Lakewood Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Baudette, Minnesota.
- Location
- 600 Main Avenue South, Baudette, Minnesota 56623
- CMS Provider Number
- 245580
- Inspections on file
- 21
- Latest survey
- June 27, 2025
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Lakewood Care Center during CMS and state inspections, most recent first.
The facility did not have a certified and credentialed dietary manager overseeing kitchen operations, as the current manager had not completed the required training and was not enrolled in a CDM course. The registered dietician provided only monthly on-site visits and remote support, while the social worker supervised daily duties. This deficiency affected all individuals consuming food from the kitchen due to non-compliance with regulatory standards.
A resident experienced a significant decline in multiple areas, including increased dependence in dressing, bed mobility, transfers, ambulation, and bowel incontinence. Despite these changes, staff did not complete a Significant Change in Status Assessment (SCSA) as required, instead performing only a quarterly MDS. Interviews and observations confirmed the resident's increased care needs and the oversight in assessment.
A discharge MDS assessment for a resident was not completed or transmitted to CMS within the required timeframe. The assessment remained in-progress and unsigned in the electronic medical record, and staff interviews confirmed the omission was not detected until later. The facility's policy did not address procedures for handling discharge MDS assessments.
A resident with severe cognitive impairment experienced significant unplanned weight loss over several weeks, but this was not accurately coded on the MDS by the dietary manager. Despite documentation of weight loss and discussions in high-risk meetings, the MDS was marked as having no or unknown weight loss, contrary to facility policy and CMS guidelines.
A resident with multiple chronic conditions and a recent MRSA diagnosis was placed on transmission-based precautions and prescribed antibiotics. Although staff were instructed to use PPE and later follow modified precautions, the care plan was not updated to include these infection management interventions. Nursing staff confirmed the omission, and the care planning policy was not provided when requested.
A resident with severe dementia and significant weight loss was not comprehensively assessed for nutritional needs, despite ongoing decline and documented eating difficulties. Staff delayed assistance at meals, did not always provide the correct diet texture, and failed to initiate recommended referrals such as a speech evaluation. The facility's required nutritional assessments were not completed, contributing to continued unaddressed weight loss.
A resident with severe cognitive impairment and chewing difficulties was not provided with the ordered mechanical soft, bite-sized diet. Instead, the resident was served foods such as french toast and a fish fillet sandwich on a bun, which did not meet the required texture and size, resulting in difficulty eating. Staff and dietary management confirmed the diet order was not followed, and the issue was attributed to improper meal preparation and lack of daily dietitian oversight.
A resident with respiratory MRSA did not have proper documentation or consistent implementation of transmission-based and enhanced barrier precautions. Staff were unclear about when to use PPE, there was no signage or PPE available outside the room, and the care plan was not updated. The facility's infection control policies were not followed, leading to inconsistent communication and a lack of clear documentation regarding the resident's precaution status.
A resident with a history of traumatic brain injury and stroke was subjected to multiple personal alarms and video cameras that restricted movement without attempts at alternate interventions. The alarms, intended to prevent falls, caused distress and anger in the resident, who was unable to turn them off. Staff used the alarms due to the resident's unsteadiness and inability to provide one-to-one supervision, despite the facility's policy against restraints for convenience.
A resident with severe cognitive impairment and high fall risk fell and fractured her humerus due to the facility's failure to implement care-planned fall interventions. The care plan required a contact guard assist with two staff and a gait belt for transfers, but the resident was left unattended at the bathroom sink, leading to the fall. Staff interviews revealed a lack of adherence to the care plan and failure to ensure necessary equipment was available, contributing to the incident.
The facility failed to ensure that unpasteurized shelled eggs were fully cooked, posing a risk of foodborne illness to residents. Observations revealed that residents were served or attempted to be served over-easy eggs from a batch without verification of pasteurization. Interviews confirmed that the facility had been ordering the same type of eggs for months without checking if they were pasteurized, despite the risk of serious infections. The USDA guidelines were cited, and a policy on food safety was requested but not provided.
A resident, who required assistance and had a history of falls, was observed without an accessible call light while sitting in their room. Despite being cognitively intact and capable of using the call light, it was placed out of reach, contrary to the facility's policy. Staff interviews confirmed the expectation for call lights to be within reach, highlighting a lapse in adherence to care protocols.
A facility failed to maintain confidentiality for 12 residents when a care sheet with personal health data was left unattended in a public area. Staff interviews confirmed that care sheets should be kept private, typically in a pocket, but the sheet was left exposed, compromising resident privacy. A facility policy on privacy was requested but not provided.
A resident with severe cognitive impairment and a history of UTIs was administered antibiotics without proper assessment or adherence to the facility's antibiotic stewardship protocols. Despite a positive urinalysis, the initial antibiotic was ineffective due to resistance, leading to a change in medication. The facility's documentation lacked evidence of symptom assessment before initiating a second course of antibiotics, and there was a delay in receiving culture results, which contributed to inappropriate antibiotic use.
Lack of Qualified Dietary Manager Overseeing Food Services
Penalty
Summary
The facility failed to ensure that a certified and credentialed dietary manager was overseeing and supervising the food preparation and services in the kitchen. The individual acting as the dietary manager had been in the lead/manager position for two years but had not enrolled in the required Certified Dietary Manager (CDM) course, citing the need to cover dietary shifts as the reason for the delay. The facility's registered dietician visited only once per month and provided guidance remotely, while the facility social worker supervised the dietary manager's daily duties. Interviews confirmed that the dietary manager did not possess the necessary qualifications to oversee the kitchen, and the facility was only in the process of looking into appropriate training. Document review showed that the job description for the Food and Nutrition Services Lead did not specify minimum qualifications, and the dietitian services agreement outlined the consultant dietician's role as advisory and supportive, with no daily on-site presence. The lack of a qualified dietary manager had the potential to affect all residents, visitors, and staff who consumed food from the kitchen, as the oversight of food and nutrition services was not in compliance with regulatory requirements.
Failure to Complete Significant Change Assessment After Resident Decline
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who experienced notable declines in multiple areas of functioning. Review of the Minimum Data Set (MDS) assessments showed that the resident went from requiring maximum assistance with dressing, being independent with bed mobility, and needing maximum assistance with transfers and ambulation, to being dependent in dressing, bed mobility, and transfers, and unable to ambulate. The resident also became always incontinent of bowel, indicating a significant change in status across several domains. Despite these changes, only a quarterly MDS was completed instead of a significant change MDS as required. Interviews and observations confirmed the resident's increased dependence, with nursing assistants needing to provide two-person assistance for transfers and full assistance for bed mobility and toileting. The registered nurse responsible for MDS completion acknowledged that the resident's decline should have triggered a significant change assessment, as the changes were not expected to resolve within two weeks and affected multiple areas of health status. Facility policy and CMS guidelines both require a comprehensive assessment in such cases, but this was not done, resulting in the deficiency.
Failure to Complete and Transmit Discharge MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) database within the required timeframe for one resident. According to the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, a discharge assessment must be transmitted within 14 calendar days of completion. In this case, the resident was admitted and later discharged home with his son, but the discharge MDS remained in-progress and unsigned in the electronic medical record. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the discharge MDS was neither completed nor submitted as required, and the omission was not identified until after the fact. The facility's Resident Assessment Instrument policy did not specify procedures for handling discharge MDS assessments.
Failure to Accurately Code Significant Weight Loss on MDS
Penalty
Summary
The facility failed to ensure accurate coding of weight loss on the Minimum Data Set (MDS) for a resident with severe cognitive impairment. The resident experienced significant weight fluctuations over a three-month period, including a weight loss of over 14% in nine weeks and over 16% in twelve weeks, as documented in the Weights and Vitals Summary. Despite these documented losses, Section K: Swallowing/Nutritional Status of the resident's significant change MDS was incorrectly coded as having no or unknown weight loss or gain since the last assessment period. Interviews with facility staff revealed that the dietary manager, who was responsible for completing Section K of the MDS, did not realize the error and acknowledged that the resident had experienced weight loss, which had been discussed in high-risk team meetings. The registered dietician noted inconsistencies in the recorded weights and stated that the resident's intake was poor, further supporting the presence of significant weight loss. The director of nursing confirmed that the resident was being monitored for weight loss and should have been coded accordingly on the MDS. The facility's policy and the CMS RAI User's Manual require accurate and comprehensive assessment and coding of resident weight changes, which was not followed in this instance.
Failure to Update Care Plan for Infection Management and Precautions
Penalty
Summary
The facility failed to revise a resident's care plan to include interventions for infection management after the resident tested positive for MRSA and was placed on transmission-based precautions. The resident, who was cognitively intact but dependent on staff for activities of daily living, had diagnoses including diabetes, renal insufficiency, and COPD. Following a positive sputum culture for MRSA and a diagnosis of pneumonia, the resident was prescribed multiple antibiotics and placed on precautions upon return from the hospital. Staff were instructed to wear full PPE when caring for the resident, and later, modified precautions were implemented based on a physician's order due to the resident's mental health needs. Despite these changes in the resident's condition and care requirements, the care plan was not updated to reflect the necessary infection control interventions or the modified precautions. Interviews with nursing staff confirmed that the care plan should have included these interventions, as staff rely on the care plan to guide resident care. The director of nursing also stated that care plans are updated by nurses and reviewed by staff for changes. However, the care plan for this resident did not include the required transmission-based precautions or infection management interventions, and a care planning policy was requested but not provided.
Failure to Comprehensively Assess and Address Resident Weight Loss
Penalty
Summary
The facility failed to comprehensively assess and develop interventions to prevent or reduce continued weight loss for a resident with severe cognitive impairment and dementia. The resident experienced significant unplanned weight loss over a three-month period, with documented weights showing a decline from 104.8 lbs. to 87.6 lbs., representing a 16.41% loss. Despite a care plan identifying unplanned weight loss and interventions such as referral to a dietician, meal assistance, and monitoring of food intake, the resident's medical record lacked evidence of a comprehensive assessment addressing the ongoing weight loss. Observations revealed that the resident had difficulty eating independently, particularly with certain food textures, and required significant prompting and assistance from staff. Staff interviews confirmed that the resident struggled with chewing and needed frequent reminders and coaching to eat. The resident was served food that did not always match the ordered diet texture, and staff sometimes delayed assistance at meals. The dietary manager and consultant dietician communicated about the resident's weight loss, but a comprehensive nutritional assessment was not completed, and recommended referrals, such as for a speech evaluation, were not initiated. The facility's policy required a thorough nutritional assessment, including review of diet, oral status, lab values, medications, and other relevant factors, but this was not completed for the resident. The consultant dietician acknowledged that comprehensive assessments had not been kept up to date, and the dietary manager had not implemented a more detailed assessment form provided by the dietician. The lack of a comprehensive assessment and timely interventions contributed to the resident's continued weight loss and inadequate management of her nutritional needs.
Failure to Provide Ordered Diet Texture to Resident with Chewing Difficulties
Penalty
Summary
The facility failed to provide the prescribed diet texture to a resident with severe cognitive impairment who required supervision and setup assistance for eating. The resident had an order for a mechanical soft, bite-sized diet (IDDSI #6), but was observed being served foods such as french toast cut into large triangles and a fish fillet sandwich on a bun, both of which did not meet the required soft and bite-sized criteria. The resident struggled to eat the french toast, was unable to break off bites, and had difficulty manipulating the food, ultimately only eating bite-sized watermelon when it was provided. Staff interviews confirmed that the resident had trouble chewing and would only take very small bites, and that bread and toast were not appropriate for the ordered diet texture. The dietary manager acknowledged that the resident should not have been served foods like french toast or hamburger buns, and that all dietary staff had been trained on diet orders and could reference posted diet information in the kitchen. The registered dietitian confirmed that the IDDSI #6 diet required soft, easily mushed, bite-sized foods and that bread products were not suitable without a specific consult. The director of nursing was aware of the issue and noted the absence of a qualified dietitian on site every day. Facility policy required assessment of nutritional needs by a registered dietitian or designated personnel, including review of diet orders and the need for assistance.
Failure to Document and Implement Precautions for Resident with Respiratory MRSA
Penalty
Summary
The facility failed to ensure proper documentation and implementation of transmission-based precautions (TBP) and enhanced barrier precautions (EBP) for a resident diagnosed with respiratory MRSA. The resident, who was cognitively intact but dependent on staff for activities of daily living, had a history of diabetes, renal insufficiency, and COPD. After a positive sputum culture for MRSA and a course of antibiotics, there was no clear documentation in the medical record regarding when TBP were initiated or discontinued, nor the rationale for these decisions. Additionally, interventions and the use of PPE were not consistently documented or communicated to staff. Observations revealed that there was no signage for EBP or PPE available outside the resident's room, and the resident was seen coughing and spitting phlegm in a public area without covering his mouth. Interviews with staff indicated inconsistent use of PPE and confusion about the resident's precaution status. Some staff reported not wearing PPE in the week prior, and there was a lack of clarity on when precautions were to be started or stopped. The care plan was not updated to reflect TBP, and staff relied on informal communication methods rather than documented protocols. The facility's policies required contact precautions for MDROs like MRSA, with clear signage and documentation when precautions were implemented or discontinued. However, the infection control nurse and DON were unable to provide evidence of proper documentation or a clear process for discontinuing precautions. The medical director stated that precautions should remain until the infection was resolved, but was not involved in the decision to discontinue them. The lack of documentation, inconsistent communication, and failure to update the care plan contributed to the deficiency in infection prevention and control for the resident with respiratory MRSA.
Failure to Identify and Address Use of Restraints
Penalty
Summary
The facility failed to identify the use of restraints for a resident, referred to as R3, by employing multiple personal alarms and video cameras that restricted R3's movement without attempting alternate interventions to prevent falls. R3 was readmitted to the facility with a history of traumatic brain injury, cerebrovascular disease, depression, and insomnia, and was identified as having moderately impaired cognition. The care plan for R3 indicated a high risk for falls and required alarms in bed, recliner chair, and dining room chair due to an inability to comprehend safe choices and ask for assistance. Observations and interviews revealed that R3 reacted negatively to the alarms, which were loud and caused distress. R3 expressed frustration and anger towards the alarms, stating they were annoying and he was unable to turn them off. Staff interviews indicated that the alarms were used because R3 was unsteady and needed supervision, but they were unable to provide one-to-one supervision. The use of a camera to monitor R3 was also noted, with staff acknowledging that R3 was aware of the camera and was always watching it. The facility's policy on restraints indicated that residents have the right to be free from any physical or mechanical restraint imposed for discipline or convenience. However, the facility did not attempt other interventions prior to using alarms, and the family member of R3 stated they had not requested the alarms. The facility's approach was based on therapy recommendations and the belief that alarms were the only way to ensure staff knew if R3 got up, despite R3's adverse reactions to the alarms.
Failure to Implement Fall Interventions Leads to Resident Injury
Penalty
Summary
The facility failed to implement fall interventions as care planned for a resident identified as a high fall risk, resulting in actual harm. The resident, who had severe cognitive impairment and required substantial assistance for activities of daily living, fell and sustained a fracture of the right humerus. The care plan specified that the resident required a contact guard assist with two staff and a gait belt for transfers, and was unsafe to walk, necessitating stand-pivot transfers only with two-person assistance. However, the care plan did not specify whether the resident could be left unattended at the bedside. On the morning of the incident, a nursing assistant left the resident unattended at the bathroom sink to retrieve a wheelchair, during which time the resident fell. The nursing assistant did not have the necessary equipment, such as a gait belt and walker, readily available, and did not request assistance. Interviews with staff revealed that the resident was known to be impulsive and unsteady, requiring constant supervision and contact guard assist. Despite this, the nursing assistant turned her back on the resident multiple times during care, leaving the resident unsupported and at risk of falling. The facility's policy on falls prevention emphasized the need for appropriate supervision and assistive devices to prevent avoidable accidents. However, the staff did not adhere to the care plan, which required a contact guard assist and the use of a gait belt. The lack of adherence to the care plan and failure to ensure the availability of necessary equipment contributed to the resident's fall and subsequent injury.
Removal Plan
- Evaluation by physician, PT/OT, Orthopedics
- Immobilize right arm with sling
- Change dressing routinely
- Education to all staff regarding assistive devices, the need for all equipment to be available to the resident when needed
- Care plan was updated for dressing and transferring needs
- Audit of all resident walkers to ensure that they were available and had their name on it
- Interviewed cognitively intact residents that use gait belt for audit of gait belt use by staff
- Creating a walk to dine policy
- Weight will be monitored and intakes to ensure continued eating and maintaining weight
Failure to Ensure Safe Preparation of Eggs
Penalty
Summary
The facility failed to ensure that unpasteurized shelled eggs were fully cooked and prepared in a manner to prevent foodborne illness. This deficiency was identified during an observation, interview, and document review process. The issue had the potential to affect all 24 residents, with specific mention of five residents who regularly ordered undercooked eggs for breakfast. During a kitchen tour, it was observed that the cook's refrigerator contained seven flats of eggs without any indication that they were pasteurized. The cook assumed the eggs were pasteurized, as residents ordered eggs over-easy, which should be pasteurized if served undercooked. Further observations revealed that residents were served or attempted to be served over-easy eggs from the unverified batch. Interviews with the social worker and dietician confirmed that the facility had been ordering the same type of eggs for six months without verifying if they were pasteurized. The dietician emphasized the risk of using unpasteurized eggs for undercooked dishes, which could lead to serious infections. The administrator also stated the expectation for food to be prepared safely, using pasteurized eggs. The USDA guidelines were cited, highlighting the risk of salmonella from improperly cooked eggs. A policy regarding food safety was requested but not provided.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to ensure that a call light or device to alert staff was accessible for a resident, identified as R21, who was observed without a way to call for assistance while sitting in their room. R21 was cognitively intact and required moderate to maximum assistance for transfers, having sustained a fall since admission. The care plan for R21, dated 8/13/24, indicated a dependency on staff for various needs and highlighted a risk for falls, with interventions including the provision of adaptive equipment. However, during observations on 9/9/24 and 9/10/24, R21 was seen sitting in a recliner without a call light within reach, as it was placed on a table three to four feet away, making it inaccessible. Interviews with staff revealed that R21 was capable of using the call light and should have had it within reach at all times. Nursing assistant NA-D was observed transferring R21 to the recliner and leaving the room without providing the call light or reacher device. Both NA-A and RN-B acknowledged the expectation for residents to have call lights accessible, with RN-B suggesting a splitter for the call light cords to ensure accessibility. The director of nursing confirmed the facility's policy that all residents should have call lights within reach, and staff were trained to check on residents' needs during deliberate rounding. The facility's policy, dated 4/1/14, emphasized prompt responses to residents' needs and the importance of positioning call lights conveniently for use.
Confidentiality Breach of Resident Records
Penalty
Summary
The facility failed to maintain the confidentiality of personal and medical records for 12 residents. During an observation, a care sheet containing sensitive information such as urinary intake/output, fasting blood sugars, and other personal care needs was found unattended on a tabletop in a public hallway. This area was accessible to staff, visitors, and residents, allowing them to view the information without obstruction. Nursing assistant (NA)-B admitted to leaving the care sheet on the table as part of her routine, acknowledging that others could view the information without her knowledge. Interviews with various staff members, including nursing assistants, trained medication aides, a registered nurse, and the director of nursing, confirmed that the care sheets should be kept private, typically folded and in a pocket. Despite this expectation, the care sheet was left exposed, compromising resident privacy. The facility's policy on privacy was requested but not provided, indicating a potential gap in policy enforcement or availability.
Failure to Implement Antibiotic Stewardship Protocols
Penalty
Summary
The facility failed to implement antibiotic stewardship protocols for a resident identified as having been taking an antibiotic. The resident, who had severe cognitive impairment and diagnoses including dementia and urinary tract infections, was found to have a positive urinalysis on a specific date. Despite the facility's policy to use a UTI tracking form and monitor symptoms before initiating antibiotics, the resident was started on ciprofloxacin before culture results were received, which later showed resistance to the antibiotic. This led to a change in medication to Rocephin. The facility's documentation lacked evidence of any assessment of signs and symptoms of infection before initiating the second course of antibiotic treatment. Interviews with nursing staff revealed that the family had requested further intervention due to the resident's decreased appetite, which they believed was a symptom of a UTI. However, there was no evidence of a patient assessment or non-pharmacological interventions, such as increased fluid intake, being implemented before contacting the physician for additional antibiotics. The director of nursing acknowledged that there was a lag in receiving culture results, which hindered timely decision-making. The facility's infection control policy aimed to optimize antibiotic use, but the lack of timely culture results and proper documentation of symptoms led to inappropriate antibiotic administration. The facility was working on improving their documentation and protocols to ensure appropriate use of antibiotics.
Latest citations in Minnesota
A resident with dry eye syndrome and degenerative eye disease had orders for cyclosporine ophthalmic emulsion and Refresh Tears, both scheduled at the same time. Medication records and direct observation showed a TMA instilled cyclosporine drops in both eyes and immediately followed with Refresh Tears in both eyes without waiting between medications. This practice conflicted with referenced professional guidance recommending several minutes between multiple eye drops and with the medical provider’s recommendation to wait fifteen minutes between the two ophthalmic medications. No facility policy on ophthalmic medication administration was provided when requested.
A resident with severe cognitive impairment, impaired mobility, and high fall risk was care planned to have wheelchair footrests in place at all times, with staff ensuring proper positioning and monitoring for leaning during transport. A NA transported the resident in a manual wheelchair from the shower without the footrests, and while going through the doorway the wheelchair struck the door frame, causing the resident, who was leaning forward, to fall out. The resident sustained a T12 fracture, head injury with concussion, abrasions and contusions, and multiple right-hand lacerations requiring sutures, and the DON confirmed the care plan had not been followed.
A high‑risk, immobile resident with MS and prior heel DTI developed an avoidable unstageable coccygeal pressure ulcer after staff failed to consistently assess and document skin status, did not transfer or timely provide ordered pressure‑relieving mattresses, and did not reliably perform q2h repositioning. The resident was repeatedly left on a bedpan for prolonged periods despite early reports of this issue, and the toileting care plan was not revised to a bedside commode until after the coccygeal wound had significantly worsened. Wound assessments lacked complete measurements and staging, changes in wound size and color were not promptly recognized as deterioration or reported to providers, and recommended interventions from a wound NP (including an air mattress and offloading) were not promptly implemented. As a result, the coccygeal ulcer rapidly progressed to a large, necrotic, malodorous wound requiring hospital transfer and surgical debridement.
A resident with spastic hemiplegia, muscle weakness, and moderate cognitive impairment was observed using bilateral bed grab bars for bed mobility and transfers, but the care plan did not address grab bar or side rail use. Review of the EMR showed no completed bed mobility device or side rail assessment to determine the necessity or safety of the grab bars, and no documentation that risks and benefits were discussed or that informed consent was obtained. An LPN and the ADON stated that a bed mobility device assessment is required before grab bars are installed and confirmed that no such assessment existed for this resident.
A resident with bilateral heel pressure ulcers and multiple comorbidities received wound care during which an RN removed dressings from both heels, cleansed both wounds, and wiped each heel without changing gloves or performing hand hygiene between wounds or after disposing of soiled dressings. This practice conflicted with the facility’s written wound care procedure, which requires glove removal and hand hygiene after dressing removal and after wound cleansing. In interviews, the RN, NP, and DON/IP acknowledged that hand hygiene and glove changes are expected between dirty and clean tasks and between separate wounds to prevent infection.
A resident with MS, neurogenic bladder, mobility limitations, and existing pressure injuries was identified as dependent for toileting hygiene and at risk for pressure ulcers, yet the care plan lacked an individualized toileting/incontinence plan and a defined repositioning schedule. Despite a new coccyx pressure ulcer and documentation that interventions such as increased repositioning and incontinent care were needed, the care plan was not revised for a period of time to reflect these changes. During this time, the resident sometimes fell asleep on a bedpan and remained on it until staff removed it, and staff were not initially informed that the bedpan should no longer be used. The DON later acknowledged that the care plan revisions for turning, repositioning, and toileting were delayed until after the resident’s coccyx ulcer had significantly worsened.
A resident with diabetes, Crohn’s disease, bowel incontinence, and a history of MASD on the right gluteus developed an open, painful lesion on the right gluteal area that was documented over time without complete wound characteristics, clear etiology, or timely provider notification. Wound care orders were written for a stage 3 pressure ulcer on the left buttocks, while staff reported the wound was only on the right side and applied the left‑sided orders to the right gluteal wound in the absence of specific right‑side treatment orders. The DON acknowledged discomfort with staging the wound, lack of early physician notification, and confusion over wound classification, despite a facility policy requiring comprehensive wound assessment, consistent measurement, and provider notification when treatment orders are absent.
A resident with diabetes, chronic leg ulcer, kidney transplant, and a documented gluteal wound was care-planned for Enhanced Barrier Precautions (EBP), with posted instructions requiring gown and gloves for high-contact care such as transfers and wound care. During a telehealth wound assessment, the DON donned a gown and initially performed hand hygiene but then applied gloves without hand hygiene, removed a soiled dressing from the resident’s gluteal area, discarded it, removed gloves, and applied new gloves again without performing hand hygiene between glove changes. On another occasion, during use of a sit-to-stand lift, an NA wore gown and gloves, but the DON handled the lift harness, the resident’s clothing, and assisted with the transfer and repositioning while wearing a gown but no gloves, despite EBP requirements for transfers. The DON stated EBP was only needed for catheter or wound care and not for transfers, contradicting the posted EBP instructions and facility policy.
A resident with severe dementia, psychiatric disorders, and high dependence for ADLs was verbally abused during evening care when a NA, frustrated with the resident’s crying and resistance, loudly ridiculed her as acting like a two-year-old, threatened to hit her back if struck, told her she would be sent to a locked unit, and questioned who would want to care for her when she cried like a baby. Multiple staff witnessed the loud, stern, and intimidating tone and reported it to an LPN, who recognized it as verbal abuse but did not immediately remove the NA from duty or promptly report the allegation per policy, allowing the NA to continue working on the unit. Following this incident, the resident demonstrated increased crying, combativeness, resistance to care, wandering, self-isolation, and refusal of food, fluids, and medications above baseline, with documentation of significant emotional distress and subsequent ED evaluation for aggressive behaviors and poor intake.
A resident with dementia, bilateral above‑knee amputations, vascular disease, and severe protein‑calorie malnutrition developed a wound on an amputation stump that had a dressing dated several days before any documentation or treatment orders appeared in the record. Although bath audits and nursing notes initially reported no skin issues, a later assessment described a full‑thickness stage 4 ulcer/diabetic ulcer on the stump with exposed bone, erythema/edema, slough, and moderate serosanguineous drainage. Nursing staff interviews showed no one could identify who first discovered the wound or applied the initial dressing, and there was no evidence that the wound was assessed, the provider notified, or standing orders implemented when it was first present, despite facility expectations that new wounds be promptly evaluated and reported.
Failure to Follow Professional Standards for Ophthalmic Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of practice for administering ophthalmic medications to a resident with dry eye syndrome and degenerative eye disease. The resident was cognitively intact, required assistance with ADLs, and had physician orders for cyclosporine ophthalmic emulsion 0.05% one drop in both eyes twice daily and Refresh Tears ophthalmic solution one drop in both eyes four times daily for dry eyes. The administration summary showed that both eye medications were scheduled for the same time and were documented as being given at the same time on multiple dates. During a medication pass observation, a trained medication aide administered the ordered oral medications, then applied gloves and instilled one drop of cyclosporine in each eye, immediately followed by one drop of Refresh Tears in each eye, without any waiting period between the two medications. The surveyors referenced guidance from the American Academy of Allergy, Asthma, and Immunology stating that when more than one eye drop is ordered, three to four minutes should be allowed between drops in the same eye, and five to fifteen minutes should be allowed between different eye medications to prevent dilution. Interviews with the DON, pharmacy consultant, and medical provider confirmed that best practice and the provider’s recommendation were to wait between administration of cyclosporine and Refresh Tears, with the medical provider specifying a fifteen-minute interval. The facility did not provide a policy on ophthalmic medications when requested. The observed practice and documented administration times demonstrated that staff did not follow these professional standards or the medical provider’s recommended interval between the two eye medications.
Failure to Follow Wheelchair Transport Care Plan Leads to Fall With Injuries
Penalty
Summary
The deficiency involves the facility’s failure to implement care-planned fall prevention interventions for a resident at high risk for falls, resulting in a fall with injury. The resident had diagnoses including aphasia, dysphagia, muscle weakness, traumatic brain injury, and impaired mobility, with severe cognitive impairment documented on the MDS and dependence on staff for transfers and wheelchair transport. A care plan addressing wheelchair transport safety and positioning directed staff to ensure the resident was fully positioned and supported in the wheelchair prior to transport, verify footrests were in place prior to transport, and monitor for leaning, sliding, or unsafe positioning. An additional care-planned approach required wheelchair pedals to be on at all times. On the date of the incident, a nursing assistant transported the resident in a manual wheelchair from the shower room to the resident’s room without the foot pedals in place, contrary to the care plan. While being wheeled through the doorway, the wheelchair struck the door frame, causing the chair to stop and the resident, who had begun leaning forward, to fall out of the wheelchair onto the floor. Progress notes and ED documentation identified that the resident sustained a T12 vertebral fracture, a head injury with concussion, an abrasion and contusion to the head, a bruise to the left knee, and multiple lacerations to the right hand requiring sutures. The nursing assistant later acknowledged awareness that the foot pedals should have been on but did not apply them because the transport was only from the shower to the room. The DON confirmed that the resident’s care plan had not been followed when the fall occurred.
Failure to Implement and Update Pressure Ulcer Prevention and Treatment Led to Avoidable Unstageable Coccygeal Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to adequately assess, monitor, and implement individualized pressure ulcer prevention and treatment interventions for multiple high‑risk residents, resulting in an avoidable, unstageable coccygeal pressure ulcer for one resident that required surgical debridement and hospitalization. The resident had primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and pre‑existing pressure‑related deep tissue injury to the left heel, and was identified as high risk for pressure ulcers on the Braden Scale due to constant moisture, chairfast status, very limited mobility, inadequate nutrition, and friction/shear risk. Hospital records on readmission documented irritant contact dermatitis of the bilateral gluteal cleft with specific cleansing and barrier cream orders, and facility documentation showed the resident could not reposition in bed or chair and required assist of two and a full‑body mechanical lift for transfers. Despite this, the admission/readmission skin assessment and weekly skin checks lacked measurements and detailed wound characteristics for the heel ulcer and gluteal dermatitis, and the care plan did not include comprehensive, individualized interventions beyond generic repositioning and wound care orders. After a new coccyx pressure ulcer was identified and documented as a stage 2 lesion, the facility failed to promptly and accurately update the care plan and implement recommended pressure‑relieving interventions. The wound nurse practitioner on 3/5 ordered coccyx wound care, an air mattress, pressure offloading, and a dietician consult, but the care plan was not revised and there was no evidence that an air mattress was placed on the bed for nearly two weeks. The environmental services director later confirmed that when the resident was moved to a new room, the gel mattress was not transferred, and the air mattress requested on 3/17 was not actually placed until the following day, despite being marked as completed. During this period, TAR documentation showed gaps in the every‑2‑hour repositioning order, and staff interviews revealed that CNAs were unaware of which residents were on repositioning programs, were not consistently repositioning residents, and had not received recent education on pressure ulcer prevention. The DON and RN case manager acknowledged that the coccyx wound increased in size and changed color between assessments, that the bed lacked the ordered gel mattress, and that the physician was not notified of the wound’s deterioration at that time. The facility also failed to timely modify toileting and incontinence care practices despite knowledge that the resident was being left on a bedpan for extended periods. The DON reported hearing before an IDT meeting that the resident had fallen asleep on a bedpan for an undetermined amount of time, but the care plan was not revised to discontinue bedpan use and implement a bedside commode until after the coccyx wound had significantly worsened. CNAs confirmed that the resident sometimes fell asleep on the bedpan and that they were not informed she should no longer use it until after the sore had worsened. Subsequent wound assessments documented rapid progression of the coccyx wound from a small stage 2 ulcer to a large, malodorous, necrotic wound with eschar, slough, erythema, and purulent drainage, ultimately classified as an unstageable pressure ulcer. The DON, NP, PA, and medical director all indicated that the lack of a pressure‑relieving mattress, failure to adjust pressure‑reducing interventions, and prolonged time on a bedpan likely contributed to the development and deterioration of the resident’s pressure ulcer, which was determined to be avoidable and resulted in hospitalization and surgical debridement. Additional documentation and interviews showed systemic assessment and communication failures related to pressure ulcer management. Weekly skin checks and wound assessments often omitted complete measurements, staging, and wound characteristics, and changes in wound size and appearance were not consistently recognized as deterioration or communicated to providers. The DON acknowledged that a 3/12 assessment showing increased wound size and purple discoloration should have been identified as a deep tissue injury and reported to the physician, but this did not occur. When nursing later documented foul odor, increased pain, and expanding necrotic tissue, telemedicine and PA responses deferred in‑person evaluation and ED transfer despite earlier recommendations that the resident be sent to the ED if an in‑person provider could not assess the wound. The NP ultimately found a large, malodorous, purulent wound with expanding eschar and ordered transfer to the hospital, where imaging and surgical findings confirmed a large necrotic sacral wound requiring extensive debridement. Throughout this sequence, the facility did not consistently follow its own pressure ulcer protocols, did not ensure ordered pressure‑relieving equipment was in place, and did not promptly revise care plans or interventions in response to known risk factors and documented wound changes. The report also notes that other residents reviewed for pressure ulcers were affected by similar failures in monitoring and individualized intervention, though detailed narratives focus primarily on this resident. Staff interviews revealed that CNAs relied on paper care guides that did not clearly identify residents on repositioning programs or at risk for skin breakdown, and that they were unaware of some residents’ special mattress orders or toileting restrictions. The DON and medical director stated that residents at risk for pressure ulcers should have immediate pressure‑relieving interventions and that existing ulcers require ongoing evaluation to prevent deterioration, but the documented practices for this resident did not align with those expectations. These combined actions and inactions—insufficient assessment detail, delayed or missing care plan revisions, failure to implement ordered support surfaces and repositioning, and delayed response to wound deterioration—constituted the deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Failure to Assess, Care Plan, and Obtain Consent for Bed Grab Bar Use
Penalty
Summary
The deficiency involves the facility’s failure to follow required procedures before installing and using bed grab bars for a resident. The resident had diagnoses including spastic hemiplegia affecting the left side and muscle weakness, and an admission MDS indicating moderate cognitive impairment. During observation, the resident was seen in a power chair with bilateral grab bars on the bed and reported using them to roll in bed and for transfers. The resident’s care plan, dated 1/23/26, documented a need for assistance with bed mobility and independence with transfers but did not mention or address the use of grab bars or side rails. Review of the electronic medical record showed no completed grab bar/side rail or bed mobility device assessment to determine the necessity of the grab bars or whether the resident could safely use them. There was also no evidence that the resident or the resident’s representative had been educated on the risks of having a grab bar on the bed or that informed consent had been obtained. In interviews, an LPN and the ADON both stated that a bed mobility device assessment was required to determine need and safety prior to installing grab bars, and both confirmed that no such assessment was present in the resident’s record.
Failure to Perform Hand Hygiene and Change Gloves During Wound Care
Penalty
Summary
Surveyors observed that a registered nurse (RN) and a nurse practitioner (NP) did not follow the facility’s established infection control practices during wound care for one resident. During a wound treatment, the RN wore gloves while removing the dressing from the resident’s left heel, then removed the dressing from the right heel, sprayed both wounds with wound cleanser, wiped the left heel with gauze, and then used a clean gauze pad to wipe the right heel. The RN did not remove her gloves or perform hand hygiene after disposing of the soiled dressings or between cleaning the left and right heel wounds, contrary to the facility’s written wound care procedure, which requires glove removal and hand hygiene after removing the previous dressing and again after cleaning the wound. The resident’s admission MDS documented diagnoses including multiple rib fractures, heart failure, dementia, anxiety, and the presence of a pressure ulcer, and indicated the resident was cognitively intact and required staff assistance with care and transfers. The resident’s care plan identified pressure ulcers on both heels requiring wound care. In interviews, the RN, NP, and the DON/infection prevention nurse each stated that gloves should be changed when moving from dirty to clean areas and that hand hygiene is expected after glove removal and between wounds to prevent infection, confirming that the observed practice did not align with facility policy or expected infection control standards.
Failure to Timely Revise Care Plan for Toileting and Skin Integrity
Penalty
Summary
The deficiency involves the facility’s failure to timely revise and individualize a resident’s care plan to address toileting and incontinence needs in relation to impaired skin integrity. The resident had diagnoses including primary progressive multiple sclerosis, hereditary spastic paraplegia, obesity, and a pressure-induced deep tissue injury to the left heel. A Significant Change MDS identified the resident as dependent for toileting hygiene, with lower extremity range-of-motion limitations, wheelchair use, dependence for transfers, occasional urinary incontinence, intact cognition, and at risk for pressure ulcers with existing unhealed pressure injuries and MASD. The resident’s skin-focused care plan, revised on various dates, included skin inspections, wound care orders, weekly skin checks, pressure ulcer care to the left heel, nutritional supplements, and a gel mattress, but did not include an individualized toileting or incontinence plan. On a weekly skin check dated 3/3/26, nursing staff identified a new Stage 2 pressure ulcer on the coccyx and contact dermatitis on both gluteal folds. An IDT Final Post Review Follow Up dated 3/10/26 (signed 3/23/26) documented that a new skin issue had occurred and that interventions after the incident included wound care treatment orders, increased repositioning, and increased incontinent care. However, the resident’s care plan from 3/3/26 through 3/16/26 did not show revisions reflecting increased incontinence care or a repositioning schedule, and the care plan was not updated to include these elements until 3/17/26. During this period, the care plan still lacked an individualized toileting plan despite the resident’s identified incontinence and new coccyx pressure ulcer. Progress notes on 3/17/26 documented that the resident’s coccyx wound had declined, with an evaluation describing a deteriorating wound characterized as a Kennedy terminal ulcer/End of Life, staged as a Stage 4 pressure ulcer, in-house acquired, with increased size, exudate, odor, pain, and surrounding erythema. On that same date, the skin focus care plan was revised to include prompt incontinence care and keeping the skin clean and dry, and the elimination focus care plan was revised to address incontinence due to neurogenic bladder with use of a bedside commode offered every 2–3 hours. A nursing assistant reported that when working with the resident, the resident would sometimes fall asleep on the bedpan and forget to ask staff to remove it, and that she was not aware the resident was not supposed to use the bedpan until after the sore had worsened. The DON stated that the resident’s care plan had not been revised earlier to include a turning and repositioning schedule or toileting changes, and that it should have been revised as soon as staff learned the resident was falling asleep on the bedpan, rather than waiting until after the pressure ulcer worsened.
Failure to Assess and Notify Provider for Right Gluteal Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and appropriately manage a non‑pressure skin issue on a resident’s right gluteal area, and to notify the physician in a timely manner. The resident had diagnoses including diabetes, Crohn’s disease, and a kidney transplant, and the MDS indicated occasional bowel incontinence, no pressure ulcers, and no moisture‑associated skin damage at that time. Earlier documentation identified a resolved MASD to the right gluteus, and a progress note later described a sacral wound with creams applied, noting that sores were still open and painful during application, but without any measurements, wound characteristics, or evidence of physician notification. Subsequent wound assessments documented an open lesion on the right gluteus with specific measurements on multiple dates, but did not identify the wound type or other characteristics, and the record did not show physician notification or treatment orders for the right gluteal lesion. Provider orders in place initially addressed cleansing the buttocks and applying barrier cream, and later included a detailed wound care order for a stage 3 pressure ulcer documented on the left buttocks. However, the resident’s record did not contain a specific treatment order for the right gluteal wound, despite the ongoing documentation of an open lesion in that area. Interviews revealed confusion and inconsistency in wound identification and classification. The DON stated that the right gluteal wound was documented as an open lesion because she did not feel comfortable determining the wound type, and acknowledged that the physician should have been notified when the wound was first identified. The DON was unaware that the NP had documented the wound as being on the left buttocks and as a stage 3 pressure ulcer, while the RN reported that the wound had never been on the left buttocks and that she had been applying the left‑sided wound orders to the right gluteal area because there was no open area on the left. The resident reported a recurring painful area on the right buttocks and chronic stool leakage since prior anal fistula surgery. The facility’s own wound treatment policy required comprehensive assessment of wound etiology and characteristics, consistent measurement and documentation, and provider notification in the absence of treatment orders, which were not followed for this resident’s right gluteal wound. The deficiency centers on the lack of a comprehensive wound assessment for the right gluteal lesion, incomplete documentation of wound characteristics, failure to clearly determine and document the wound etiology, and failure to notify the physician and obtain appropriate treatment orders when the wound was identified and remained open. These actions and inactions resulted in a discrepancy between the documented wound location and type and the actual clinical presentation, as well as a period during which the right gluteal wound had no specific, clearly ordered treatment despite being open and painful.
Failure to Perform Hand Hygiene and Implement Enhanced Barrier Precautions During Wound Care and Transfers
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene during wound care and to consistently implement Enhanced Barrier Precautions (EBP) for a resident requiring such measures. The resident had diagnoses including diabetes, a non-pressure chronic ulcer of the right lower leg, and a kidney transplant, and a wound assessment documented an open lesion on the right gluteal area. The resident’s care plan and a sign posted outside the room specified that EBP, including gown and gloves, were required for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, catheter care, and wound care. During one observation, the DON performed hand hygiene and donned a gown before entering the resident’s room for a telehealth wound assessment. Inside the room, the DON went into the bathroom, applied gloves without performing hand hygiene, removed the resident’s brief, and removed a foam dressing from the right gluteal area that had stool on one corner. After discarding the soiled dressing, the DON removed gloves and then applied new gloves without performing hand hygiene between glove changes. When questioned, the DON stated that hand hygiene should be done when hands or gloves are visibly soiled and before and after removing or applying gloves, and acknowledged that hand hygiene had not been performed each time gloves were removed and reapplied. In a separate observation, the resident was transferred using a sit-to-stand mechanical lift while EBP requirements were not fully followed. An NA entered the room wearing a gown and gloves with the lift, and the DON applied the lift harness under the resident’s arms and cinched the waist strap, encountering the resident’s clothing, while not wearing gloves. After the transfer to bed, the DON pulled down the resident’s pants and removed the harness while touching the resident’s clothes. Following wound care by a CNP-WOC, the DON again assisted the resident by sitting the resident on the edge of the bed, applying the lift harness, and adjusting the resident’s pants and shirt while wearing a gown but no gloves. The DON stated that EBP was only needed for catheter or wound care and not for transfers, and only upon reading the posted EBP sign acknowledged that EBP was required for all high-contact resident care activities, including transfers.
Failure to Protect Resident From Verbal Abuse and Delay in Removing Alleged Perpetrator
Penalty
Summary
The deficiency involves the facility’s failure to protect a vulnerable resident from mental abuse and to respond appropriately to an allegation of abuse. The resident had severe cognitive impairment, Alzheimer’s disease, dementia, anxiety, depression, psychotic disorder, and significant functional dependence, including frequent incontinence and the need for extensive assistance with ADLs and transfers. Her care plan identified behavioral and mood issues such as wandering, yelling, combative behavior, and calling staff names, with interventions including calm approaches, emotional support, redirection, and monitoring for emotional distress and mood/behavior changes. She was identified as a vulnerable adult, with instructions to monitor for signs of emotional distress and to follow the facility’s abuse reporting policy. On the evening in question, while the resident was crying on the phone with her son and expressing a desire to leave, NA-A and NA-B entered to provide evening care using an EZ stand lift. After the resident ended the phone call, multiple staff reported that NA-A spoke to the resident in a loud, stern, and frustrated tone, telling her to stop crying and that she was acting like a two-year-old. When the resident swatted at NA-A, NA-A stated, “If you hit me, I’m going to hit you back,” and later told the resident she was “in trouble now.” Staff reported that NA-A told the resident she would be sent to a locked unit so she could not get out, and questioned who would want to care for her when she cried like a baby, and that nobody would want to keep working with her. NA-C described NA-A yelling commands such as “HOLD ON!” and “Stop crying! Where would you be if you were not here? Probably lying on the floor,” and felt NA-A was obviously upset and overwhelmed. These statements were made in the presence of the resident while she was already distressed and crying. Following this interaction, the resident exhibited crying, yelling, combativeness, resistance to care, wandering into other residents’ rooms, self-isolation, and refusal of food, fluids, and medications above her prior baseline, as documented in behavior charts, target behavior monitoring, and nursing progress notes. Staff documented that she cried most of the morning, was very restless, difficult to redirect, hit and pinched staff, called staff names, and refused care and meals. She required repeated redirection, 1:1 attention, and non-pharmacological interventions, and was ultimately sent to the ED for evaluation of combativeness and emotional distress, where she was treated for dementia with aggressive behavior and hypoglycemia related to poor intake. The report identifies that the resident’s actual response and the reasonable person concept showed serious psychosocial harm, including increased crying and combative behavior above baseline, fear/anxiety manifested as combativeness, resistance to care and social interaction, and self-isolation. The facility also failed to immediately remove the alleged perpetrator from resident care and to promptly report and investigate the allegation in accordance with its abuse policy. After NA-B and NA-C reported to LPN-A that NA-A had yelled at and threatened the resident, LPN-A acknowledged it as verbal abuse but did not initiate immediate protective measures or timely reporting. LPN-A stated she believed she had 24 hours to report because there was no injury, despite facility policy requiring reporting within two hours. NA-A remained on the unit and continued working until the end of her shift, including after staff had clearly communicated their concerns to LPN-A. TMA and NA staff described uncertainty about their authority to remove NA-A and reliance on the nurse to act, while the DON later informed LPN-A that NA-A should have been removed from the floor to prevent further danger to residents. The Immediate Jeopardy was determined to have begun when NA-A’s derogatory, intimidating, and threatening statements were made and continued while she remained on duty with access to the resident and other vulnerable residents.
Failure to Timely Assess and Treat Newly Discovered Stump Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely treatment and care for a newly discovered wound on a resident’s above‑knee amputation stump. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbances, vascular dementia, bilateral above‑knee amputations, vascular disease, reduced mobility, and severe protein‑calorie malnutrition, and had no documented ulcers or skin problems on admission or on the most recent MDS. A weekly bath audit on 3/17/26 documented only non‑tender lymph nodes on the right upper hip and did not identify any open areas. However, when the wound was later assessed, the dressing on the stump was dated 3/16/26, indicating that a wound and dressing existed at that time, even though no corresponding assessment, provider notification, or treatment orders were documented. On 3/23/26, nursing staff documented a new skin issue above the resident’s knee at the amputation site, describing a stage 4 pressure ulcer/injury with full‑thickness skin and tissue loss, exposed bone, erythema/edema, and moderate serosanguineous exudate. The wound measured 1.56 cm by 1.64 cm, with 20–29% granulation tissue and 80% slough. A progress note and skin issues assessment on that date confirmed the wound characteristics and staging, and the NP, after reviewing a picture, determined the wound to be a diabetic ulcer with peripheral vascular disease and severe protein‑calorie malnutrition as contributing factors. On that same date, the NP was notified, antibiotic therapy (doxycycline) was ordered for possible cellulitis, and specific wound care orders were initiated, with documentation on the MAR that these treatments were carried out beginning 3/23/26. Multiple interviews with nursing staff revealed that no one could identify who discovered the wound or who applied the initial dressing dated 3/16/26, and there was no documentation of a wound assessment, provider notification, or interim treatment between 3/16/26 and 3/22/26. Several RNs and LPNs who worked shifts from 3/16/26 through 3/20/26 stated they did not notice a wound on the stump and that, per their usual practice, they would have contacted the provider and initiated treatment if they had found one. One LPN recalled seeing a band‑aid with a date on the stump but could not recall the date, and another LPN stated she did not see the wound because she was not looking for one. The facility’s standing orders required staff to assess all wounds daily, change dressings every three days and as needed, treat with normal saline or non‑cytotoxic cleanser and appropriate dressings, and notify the provider the next business day when a new wound or injury was found. Despite these expectations, the wound identified by the dated dressing on 3/16/26 was not assessed, reported, or treated according to orders and facility policy until 3/23/26.
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