Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Linden Woods Village during CMS and state inspections, most recent first.
Food Storage and Kitchen Sanitation Deficiencies: A kitchen inspection found dirty equipment, a damaged and dirty floor area, ceiling stains, a broken oven, and food stored open, unlabeled, or on the floor in dry storage, the refrigerator, the freezer, and the walk-in cooler. Staff interviews confirmed the oven had been broken for weeks, the floor grout was deteriorating, and food should have been labeled, dated, and stored properly.
Dirty Vents, Scuffed Handrail, and Damaged Dining Room Ceiling: Multiple vents in hallways and outside resident rooms were observed covered in dust, dirt, and debris, the handrail near the serving station had a black scuff mark running its length, and the dining room ceiling had brown spots and a 3-foot piece falling down. The Maintenance Supervisor said he was responsible for cleaning vents and keeping the dining room ceiling, handrail, and facility in good repair, but could not remember the last time the vents were cleaned.
Failure to Provide Proper Perineal Care and ADL Assistance: Staff did not provide proper peri-care for dependent residents during toileting and incontinence care. An LPN wiped feces toward a resident’s peri-area, reused wipes multiple times, and left soiled items improperly placed during care for a resident with severe functional dependence and multiple diagnoses. In two other instances, CNAs failed to clean all urine-exposed areas after toileting, despite residents needing assistance with hygiene and skin protection. Staff and the DON confirmed that urine- and feces-contaminated areas should be cleaned fully, including the buttocks, thighs, and peri-area.
An LPN provided improper catheter and perineal care for a resident with an indwelling catheter by wiping feces toward the peri-area and catheter insertion point, using multiple swipes with the same wipe, leaving soiled wipes on the bed, and failing to secure the catheter tubing to the thigh. The facility also delayed collecting a physician-ordered UA for another resident with urinary symptoms for eight days, delaying treatment for the resident’s UTI.
Medication administration errors occurred when an LPN/CMT crushed medications that were ordered not to be crushed and failed to follow food and water instructions for a resident with dementia, diabetes, and respiratory failure. The staff member did not verify the MAR/orders before placing multiple meds in one cup, crushed Meloxicam, Metoprolol Succinate ER, Donepezil, and Potassium Chloride, mixed them with applesauce, and gave only about 60 mL of water while the resident was still in bed; the DON stated physician orders were expected to be followed.
Improper dating and storage of open medications and glucose control solutions were observed in the nurse's medication room and on a medication cart. An open bottle of lorazepam for a resident with impaired cognition and multiple diagnoses had no open date, along with open bottles of aspirin, acetaminophen, Vitamin B12, and glucose control drops/solutions with no open dates. Staff were unsure of the dating requirements, and the DON stated that opened medications should be dated.
Staff failed to follow EBP and hand hygiene practices when providing care to two residents. An RN entered a room with vital sign equipment without gown or gloves, used the BP cuff and thermometer, and left without cleaning them; CNAs also provided high-contact care to a resident with a suprapubic catheter without proper PPE. In another instance, a CNA used the same soiled gloves for dirty and clean tasks, touched the resident's face, and set up oral care items before removing gloves and washing hands.
PASARR Screening Not Completed Before Admission: A resident with quadriplegia, encephalopathy, schizophrenia, psychotic disorder, and impaired cognition was admitted without documentation of a required Level I PASARR. The record showed the resident was totally dependent for care, on palliative services, and receiving psychotropic and anti-anxiety medications, while the DON and MDS coordinator reported the facility could not locate the PASARR and had not been aware the screening was required before admission.
A resident with chronic pain, heart failure, HTN, and urinary incontinence had weekly LTC evaluations that documented no pain and bladder continence even though nursing notes showed frequent incontinence and the MAR showed repeated scheduled, PRN, and topical pain medication use. Pain assessments also lacked required detail, and the resident stated he/she had daily pain for years and preferred around-the-clock pain meds to prevent worsening pain.
The facility failed to maintain proper sanitization levels for food contact surfaces and did not adhere to food labeling and discarding policies. Sanitizer containers tested at zero ppm, below the required 150-400 ppm. Additionally, food items in the walk-in and resident refrigerators were found with expired or missing dates, contrary to the facility's policy of discarding food within seven days of opening.
Two residents in an LTC facility were not involved in their care planning process, as required. One resident, with multiple medical conditions, reported no care plan meetings, and facility records confirmed the absence of a care plan conference. Another resident, with dementia and other health issues, also reported no discussions about care, and facility records lacked documentation of care plan conferences. The MDS Coordinator acknowledged missed meetings, and the DON stated that resident participation in care plans is expected.
The facility failed to notify the Ombudsman of emergent hospital transfers for two residents, as required by policy. One resident was transferred twice for medical issues, and another was transferred due to a change in condition. The facility's reports did not include these transfers, confirmed by the SSD and the Ombudsman. The issue was linked to the facility's EMR system not accounting for residents with paid bed holds.
A facility failed to document indications for increasing a resident's antipsychotic medication, Seroquel, and did not attempt a gradual dose reduction without clinical rationale. The increase was ordered by hospice at the request of the resident's daughter, despite the facility's policy requiring supporting documentation and attempts at dose reduction. The Director of Nursing acknowledged the lack of justification and noted the family's refusal to agree to a trial dose reduction.
The facility failed to properly label and store Mantoux tuberculin PPD vials, as one open vial in the medication room was undated, contrary to facility policy and CDC guidelines. An LPN confirmed the issue, and the DON stated that vials should be dated upon opening and discarded when expired. This oversight could lead to inaccurate tuberculosis testing.
A resident with chronic health conditions received inappropriate food items, such as bacon, despite having dietary restrictions. The facility staff failed to communicate and adhere to the resident's preferences, resulting in the resident receiving food they should avoid. This was due to a miscommunication between the Restorative Aide and the Dietary Aide, and a lack of review of the tray card notes.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Food was not stored in a sanitary manner, and the kitchen was not kept clean and in good repair. Observation of the kitchen showed a microwave with dirt and food debris on the roof and vents, a dirty floor by the dishwasher with black, gravel-like grout that was peeling off, and a broken oven on the right side of the stove. In dry storage, an open box of red potatoes was on the floor. In the refrigerator and freezer, multiple items were left open or unlabeled, including milk, whipping cream, ice cream, frozen hamburger patties, pinwheel sandwiches, and an unknown blue bag of frozen food, all without open dates or proper labeling. Further observation showed the same dirty microwave and damaged dishwasher-area floor, three golf ball-sized stains on the kitchen ceiling outside the walk-in cooler, a broken oven, boxes of dessert on the floor in the walk-in cooler, an unsealed bag of ground meat dated 04/20, and an open package of frozen chicken patties with no date. The Dietary Aide stated the floor by the dishwasher had poor repair and that the oven had been broken for two weeks, while the Dietary Manager said the kitchen should be clean and in good repair, food should not be on the floor, the ceiling should be free of stains, and food should be labeled and dated. The Maintenance Supervisor said he was responsible for kitchen repairs and was not aware the oven was not working, and the Administrator stated the kitchen should be clean, sanitary, and have working equipment.
Dirty Vents, Scuffed Handrail, and Damaged Dining Room Ceiling
Penalty
Summary
The facility failed to provide a clean and home-like environment when multiple vents in the hallways and outside resident rooms were observed covered in dust, dirt, and debris, the handrail across from the public bathroom near the serving station had a black scuff mark running the length of the rail, and the dining room ceiling had three brown spots the size of grapefruits. A 3-foot piece of the ceiling was also observed falling down in the dining room by the door with a high voltage sign on it. These conditions were observed on multiple dates and remained present during repeated observations. During interview, the Maintenance Supervisor stated he was responsible for cleaning the vents, checking them for cleanliness and disrepair at least every quarter, but he could not remember the last time the vents were cleaned. He also stated he was responsible for ensuring the dining room ceiling was clean and in good repair, that the handrail by the dining room should be clean and in good repair, and that he was responsible for ensuring the facility was in good repair. The Administrator stated she expected the facility to be clean and in good repair and expected the vents to be clean and monitored for dust and dirt at least every week or so.
Failure to Provide Proper Perineal Care and ADL Assistance
Penalty
Summary
The facility failed to ensure dependent residents received proper perineal care and assistance with activities of daily living when staff did not clean residents appropriately after incontinence or toileting episodes. The report cites three residents who were dependent on staff for hygiene-related care and who had care plans or assessments indicating the need for assistance with toileting hygiene, personal hygiene, and skin protection. Facility training and policy stated that soiled items should not be placed on clean surfaces, wipes should not be reused, and cleansing should be performed away from the peri-area. For one resident with quadriplegia, encephalopathy, schizophrenia, psychotic disorder, an indwelling catheter, and bowel incontinence, an LPN was observed performing wound care and peri-care while feces was present in the brief. The LPN wiped feces from the lower abdominal area down toward and into the peri-area, used multiple swipes with the same wipe, placed soiled wipes between the resident’s legs, and left trash bags and soiled items on the floor and bed area. The resident stated the care hurt, and the LPN acknowledged afterward that feces should not have been wiped toward the peri-area, that only one swipe per wipe should have been used, and that help should have been obtained. For another resident who was incontinent of urine and required maximum assistance with toileting hygiene, a CNA assisted the resident to the toilet, removed the saturated brief, and after the resident urinated, helped the resident stand and dressed the resident without providing perineal hygiene. For a third resident who was dependent on staff for all hygiene, toileting, and transfers and was at risk for skin breakdown related to urinary incontinence, staff assisted the resident to the toilet with a mechanical lift, removed the saturated brief, and wiped only the front perineal area before changing the brief and clothing. Neither staff member wiped the buttocks or inner thighs. Interviews with staff and the DON confirmed that all areas touched by urine should be cleaned, including the penis, thighs, buttocks, and other perineal areas.
Failure to Provide Proper Catheter Care and Timely Urine Collection
Penalty
Summary
The facility failed to provide appropriate catheter care and perineal care for a resident with an indwelling catheter and total dependence for activities of daily living. The resident had a history of urinary tract infections, was cognitively impaired, incontinent of bowel, and dependent on staff for care. During observation, an LPN entered the room to provide wound care and found feces in the resident’s brief, then wiped feces from the lower abdominal area down into the peri-area and catheter insertion point using multiple swipes with the same wipe. Soiled wipes were left on the chuck beneath the resident, the catheter tubing was stretched tightly and not anchored to the thigh, and the catheter tube was not cleaned directly or secured with a catheter lock or leg-anchoring device. The resident’s care plan identified the resident as totally dependent on staff and at risk for urinary tract infection, with staff to monitor and report signs and symptoms of UTI. The facility’s catheter care and perineal care training stated that staff should use one wipe, one swipe, wipe away from the peri-area, avoid placing soiled items on clean surfaces, and ensure catheter tubing is strapped to the inner thigh. During interview, the LPN acknowledged that feces should not be wiped toward the catheter or peri-area and that an anchoring device should be in place. The IC nurse and DON also stated that feces should be wiped away from the catheter and peri-area, that only one swipe should be used per wipe, and that the catheter tubing should not be stretched tightly. The facility also failed to collect a physician-ordered urine sample for eight days for another resident who was incontinent of urine and dependent on nursing staff for hygiene, toileting, and transfers. The resident had complaints of burning and irritation with urination, later reported bladder pain and fullness, and a UA was ordered. The record showed a device was placed in the toilet for urine collection, but the urine sample was not collected until eight days after the initial complaint and order. The resident later received Bactrim DS for UTI treatment. During interview, the resident stated there was a delay in collecting the UA and that this caused a shot of antibiotics. The DON stated urine should be collected the day the order is received and that the delay in analysis and treatment was not reasonable.
Medication Administration Errors With Crushing and Fluid/Food Instructions
Penalty
Summary
Medication administration errors occurred when staff failed to follow physician orders and medication instructions for Resident #16, whose quarterly MDS showed intact cognition, dementia, diabetes, respiratory failure, and need for assistance with ADLs. The physician order sheet included Meloxicam 7.5 mg to be taken with food and plenty of water, Metoprolol Succinate Extended Release 25 mg with instructions not to crush, and Potassium Chloride 20 mEq with instructions not to crush and to give with or after food and at least 120 mL of water. The facility also had an order that medications could be crushed if appropriate. During observation, CMT B obtained the medications without verifying the orders, placed all medications in one medicine cup, crushed all of them, and mixed the crushed tablets with applesauce before administering them to the resident while he/she was still in bed. The medications given included Meloxicam, Metoprolol Succinate, Donepezil, and Potassium Chloride, and only about 60 mL of water was provided during administration. CMT B stated the MAR showed which medications could not be crushed and that a daily report was received with medication preferences. The DON stated physician orders were expected to be followed and that medications should not have been crushed unless ordered.
Improper Dating and Storage of Open Medications and Glucose Control Solutions
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals. During observation of the nurse's medication room, an opened bottle of lorazepam for Resident #8 was found with no open date. Resident #8's MDS showed cognition was not intact, the resident required staff assistance to receive medications, and the resident had diagnoses of anxiety, heart failure, and diabetes. An observation of the East Hall medication cart also found an open bottle of Aspirin 81 mg, an open bottle of acetaminophen 650 mg, an open bottle of Vitamin B12 25 mcg, and open multi-use vials of high glucose control drops and regular glucose control drops, all with no open dates. The facility also had three opened bottles of glucose control solution with no open date. Staff interviews showed uncertainty about dating opened medications and glucose control drops, and the DON stated that all medications should be dated when opened and that a multi-dose bottle of lorazepam is good to use for 30 days.
Failure to Use PPE, Change Gloves, and Clean Shared Equipment
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when staff did not use proper PPE during high-contact care, did not change gloves or perform hand hygiene between dirty and clean tasks, and did not sanitize vital sign equipment between resident uses. The deficiency affected two of 12 sampled residents in a census of 32. The facility policy on Enhanced Barrier Precaution required gown and glove use for high-contact resident care activities, including bathing, transferring, and providing hygiene, and the hand hygiene policy stated that gloves are for single use only, hands should be sanitized before applying gloves, and gloves must be changed between dirty and clean tasks. One resident had a suprapubic catheter, was dependent on staff for care and transfers using a mechanical lift, and had diagnoses including high blood pressure, kidney disease, and obstructive uropathy. Staff entered the room without gown or gloves, used facility vital sign equipment to assess vitals and administer medications, and then left the room with the blood pressure cuff and thermometer without cleaning them. The same resident was later observed receiving morning care from CNA staff who entered without appropriate PPE and provided transfer, peri care, grooming, and dressing without isolation gowns. A second resident required maximum assistance with toileting hygiene and had diagnoses including high blood pressure, malnutrition, and high cholesterol, along with foot wounds and need for assistance with personal hygiene. During care, a CNA used the same soiled gloves while removing an incontinent brief, applying clean clothing, transferring the resident, touching the resident's face, and setting up toothbrush and toothpaste, then removed the gloves and washed hands only after leaving the room.
PASARR Screening Not Completed Before Admission
Penalty
Summary
Failure to ensure a Level I PASARR assessment was completed before admission occurred for one resident with significant mental and physical health needs. The resident’s MDS dated 03/27/26 showed cognition was not intact, dependence on staff for activities of daily living, and diagnoses including quadriplegia, encephalopathy, schizophrenia, and psychotic disorder. The care plan revised 03/31/26 noted the resident was on palliative services, used psychotropic and anti-anxiety medications related to schizophrenia, mood disorder with psychotic features, and dementia with behavioral features, and was totally dependent on staff for care. The medical record contained no documentation that a Level I PASARR had been completed. During interviews, the MDS coordinator stated the first authorization process was when the PASSAR was collected and that the Administrator handled that process, while the DON said the facility did not have social services for six months and had been unable to locate a PASSAR for the resident. The DON also stated a PASSAR level one pre-screening should be completed before admission and that the facility had not been aware of the requirement to complete the screening.
Inaccurate pain and continence documentation on weekly LTC evaluations
Penalty
Summary
The facility failed to provide care and services that met professional standards when nursing staff did not accurately document pain and urinary continence status on weekly LTC evaluations for one resident. The resident’s quarterly MDS dated 04/08/26 showed no cognitive impairment, frequent pain, always incontinent of urine, dependence on nursing staff for all hygiene cares, toileting, and transfers, and diagnoses including heart failure, high blood pressure, and chronic pain. The care plan dated 03/25/26 identified chronic pain to the arm, legs, and back due to osteoarthritis and directed staff to monitor and record pain characteristics every four hours while awake, including quality, severity, location, onset, duration, and aggravating or relieving factors. Review of the EMR showed weekly LTC evaluations documenting no pain for the prior seven days and continence of urine, even though nursing documentation during those same periods showed the resident was incontinent on most shifts and received frequent scheduled, PRN, and topical pain medications. The record also showed multiple physician-ordered pain assessments where the resident rated pain at 1 or more, but many lacked additional required details such as quality, onset, and location. During interviews, the resident stated he/she had daily pain for years and preferred around-the-clock oral pain medication to prevent worsening pain. Nursing and management staff stated that pain documentation should reflect the resident’s status, that weekly LTC evaluations should indicate pain for residents on scheduled pain medications, and that documentation from the EMR is used by staff, physicians, and other providers to gather resident information.
Sanitization and Food Storage Deficiencies
Penalty
Summary
The facility failed to ensure that the sanitizer used for cleaning food contact surfaces was at the appropriate concentration to effectively sanitize these surfaces. During observations, it was found that three containers of sanitizer in the kitchen tested at zero parts per million (ppm) of quaternary sanitizer, which is below the required 150 to 400 ppm as per the manufacturer's instructions. The Culinary Director confirmed that the sanitizer was not at the correct concentration and should have been at 400 ppm. This deficiency was observed during multiple instances, indicating a consistent failure to maintain proper sanitization levels. Additionally, the facility did not adhere to its policy regarding the labeling and discarding of food items. Observations revealed that food stored in the walk-in refrigerator and the resident refrigerator was either not labeled with a use-by date or was kept beyond the expiration date. Items such as sliced turkey, bologna, corn beef, and yogurt were found with expired dates or no dates at all. The Culinary Director verified these findings and acknowledged that the facility policy required food to be discarded within seven days of opening, which was not followed in these instances.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure that residents' rights to participate in the care planning process were honored for two residents, R11 and R32, out of a sample of 16. R11, who was admitted with multiple medical diagnoses including chronic ischemic heart disease and atrial fibrillation, reported not having any care plan meetings. The facility's records showed no documentation of a care plan conference or provision of baseline care plan goals for R11, despite being admitted over three months prior. The MDS Coordinator confirmed that no care plan meeting had occurred and there was no signed baseline care plan available. Similarly, R32, who was admitted with conditions such as a knee periprosthetic fracture and dementia, also reported not having any discussions about care or medications. The facility's records lacked documentation of care plan conferences or invitation letters for R32, and although a baseline care plan was found, it was unclear who received it due to an illegible signature. The MDS Coordinator acknowledged that a care plan meeting for R32 was missed due to changes in the resident's plans to stay or go home. The Director of Nursing stated that residents should ideally participate in care plans, but this expectation was not met for R11 and R32.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman of emergent hospital transfers for two residents, R31 and R35, as required by their policy. The policy titled 'Transfer or Discharge - Emergency' did not address the necessary Ombudsman notification, and the 'Requirements for Emergency Discharge' policy required that a copy of the transfer or discharge notice be sent to the Ombudsman. R31 was transferred to the hospital on two occasions, once for dizziness and a change in responsiveness, and another time for a critical low hemoglobin level. Despite these transfers, the facility's reports to the Ombudsman did not include R31's name for either incident, which was confirmed by the Social Services Director (SSD) and the Executive Director. Similarly, R35 was transferred to the hospital due to a change in condition and non-responsiveness, and was readmitted to the facility two days later. However, the SSD confirmed that R35's transfer was not included in the list of discharges sent to the Ombudsman for that month. The Ombudsman verified that they were not notified of R35's transfer or discharge. The failure to include these residents in the Ombudsman notifications was attributed to an issue with the facility's electronic medical record system, which did not account for residents with paid bed holds.
Failure to Document Indications for Antipsychotic Medication Increase
Penalty
Summary
The facility failed to ensure that a resident, identified as R5, had documented indications for an increase in their antipsychotic medication, Seroquel, and did not attempt a gradual dose reduction without clinical rationale. R5, who was admitted with diagnoses including congestive heart failure, dementia, and generalized anxiety disorder, was receiving Seroquel at a dose of 50 mg three times a day. The increase in dosage was ordered by hospice at the request of the resident's daughter, who was concerned about managing the resident's behaviors while she was recovering from surgery. The facility's policy on psychoactive drug monitoring requires that residents receive such medication only with supporting documentation in the medical record, and that gradual dose reductions be attempted unless clinically contraindicated. However, the review of R5's records did not show an increased number of behaviors that would justify the dosage increase. The Director of Nursing (DON) acknowledged that the increase was ordered by hospice without asking for justification and noted that it would be ideal if indications for use were documented. Behavior monitoring for September 2024 documented several incidents of care rejection and other behaviors, but the facility did not provide sufficient clinical rationale for the dosage increase. Additionally, the resident's care plan included a focus on behavior management with an intervention to consider dosage reduction when clinically appropriate, but this was not followed. The DON also noted that the family was not agreeable to a trial dose reduction, despite the lack of an appropriate diagnosis for the increased dosage.
Improper Labeling and Storage of PPD Vials
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals, specifically concerning the Mantoux tuberculin purified protein derivative (PPD) vials. During an observation in the medication room, it was found that one of the three vials in the refrigerator was open and undated, which is against the facility's policy and CDC guidelines. The policy requires that medications and biologicals be stored safely and properly, following the manufacturer's recommendations, which include discarding vials 30 days after opening if not used. The Licensed Practical Nurse (LPN) confirmed the absence of an open date on the vial and set it aside for disposal. The Director of Nursing (DON) stated that the expectation was for vials to be dated upon opening and discarded when expired. The failure to date the open vial could lead to inaccurate tuberculosis testing due to the potential degradation of the PPD solution, which might result in false positive or negative results. This oversight was identified during a facility survey, highlighting a deficiency in the facility's medication management practices.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to accommodate a resident's dietary preferences, which was observed during a survey. The resident, who has a history of chronic ischemic heart disease, atrial fibrillation, and congestive heart failure, expressed concerns about receiving foods that were not suitable for their condition. Despite having a list of foods to avoid, including bacon, posted on their bulletin board, the resident reported receiving bacon for breakfast, which they had not requested. This discrepancy was confirmed during an observation of the resident's breakfast tray, which included bacon despite the tray card indicating a dislike for it. Interviews with facility staff revealed a lack of communication and adherence to the resident's dietary preferences. The Dietary Aide responsible for serving the meal was unaware of the notes and dislikes section on the tray card, and the Restorative Aide admitted to mistakenly writing down bacon instead of sausage, which the resident had requested. The Director of Nursing indicated that CNAs were responsible for communicating menu choices to residents, but this process failed in this instance, leading to the resident receiving inappropriate food items.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Gladstone
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ignite Medical Resort Kansas City, Llc | 2.4 mi | ★★★★★ | 11 | 0 |
| Pleasant Valley Manor Care Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Northland Rehabilitation & Health Care Center | 4.4 mi | ★★★★★ | 2 | 0 |
| Mccrite Plaza At Briarcliff Skilled Facility | 5 mi | ★★★★★ | 3 | 0 |
| Pinnacle Point Wellness & Rehabilitation | 5.2 mi | ★★★★★ | 14 | 0 |
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