remained active in the medical record.
Failure to Investigate Staff-Reported Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to investigate allegations of abuse and neglect after receiving written statements from staff that some residents were fearful and that a staff member had neglected resident care. The facility’s Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, effective 6/2016 and revised 03/2025, requires the identification and investigation of all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Despite this, the DON received a dated written statement on 9/25/25 from a staff member reporting that a handful of residents were scared and that another staff member had neglected some residents’ care, and also received an additional unsigned, undated written statement reporting that a resident looked scared and that another staff member was rough and mean. During interviews with surveyors, the DON and the Administrator confirmed that the facility was unable to provide evidence that these allegations of abuse or neglect were investigated and that no investigations were completed in response to these staff-reported concerns. No additional clinical details, medical histories, or specific conditions of the affected residents were documented in the report beyond their expressed fear and the alleged rough and neglectful treatment by a staff member.
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