Lotus Village Center For Nursing And Rehabilitatio
Inspection history, citations, penalties and survey trends for this long-term care facility in Sparta, North Carolina.
- Location
- 179 Combs Street, Sparta, North Carolina 28675
- CMS Provider Number
- 345261
- Inspections on file
- 30
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Lotus Village Center For Nursing And Rehabilitatio during CMS and state inspections, most recent first.
A resident admitted for rehab after an exploratory laparotomy with new colostomy had a hospital discharge order for twice-daily wet-to-dry NS dressings to a 4 cm abdominal wound with seropurulent drainage, but this order was not transcribed onto the physician orders or TAR. The admitting nurse reviewed the discharge summary only for medications, and the DON skimmed the summary and later forgot to recheck for incision care orders, resulting in no wound treatment being set up. Subsequent nurses assessed the incision but did not provide wound care, and the PA later stated that staff should have read the entire discharge summary and contacted him if no incision orders were found.
A resident admitted after abdominal surgery with a new colostomy had no documented assessments of the colostomy or abdominal incision for the entire stay. Multiple RNs and the DON reported that they assessed the colostomy and incision and that new admissions should have shift-by-shift documentation focused on the reason for admission, but each either forgot to chart or could not confirm their assessments when shown the lack of entries. The Regional Nurse Consultant confirmed the absence of any such documentation, and a PA noted he relies on nursing assessments in the medical record for treatment planning, demonstrating that required clinical assessments were not recorded.
A resident with a neurogenic bladder and chronic indwelling urinary catheter did not have their catheter changed as ordered due to a failure to transcribe the physician's order onto the MAR/TAR. Staff interviews confirmed the omission, and the DON acknowledged that the order was not visible to nursing staff, resulting in the catheter not being changed as scheduled.
A resident with multiple chronic conditions experienced a worsening allergic reaction, including a spreading rash and low-grade fever, after starting an antibiotic. A one-time IM dose of methyl prednisolone was ordered but not administered as scheduled, and nursing staff failed to notify the physician of the delay. The medication was not given until five days later, despite the resident's ongoing symptoms and the nurse practitioner's expectation for timely administration or notification.
A resident with a worsening allergic reaction did not receive a prescribed one-time IM methylprednisolone injection for five days due to nursing staff failing to check the backup medication supply, despite the medication being available. The resident experienced severe itching and rash during this period, and the error was only discovered after the NP followed up on the unadministered order.
A resident's MDS assessment was inaccurately coded in the dental section because the remote MDS Coordinator did not request or ensure a dental assessment was completed during the required period. Nursing documentation confirmed that no dental assessment was performed, and facility leadership expected the dental status to be accurately documented.
A resident with multiple chronic conditions was scheduled for dental extractions, but the facility failed to withhold aspirin as ordered by the NP. The order to hold the antiplatelet medication was documented but not transcribed to the MAR, resulting in continued administration of aspirin and a delay in the dental procedure. Communication lapses among staff contributed to the failure to follow the physician's order, and the resident later required antibiotics and eventually received the extractions.
A resident with severe cognitive impairment was found with Sodium Polyacrylate and solidified fruit punch within reach, posing a potential ingestion hazard. The facility staff, including nurse aides and the DON, were unable to determine how the substance entered the facility. Despite monitoring the resident for gastrointestinal symptoms, no adverse effects were observed.
A cognitively impaired resident in a memory care unit managed to remove a windowpane and exit the facility unsupervised after being denied a smoke break. The resident walked to a nearby gas station before being found and returned by law enforcement. The incident revealed lapses in supervision and security, as the resident had no prior history of elopement and was not considered at risk.
A facility failed to notify the medical provider of an alleged sexual abuse incident involving two residents. Despite staff reporting the incident to the Administrator and DON, the medical provider and family were not informed immediately. The NP was only notified days later, delaying potential medical intervention. The Administrator assumed the notification would be handled the next day, resulting in a deficiency.
A resident with cognitive impairments hit another resident in the eye, believing the victim was viewing inappropriate content on a shared computer. The victim, who had aphasia, avoided the aggressor and the computer for over a week. Staff intervened, and the aggressor was placed under supervision. The facility's computer system was designed to prevent access to inappropriate content.
A facility failed to prevent illegal substances from entering, affecting resident safety. A resident, legally blind, mistakenly ingested methamphetamine left in her room by an unknown individual. Another resident tested positive for THC, linked to a shared vape pen. Drug canines detected scents, but no substances were found. A known drug dealer's visit raised security concerns.
A resident with a history of brain damage, dysphagia, hypertension, and gastrostomy experienced severe septic shock, UTI, and necrotic changes to the left testicle, necessitating its removal. The facility did not recognize the urgency of a Nurse Practitioner's order for a urology appointment following an ultrasound indicating decreased vascular flow. The appointment was scheduled for a later date, resulting in delayed care. Additionally, the facility failed to conduct thorough and ongoing nursing assessments and did not notify the NP or MD when the appointment was not scheduled as ordered, leading to an acute change in the resident's condition.
A facility failed to promptly address decreased vascular flow to a resident's left testicle, despite reports of scrotal swelling and tenderness. Initial assessments led to an ultrasound and antibiotics, but delays in scheduling a urology consultation prolonged necessary medical interventions. The resident's condition worsened, resulting in severe septic shock, a urinary tract infection, and necrotic changes, ultimately necessitating the removal of the testicle. Multiple staff members were aware of the issue, but consistent documentation and follow-up were lacking, and scheduling challenges further delayed care.
A facility experienced a communication breakdown when a urology consult could not be scheduled as ordered by the NP for a resident with a history of anoxic brain injury, persistent vegetative state, and neurogenic bladder. An ultrasound indicated decreased vascular flow to the resident's left testicle, prompting the NP to order an urgent urology consult. The Scheduler faced difficulties in securing the appointment and did not notify the NP or MD, leading to a delay. This delay resulted in the resident developing severe sepsis and requiring an emergency left orchiectomy.
The facility's QAA committee failed to maintain procedures and monitor interventions, leading to repeated deficiencies in Notification of Change, Neglect, and Quality of Care. A resident experienced severe sepsis and an emergency orchiectomy due to delayed medical consultations and inadequate nursing assessments.
Failure to Transcribe and Provide Ordered Surgical Wound Care on Admission
Penalty
Summary
The deficiency involves the facility’s failure to transcribe and implement a physician’s order for surgical wound care upon admission, resulting in the absence of ordered treatment for a resident’s abdominal incision. The resident was admitted following an exploratory laparotomy with creation of a colostomy related to diverticulitis with perforation. The hospital discharge summary documented that on the day of discharge the physician opened a 4 cm portion of the wound below the umbilicus due to seropurulent drainage and ordered wet-to-dry dressing changes with normal saline twice daily. Review of the admission physician orders and the Treatment Administration Record for the admission and following day showed no orders for wet-to-dry dressings or any surgical wound care. The resident’s discharge MDS later documented discharge to home/community with return not anticipated. Nurse #1, who admitted the resident, stated she reviewed the hospital discharge summary only for medication orders and did not read the entire summary, resulting in failure to transcribe the wound care order to the TAR. She reported having a very busy day and acknowledged that between herself and the DON, the treatment order should have been entered. The DON confirmed she assisted with the admission, entered medication orders, assessed the incision, and skimmed the discharge summary, recognizing later that she had not seen incision care orders and then forgot to recheck the summary. Nurse #2 and Nurse #3, who cared for the resident on subsequent shifts, recalled the resident and his new colostomy but indicated they would need to review the record to identify any treatment orders; Nurse #3 confirmed she assessed the incision but did not provide treatment. The Physician Assistant stated nurses are expected to read the entire discharge summary for all discharge orders and that, in the absence of incision care orders, the facility should have contacted him for interim orders.
Failure to Document Assessments for New Colostomy and Abdominal Incision
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident admitted after an exploratory laparotomy with creation of a new colostomy. From admission to discharge, the resident’s chart contained no documented assessments of the abdominal incision or the new colostomy. Multiple nurses, the DON, and the Regional Nurse Consultant all acknowledged that assessments should be documented every shift for new admissions, particularly related to the reason for admission, yet no such documentation existed for this resident during the entire stay. Nurse #1 reported assessing the resident’s new colostomy and abdominal incision, describing a damp gauze packed in the bottom of the incision with a dry gauze over it, but admitted she did not document her assessment, intending to do so later and then forgetting after the resident was discharged. Nurse #2 stated that assessments should be documented every shift and recalled the resident had a colostomy, but when informed there was no assessment documented, she could not confirm whether she had assessed the colostomy or incision and said she would need to refer to the record. Nurse #3 stated she assessed the colostomy, which was almost full with a good seal, and also assessed the abdominal incision, but when shown there was no documentation, she acknowledged she must have forgotten to chart it. The DON stated she also looked at the resident’s colostomy and incision but did not document her assessment and did not follow up with nurses when she later noted the absence of documentation. The Regional Nurse Consultant confirmed there were no documented assessments of the colostomy or incision, and the Physician Assistant stated he relies on nurses’ assessments in the medical record for treatment planning, underscoring the absence of required documentation.
Failure to Change Indwelling Urinary Catheter as Ordered
Penalty
Summary
A resident with a history of neurogenic bladder and a chronic indwelling urinary catheter was admitted to the facility with physician orders specifying that the catheter should be changed on a particular date. The order for the catheter change was transcribed into the resident's medical record by a nurse, but it was not entered into the Medication Administration Record (MAR) or Treatment Administration Record (TAR). As a result, the scheduled catheter change was not performed as ordered. Interviews with facility staff, including the nurse responsible for the admission and the Director of Nursing (DON), confirmed that the omission occurred because the order was not properly processed to appear on the MAR or TAR. The DON acknowledged that without the order on these records, nursing staff would not be aware of the need to change the catheter. The Nurse Practitioner (NP) and Administrator both stated that their expectation was for the catheter to be changed as ordered, but this did not occur during the resident's stay.
Failure to Notify Physician of Missed Steroid Dose for Allergic Reaction
Penalty
Summary
The facility failed to notify the physician when a one-time dose of methyl prednisolone, ordered for the treatment of an allergic reaction, was not administered as prescribed. Nursing staff documented that the medication was on order but did not inform the physician of the delay or request further instructions. The medication, intended to address a worsening rash, increased redness, hives, itching, and a low-grade fever, was not given until five days after it was ordered. The nurse initialed the Medication Administration Record (MAR) and noted the medication was on order, but did not communicate the missed dose to the physician as expected. The resident involved had a history of heart failure, hypertension, and chronic pain, and developed a severe rash after starting an antibiotic. The rash worsened over several days, spreading and causing significant discomfort, including intense itching and skin peeling. Despite the resident's deteriorating condition and the nurse practitioner's expectation for prompt administration or notification if the medication could not be given, the physician was not notified of the delay, resulting in a significant lapse in care.
Failure to Administer Ordered Steroid Injection Resulting in Significant Medication Error
Penalty
Summary
A deficiency occurred when the facility failed to ensure a one-time dose of methylprednisolone (a steroid) intramuscular injection, prescribed for the treatment of an allergic reaction, was administered as ordered. The resident, who had a history of heart failure and chronic pain, developed an itchy, erythematous rash with hives and a low-grade fever after being treated with clindamycin for a gum abscess. The nurse practitioner (NP) discontinued clindamycin and prescribed alternative medications, including oral and topical treatments, but as the rash worsened, the NP ordered a one-time intramuscular injection of methylprednisolone. Despite the order, the injection was not administered for five days. Nurse #1, who was responsible for giving the injection, did not find the medication on the cart and was incorrectly informed by another nurse that it was not available in the backup medication supply. Although the backup supply did contain the medication, Nurse #1 did not access it and instead passed the responsibility to the oncoming nurse, assuming the medication would be administered once delivered by pharmacy. The medication remained unadministered until the NP discovered the omission during a subsequent visit and directed that the injection be given. Interviews with facility staff, including the Director of Pharmacy Operations, confirmed that the medication was available in the backup supply and had not been removed or administered as ordered. The Director of Nursing and Administrator acknowledged that the nurse should have checked the backup supply and administered the medication as ordered. The resident continued to experience significant discomfort, including widespread rash and severe itching, during the delay in administration.
Inaccurate MDS Dental Assessment Due to Lack of Coordination
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment in the area of dental for one resident. The resident was admitted to the facility and had a significant change MDS assessment completed, which indicated that the dental status was unable to be examined. The MDS Coordinator responsible for this assessment was working remotely at the time and was no longer employed by the company, making them unavailable for follow-up. Interviews with the Administrator and Director of Nursing (DON) revealed that the remote MDS Coordinator did not reach out to nursing staff or the DON to request a dental assessment during the lookback period, and a review of nursing documentation confirmed that no dental assessment was completed at that time. Both the Administrator and DON stated that they expected the dental status to be accurately completed on the MDS assessment.
Failure to Withhold Antiplatelet Medication Prior to Dental Procedure
Penalty
Summary
The facility failed to withhold an antiplatelet medication, specifically aspirin, as ordered by the Nurse Practitioner prior to a scheduled dental extraction for a resident with diagnoses including heart failure, hypertension, and chronic pain. The physician's order to hold aspirin for three days before the dental procedure was documented on the dental consent form but was not transcribed to the Medication Administration Record (MAR). As a result, nursing staff continued to administer aspirin to the resident from 11/1/24 through 11/6/24, contrary to the order. This oversight led to the cancellation of the scheduled dental extractions, as the dental provider could not proceed while the resident was still taking aspirin. Interviews with facility staff revealed a breakdown in communication and process regarding the handling and transcription of physician orders related to dental procedures. The DON and Administrator stated that the expected process was for the signed dental form to be given to the Unit Manager and then to the assigned nurse for transcription to the MAR, but this did not occur. The Unit Manager reported not receiving the relevant dental notes or forms. The resident did not report pain at the time of the missed extraction, but later developed a gum abscess requiring antibiotics and eventually underwent extractions after the medication issue was resolved.
Potential Hazard from Sodium Polyacrylate in Resident's Room
Penalty
Summary
The facility failed to maintain an environment free from potential hazards when Sodium Polyacrylate, a super-absorbent powder, and a glass of solidified fruit punch were left within reach of a resident with severe cognitive impairment. The resident, who required extensive assistance for daily activities and was on a dysphagia mechanical diet, was found with these items on his bedside table. The presence of these items posed a risk of ingestion, which could lead to gastrointestinal obstruction, as noted by Poison Control. The incident was discovered by a nurse aide who found the bottle of Sodium Polyacrylate and the solidified fruit punch during her shift. She reported the findings to the nurse, who then contacted Poison Control for guidance. Despite the uncertainty of whether the resident ingested the substance, the facility's staff monitored the resident for any signs of gastrointestinal distress as advised by Poison Control. The resident showed no symptoms and was stable throughout the monitoring period. Interviews with various staff members, including the Dietary Manager, Nurse Aides, and the Director of Nursing, revealed that the source of the Sodium Polyacrylate was unknown, and it was not a substance typically used or ordered by the facility. A search of the facility did not uncover any additional Sodium Polyacrylate, and the maintenance and supply staff confirmed that they had not ordered or used the substance. The facility was unable to determine how the Sodium Polyacrylate ended up in the resident's room, highlighting a lapse in ensuring a safe environment for residents.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to adequately supervise a cognitively impaired resident, leading to the resident exiting the locked memory care unit unsupervised. The resident, who had Alzheimer's disease, dementia, and other conditions, was able to remove a windowpane and exit through a window. This incident occurred after the resident requested to go outside to smoke and was told by staff that it would be a while before they could take him out. The resident returned to his room, and staff continued with their duties, unaware of his subsequent actions. The resident managed to exit through a window in an adjoining room, which was 79 inches from the ground, and walked approximately 2/10 mile to a convenience store. The staff discovered the resident missing during routine rounds and initiated a search. The resident was found by a staff member at a nearby gas station and was returned to the facility by law enforcement. The incident highlighted a significant lapse in supervision and security measures, as the resident was able to remove a heavy glass windowpane and leave the facility unnoticed. Interviews with staff and law enforcement revealed that the resident had no prior history of elopement and was not considered at risk for such behavior. The facility's maintenance staff had previously conducted audits to ensure windows could not open more than 7 inches, but the resident was still able to remove the windowpane. The incident raised concerns about the facility's ability to prevent similar occurrences, given the resident's cognitive impairments and the potential for serious harm.
Failure to Notify Medical Provider of Alleged Abuse
Penalty
Summary
The facility failed to notify the medical provider of an alleged sexual abuse incident involving Resident #2. On the night of the incident, Nurse Aides reported to Nurse #4 that Resident #1 had confessed to being sexually inappropriate with Resident #2. Nurse #4, who was not directly responsible for either resident, informed Nurse #5, the supervisor, about the allegation. Both nurses then contacted the facility Administrator and Director of Nursing (DON) for further instructions. However, neither the medical provider nor the family of Resident #2 was notified immediately, as the Administrator assumed the notification would be handled the following day. The Nurse Practitioner (NP) was not informed of the alleged abuse until several days later, which delayed any potential medical examination or intervention. Upon learning of the incident, the NP conducted a vaginal examination on Resident #2, which showed no signs of trauma. The DON expected that the medical provider and family would be notified, but this did not occur. The Administrator acknowledged that the notification was not completed as expected, leading to a deficiency in the facility's response to the alleged abuse.
Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when one resident hit another resident in the left eye with a closed fist. This incident occurred after the aggressor believed the victim was looking at inappropriate pictures on a shared facility computer. The victim, who had a red area under his left eye, avoided the aggressor and the use of the shared computer for approximately a week and a half following the incident. The victim, identified as Resident #4, was admitted to the facility with diagnoses including aphasia, which affected his ability to communicate verbally. His care plan emphasized the importance of engaging in meaningful daily routines, including using the computer. Despite being moderately cognitively impaired, Resident #4 was usually able to make himself understood and had no prior behaviors. The aggressor, identified as Resident #7, was admitted with diagnoses including schizophrenia and generalized anxiety. He was also moderately cognitively impaired and exhibited signs of delirium and delusions. On the day of the incident, staff members, including nurses and nurse aides, responded to the altercation. Resident #7 was placed on one-on-one supervision following the event. Interviews with staff and residents revealed that Resident #7 was confused and had difficulty being redirected, while Resident #4 was known to spend significant time on the computer without accessing inappropriate content. The facility's computer system was designed for the elderly population, making it unlikely for inappropriate content to be accessed.
Failure to Prevent Illegal Substances in Facility
Penalty
Summary
The facility failed to prevent illegal substances from entering the premises, affecting the safety and supervision of residents. Resident #3, who is legally blind and has a history of methamphetamine use, reported that an unknown individual in a wheelchair entered her room and left a substance on her table, which she mistakenly identified as candy. Upon tasting it, she recognized it as methamphetamine laced with fentanyl. The resident's family member, a Sheriff's Deputy, confirmed the substance's identity after testing it at the police department. Despite the resident's inability to identify the individual, the incident raised concerns about the facility's security measures and supervision protocols. Resident #1, who is cognitively intact, was involved in a separate incident where he tested positive for THC after being transferred to the hospital. During a police investigation, drug canines detected a scent at Resident #1's room, although no illegal substances were found. Resident #1 initially claimed to have received marijuana from another resident but later admitted to sharing a vape pen containing marijuana with his girlfriend, Resident #6. The vape pen was reportedly stolen from a staff member, although the staff member denied owning it. The facility's administrator was informed of these incidents and requested a search of the facility using drug canines. The investigation revealed that a known drug dealer had visited the facility earlier, raising further concerns about the facility's ability to control access and prevent illegal substances from entering. The administrator's efforts to address the situation included interviewing staff and residents, but the incidents highlighted significant lapses in the facility's supervision and security protocols.
Delayed Urology Appointment Leads to Severe Medical Complications
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect when they did not identify the seriousness of a left swollen testicle for Resident #1. Despite a Nurse Practitioner's order for a urology appointment due to decreased vascular flow noted in an ultrasound, the facility scheduled the appointment for a later date, leading to a delay in care. Resident #1 experienced a serious adverse outcome with severe septic shock, urinary tract infection, and necrotic changes to the left testicle, ultimately requiring its removal. Immediate Jeopardy was identified when the facility did not recognize the urgency of the situation, resulting in a delay in necessary medical intervention. The deficiency was further highlighted by the failure to complete thorough and ongoing nursing assessments of the testicle and to notify the Nurse Practitioner or Medical Doctor when the urology appointment was not scheduled as ordered. This lack of timely action led to Resident #1's acute change in condition, requiring emergency care and eventual orchiectomy. The deficiency was exacerbated by the facility's failure to promptly address the medical concerns for Resident #1, who had a history of brain damage, dysphagia, hypertension, and gastrostomy upon admission. The delay in scheduling the urology appointment, inadequate assessments, and lack of communication regarding the testicle's condition culminated in a serious medical emergency for Resident #1, underscoring the facility's failure to protect the resident from neglect.
Delayed Urology Consultation and Inadequate Documentation of Vascular Flow Issues
Penalty
Summary
The deficiency identified in the report pertains to the facility's failure to recognize and address the seriousness of decreased vascular flow to Resident #1's left testicle. Despite reports of scrotal swelling and tenderness, thorough and ongoing nursing assessments of the left testicle were not documented. The Nurse Practitioner (NP) ordered an ultrasound and antibiotics upon initial assessment of the swelling, but delays in scheduling a urology consultation prolonged the Resident's access to necessary medical interventions. The Resident's condition deteriorated, leading to a diagnosis of severe septic shock, urinary tract infection, and necrotic changes in the left testicle, ultimately resulting in the removal of the testicle. Multiple staff members, including Nurse Practitioners, Wound Physicians, and Nurse Aides, were aware of the Resident's scrotal swelling but there was a lack of consistent documentation and follow-up on the issue. The facility's Scheduler faced challenges in scheduling a timely urology consultation, leading to significant delays in the Resident receiving appropriate care. Despite concerns raised by the Resident's family member and healthcare providers, the urgency of the situation was not fully recognized or acted upon promptly, contributing to the Resident's worsening condition.
Communication Breakdown in Scheduling Urology Consult Leads to Acute Condition
Penalty
Summary
The facility failed to notify the Nurse Practitioner or the Medical Doctor when a Urology Consult was not able to be scheduled per the Nurse Practitioner's order for Resident #1, who had a history of anoxic brain injury, persistent vegetative state, and neurogenic bladder. The Nurse Practitioner ordered a urology consult as soon as possible after an ultrasound showed decreased vascular flow to Resident #1's left testicle on 02/19/24. However, the Scheduler encountered difficulties in scheduling the appointment promptly, leading to a delay in Resident #1 receiving the necessary urology consultation. This delay resulted in Resident #1 experiencing an acute change in condition on 03/11/24, leading to a diagnosis of severe sepsis and necessitating an emergency left orchiectomy. Despite the Nurse Practitioner's order for an urgent urology consult, the Scheduler faced challenges in promptly securing an appointment for Resident #1. The Nurse Practitioner was unaware of these difficulties and assumed the appointment had been made, highlighting a breakdown in communication within the facility. This lack of notification to the medical providers about the scheduling issues prevented timely intervention that could have potentially averted the adverse outcome experienced by Resident #1.
Repeated Failures in Quality Assessment and Assurance
Penalty
Summary
The facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions following previous surveys. This failure resulted in repeat deficiencies in the areas of Notification of Change, Neglect, and Quality of Care. Specifically, the facility did not notify the Nurse Practitioner or Medical Doctor when a Urology Consult could not be scheduled for a resident with decreased vascular flow to the left testicle, leading to severe sepsis and an emergency orchiectomy. Additionally, the facility failed to identify the seriousness of the resident's condition, complete thorough nursing assessments, and schedule timely medical consultations, resulting in delayed care and treatment. The deficiencies were observed in multiple instances, including a failure to notify the Medical Director during an acute change in condition, neglecting to seek medical assistance, and not performing necessary skin assessments and treatments. These repeated failures indicate a pattern of the facility's inability to sustain an effective QAA program. The deficiencies affected the quality of care provided to residents, leading to serious adverse outcomes, including severe septic shock and the need for emergency medical interventions.
Latest citations in North Carolina
A cognitively impaired, exit-seeking resident with dementia, insomnia, gait abnormalities, orthostatic hypotension, and high fall risk repeatedly wandered at night and was known by staff to push on an emergency exit door. On two consecutive nights, the resident left the building unsupervised through a west hall emergency exit that had been manually left unlocked and with its door alarm turned off, so no alarm sounded when it was used. After the first elopement, the nurse and NA did not verify that the door’s lock and alarm were re-engaged, and no new monitoring was implemented, allowing the resident to exit again a few hours later. Maintenance later confirmed the door hardware and alarm were functioning properly and could only be disabled manually, meaning staff actions and inactions in securing and monitoring the door directly enabled both elopements.
Surveyors identified multiple failures in food labeling, storage, and sanitation, including dirty water spigots above the cooking range, a scoop stored with its handle in direct contact with rice, and unsealed croissants without open or use-by dates in a walk-in cooler. In three nourishment rooms, open food items such as a half-eaten creme pie with used forks, a reusable container of dressing, a pudding cup, a fast-food sandwich, and a milkshake were found without required open and/or use-by dates. The Dietary Manager reported that all nourishment room food must be labeled with both an open date and a 7-day use-by date and noted that new staff and nursing staff were not consistently labeling items as required.
A resident with severe cognitive impairment who used a wheelchair for mobility was observed being quickly pulled backward down a hallway while reclined in a geriatric chair, instead of being pushed forward in a dignified manner. The NA reported he pulled the chair backward because he felt it was harder to push forward, and he was unaware of any equipment problems. A SW later tested the same geriatric chair and found it functioned properly. Facility leadership, including the Staff Development Director, DON, and Administrator, stated that staff are educated on residents’ rights, dignity, and wheelchair use, and confirmed the expectation that residents be pushed forward in wheelchairs and geriatric chairs at a normal, dignified pace.
A resident with severe cognitive impairment and ADL deficits, including dependence on staff for bathing and grooming, was observed multiple times with long, stringy, visibly greasy and dirty hair despite being scheduled for twice-weekly showers. Nursing staff reported providing bed baths instead of full showers and only wetting the resident’s hair, while hospice staff provided intermittent bed baths with no-rinse shampoo and were unsure of the facility’s regular shower routine. The resident had not been to the beauty shop for hair care in over two months due to being mistakenly left off the beauty shop list. Facility leadership expected that the resident’s hair would be properly washed on scheduled shower days but could not identify when the hair was last washed, resulting in a failure to provide appropriate hair washing services.
Staff failed to follow Enhanced Barrier Precautions (EBP) by not wearing gowns during high-contact care activities for two residents on EBP. In one case, a nurse provided catheter care to a resident with an EBP sign and available PPE but wore only gloves, later stating she believed gowns were needed only when changing the catheter. In another case, two NAs used a mechanical lift to transfer a resident with a gastrostomy tube, again with EBP signage and PPE present, but wore only gloves; one NA stated he did not view transferring as high-contact care, and the other reported she did not always use gowns for transfers. These actions conflicted with the facility’s EBP policy and posted instructions requiring both gown and gloves for high-contact activities such as catheter care and transfers.
The facility failed to obtain and document informed consent for psychotropic medications for three residents. One resident with dementia and behavioral symptoms received quetiapine and divalproex, including a dose increase, without documented evidence that the responsible party was informed of risks and benefits or consented. Another resident with anxiety and depression, severe cognitive impairment, and disruptive behaviors was started on duloxetine and given multiple doses of PRN lorazepam, again without documentation that the responsible party was informed or consent obtained. A third cognitively intact resident with depression and anxiety received escitalopram 20 mg daily with no record that she was informed of the medication’s risks and benefits or that she consented. The Nurse Team Lead, identified as responsible for obtaining psychotropic consents, and the DON both confirmed that the expected notifications and consent documentation were not present in the medical records.
A resident with intact cognition was discharged to the community without a complete discharge summary that recapitulated the course of treatment. The electronic Transfer/Discharge Report contained basic demographic and clinical data but left key sections blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning, and lacked a signed acknowledgment that a copy was provided to the resident or representative. The SW reported she arranged post-discharge services, provided a medication list and satisfaction survey, and documented discharge arrangements, but was unaware that a comprehensive discharge summary with a recapitulation of the stay was required, and the Administrator confirmed the form used did not include this required summary with interdisciplinary input.
A resident admitted with bipolar disorder and receiving routine antipsychotic and antidepressant medications had only a prior Level I PASRR on file, with no Level II PASRR request submitted despite ongoing documentation of an active psychiatric diagnosis and psychotropic treatment in MDS assessments, NP notes, and the care plan. The SW confirmed she verified the existence of a PASRR before admission but did not request a Level II evaluation, believing it was only necessary if the resident exhibited behaviors, and the administrator acknowledged that no Level II PASRR request was made for this resident with a mental health diagnosis.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with dementia, osteoporosis, and prior femur fracture experienced an unwitnessed fall and subsequently developed severe hip pain and decreased ability to ambulate and transfer. Nursing staff failed to document the fall on the day it occurred, did not complete comprehensive lower‑extremity or mobility assessments, and repeatedly charted pain scores of 0 despite the resident’s complaints and nurse aide reports of significant pain with movement and increased assistance needs. An NP evaluated the resident for hip pain but was not informed of the fall, did not assess the hips or legs, and treated the pain as baseline neuropathic discomfort. Over several days, PRN acetaminophen was given intermittently without consistent pain scoring, multiple shifts lacked progress notes or assessments, and aides assumed nurses were aware of the resident’s worsening pain and functional decline. Bilateral hip x‑rays were eventually ordered after internal communication about hip pain, and the report later showed an acute displaced femoral neck fracture, after which the resident was sent to the hospital and underwent a left hip hemiarthroplasty.
Unsecured Emergency Exit Allows Repeated Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to keep an emergency exit door secured and alarmed, which allowed a cognitively impaired, exit-seeking resident at high fall risk to leave the building unsupervised on two consecutive nights. The resident had dementia with psychotic disturbance, severe cognitive impairment, a history of wandering and exit-seeking, orthostatic hypotension, gait abnormalities, and muscle weakness. Care plans and assessments identified wandering, exit seeking, fall risk, and insomnia, and interventions included a wander guard bracelet, frequent safety checks, environmental monitoring, and redirection from exits. Despite this, the resident routinely wandered at night, roamed the halls, entered other residents’ rooms, and was known by staff to push on the emergency exit door in attempts to leave. On the first night, in the early morning hours while it was still dark, the nurse noticed the resident was no longer in the hallway or in his room. The assigned NA, positioned near the west hall emergency exit, reported hearing a door slam but assumed it was a nearby resident’s room door because the emergency door alarm had not sounded. When the nurse checked the emergency exit, he found it unlocked and non-alarming, exited through it, and after walking several minutes from the back of the building to the front, located the resident standing at the main entrance. The resident’s wander bracelet triggered the main entrance door alarm when they re-entered, confirming the bracelet was in place. The nurse believed the emergency door locked and re-armed automatically and did not verify the lock or alarm status of the door after the incident or before the end of his shift, and no additional monitoring or new interventions were implemented at that time. On the second night, the same nurse observed the resident in bed at approximately 1:30 AM, but by about 2:00 AM the resident was again missing from his room. The nurse immediately went to the same west hall emergency exit and saw the resident outside through the door’s glass, walking away from the building. The door was again unlocked and did not alarm when opened. The nurse brought the resident back inside through that door and assessed him with no injuries noted. Staff interviews and maintenance inspection confirmed that the emergency exit door’s magnetic lock was controlled by a wall switch and the red alarm box on the door could only be turned on or off with a key; the system did not malfunction and could not be defeated by holding the push bar. This meant the door’s lock and alarm had been manually disabled by staff on at least one prior shift, and staff on subsequent shifts, including nurses and NAs who were aware of the resident’s exit-seeking behavior and the first elopement, did not verify that the door was secured and alarmed, allowing the resident to exit a second time without staff knowledge.
Removal Plan
- Identify recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance
- Ensure Resident #89 has a wander bracelet in place
- Pursue or redirect Resident #89 back into the facility if he exits
- Assess Resident #89 for acute distress or injury after an elopement event
- Administer scheduled bedtime medications for insomnia (melatonin 3 mg and trazodone 50 mg) as ordered
- Initiate an order for checks of Resident #89’s whereabouts
- Document completion of checks on the Medication Administration Record
Improper Food Labeling, Storage, and Sanitation in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to properly label, date, and store food items and to maintain cleanliness in food preparation and nourishment areas. During an initial kitchen tour with the Dietary Manager, surveyors observed visible dirt and grime buildup on three water spigots above the cooking range and found a plastic scoop left in a rice bin with the handle and bottom in direct contact with the rice. In walk-in cooler #2, a cardboard flat of croissants had been cut open, with seven croissants already used, and the remaining croissants were not resealed or labeled with an open or use-by date. The Dietary Manager acknowledged that the open croissants had been missed by kitchen staff and that the rice scoop should have been stored in its designated holder on the bin. In three nourishment rooms, surveyors found multiple food items that were open but not properly labeled with open and/or use-by dates. In one nourishment room refrigerator, there was a half-eaten creme pie with three used plastic forks left in the pan and a small reusable container of ranch dressing, both open and unlabeled. In another nourishment room refrigerator, a vanilla pudding cup and a wrapped fast-food sandwich were open and labeled only with open dates, but no use-by dates. In a third nourishment room refrigerator, a fast-food milkshake was open with no open or use-by date. The Dietary Manager stated that all nourishment room food items were required to be labeled with both an open date and a use-by date set seven days after opening, and reported that some new staff were not labeling items correctly and that nursing staff often left items in nourishment refrigerators without appropriate labeling.
Resident Dignity Compromised During Transport in Geriatric Chair
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity and right to a dignified existence and self-determination when a nurse aide transported the resident in a manner inconsistent with facility expectations. The resident, who had clear speech but severe cognitive impairment and required a wheelchair for mobility, was observed during a continuous observation being quickly pulled backward approximately 30 feet down the South Hall from the day room to her room while reclined in a geriatric chair. A reasonable person would have expected to be treated with dignity and to be wheeled forward in the chair. During interviews, the nurse aide stated he chose to pull the resident backward because he felt it was harder to push the reclined geriatric chair forward and reported no awareness of problems with the chair. The social worker later pushed the same geriatric chair forward and backward in the hallway and noted no functional concerns, stating the chair worked fine and needed no repairs. The Staff Development Director reported that staff receive education on residents’ rights, dignity, and wheelchair use, including speed and footrest use, and acknowledged the resident should not have been pulled backward in the geriatric chair. The DON and Administrator both stated they expected staff to push residents in wheelchairs and geriatric chairs forward, at a normal pace, and in a dignified manner.
Failure to Provide Adequate Hair Washing for Dependent Resident
Penalty
Summary
The facility failed to provide adequate hair washing services for a dependent resident with ADL deficits. The resident was admitted with senile degeneration of the brain, COPD, and heart failure, and had a care plan identifying ADL deficits due to generalized weakness, with interventions including setup for hair and oral hygiene daily and assistance with bathing and dressing. An annual MDS showed the resident was severely cognitively impaired and required extensive staff assistance for ADLs, with no behaviors or rejection of care documented. The shower schedule indicated the resident was to receive showers twice weekly on specific mornings. However, multiple observations over several days showed the resident in bed with long, stringy, visibly greasy and dirty hair that was stuck flat against her head, including on a scheduled shower day. Record review showed documentation that the resident received a shower on one of the observed days, but the NA assigned that day reported she actually provided a bed bath rather than a full shower and typically only wet the resident’s hair, noting it was becoming tangled, especially in the back. The NA stated a hospice bathing team visited a couple of times a week and used a no-rinse shampoo, but she was unsure of their specific care for this resident. The hospice nurse confirmed providing bed baths with no-rinse shampoo a couple of times a week and was unsure of the facility’s regular shower routine for the resident. The beauty shop operator and unit secretary both indicated it had been longer than two months since the resident’s last beauty shop visit, and the unit secretary acknowledged the resident’s name had been left off the beauty shop list by mistake. The DON stated NAs were expected to bathe the resident twice weekly and was unaware of when the resident’s hair was last washed, while the administrator stated his expectation that the resident’s hair would be properly washed on scheduled shower days.
Failure to Use Required Gowns Under Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to follow its own Enhanced Barrier Precautions (EBP) policy requiring the use of gowns and gloves during high-contact resident care activities for residents on EBP. The written policy, revised on 7/26/2022, defined EBP as an infection control intervention to reduce transmission of multidrug-resistant organisms (MDRO) by using gowns and gloves during high-contact activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, and device care or use, including urinary catheters and feeding tubes. Facility signage for EBP instructed staff to don a gown and gloves for high-contact resident care activities, and personal protective equipment (PPE), including gowns, was made available in holders at resident room doors. During an observation of catheter care for Resident #132, who was on EBP and had an EBP sign and PPE bin with gowns posted outside the room, Nurse #5 entered the room without wearing a gown. She washed her hands, donned gloves, removed the resident’s brief, and provided catheter care, then discarded supplies and gloves and washed her hands. In a subsequent interview, Nurse #5 acknowledged awareness that the resident was on EBP but stated she believed a gown was only required when changing the catheter, not when providing catheter care, and indicated she must have misunderstood the EBP instructions despite having received infection control training. In a separate observation, Resident #161’s room also had an EBP sign and PPE holder on the door, and the resident had a gastrostomy tube with tube feeding formula hanging at the bedside. When the resident returned from an outside appointment in a wheelchair, two nurse aides entered the room with a mechanical lift to transfer the resident to bed. Both aides wore gloves but did not wear gowns while completing the mechanical lift transfer. One aide stated he knew the resident was on EBP due to the gastrostomy tube but believed a gown was only required when performing “some type of care” and did not consider transferring to be a high-contact activity, even when shown the sign indicating gowns and gloves were required for transfers. The other aide, who usually worked on a different unit, stated she followed EBP signage but sometimes used a gown for transfers and not all the time, and both aides had previously received EBP and PPE training. The Infection Preventionist, DON, and Administrator each stated that staff should have worn gowns in these situations according to the posted EBP signage and facility expectations.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for psychotropic medications prior to initiation or dose changes for multiple residents. For one resident with unspecified dementia, anxiety disorder, depression, and delusional disorder, the physician ordered quetiapine for anxiety and agitation and later ordered divalproex for dementia with aggression and agitation, with a subsequent dose increase. The resident’s MDS showed moderate cognitive impairment, use of antipsychotic, antidepressant, and anticonvulsant medications, and behavioral symptoms including rejection of care. Record review showed these medications were administered as ordered, but there was no documentation that the responsible party was informed in advance of the risks and benefits of starting or increasing these psychotropic medications or that consent was obtained. Another resident with anxiety disorder and depression was started on duloxetine for depression and later had PRN lorazepam ordered for daytime and bedtime anxiety with agitation. The MDS indicated severe cognitive impairment, behavioral symptoms that interfered with social interactions and disrupted care, and use of anti-anxiety and antidepressant medications. The MAR confirmed that duloxetine was given as ordered and lorazepam was administered on multiple days. However, the electronic medical record contained no documentation that the responsible party was informed in advance of the risks and benefits of initiating duloxetine or lorazepam or that consent was obtained. The Nurse Team Lead, who was responsible for obtaining psychotropic consents, could not locate any consent forms for this resident and could not recall whether the responsible party had been called. A third resident with major depressive disorder and generalized anxiety disorder, and intact cognition per the MDS, had an active order for escitalopram 20 mg daily for depression and anxiety. The MDS showed no behavioral symptoms and receipt of antidepressant medication. Review of the medical record revealed no documentation that this resident was informed in advance of the risks and benefits of initiating escitalopram and consented to the treatment. In interviews, the Nurse Team Lead consistently stated she was responsible for obtaining psychotropic consents when new orders were received from providers, but she was unable to find consent forms for the involved residents or explain what had occurred. The DON described a process in which providers communicated new or changed psychotropic orders to the Nurse Team Lead, who was expected to notify residents or responsible parties and document the notification, but acknowledged that for these residents the required documentation and consent forms were missing.
Failure to Complete Required Discharge Summary With Recapitulation of Stay
Penalty
Summary
The facility failed to complete a required discharge summary that included a recapitulation of the resident's stay for one resident who was discharged to the community. The resident was admitted to the facility and had a 5-Day MDS showing intact cognition and active discharge planning. A subsequent discharge-return not anticipated MDS documented that the resident was discharged to the community. Review of the electronic medical record showed an undated Transfer/Discharge Report containing demographic and clinical information such as date of birth, admission date, age, insurance, allergies, primary contact and physician information, diagnoses, most recent vital signs, and immunization history, with a notation to refer to the MAR for current medications. However, several sections of this report were left blank, including advanced directives, diet type/texture/fluid consistency, and resident-specific information on behaviors, ambulation, bladder/bowel status, feeding, and usual level of functioning. There was also no signature or date indicating the resident or representative received a copy of the Transfer/Discharge Report. In interviews, the SW reported she was responsible for long-term resident discharges while a Discharge Planner/Case Manager handled short-term discharges. The SW described her discharge process as arranging post-discharge needs such as follow-up appointments, home health, or equipment, providing a satisfaction survey and a list of medications with administration times, and documenting a progress note outlining discharge arrangements. She stated that when follow-up appointments were arranged, records including provider notes, therapy notes, and medication lists were faxed to the receiving provider. The SW also indicated she was not aware that a discharge summary including a recapitulation of the resident's course of treatment in the facility was required. The Administrator acknowledged that the Transfer/Discharge Report in use contained some required components but did not summarize the resident's course of treatment and that a discharge summary with input from all disciplines should have been completed per regulatory guidelines.
Failure to Request Level II PASRR for Resident With Bipolar Disorder
Penalty
Summary
The facility failed to submit a request for a Level II PASRR evaluation for a resident with a serious mental health diagnosis. The resident was admitted with a diagnosis that included bipolar disorder and had only a Level I PASRR documented from an evaluation completed in 2022. The admission MDS indicated the resident was not considered by the state Level II PASRR process to have serious mental illness or intellectual disability, despite documenting an active bipolar disorder diagnosis and routine antipsychotic use. Subsequent psychiatric NP progress notes in 2024 and 2026 confirmed an active bipolar disorder diagnosis and ongoing treatment with aripiprazole and bupropion. The annual MDS again indicated the resident was not considered by the Level II PASRR process to have serious mental illness or intellectual disability, while also documenting routine antipsychotic and antidepressant use and a care plan addressing psychotropic medications related to bipolar disorder. The social worker, who had been in the role for five years and was responsible for ensuring newly admitted residents had a PASRR prior to admission, verified that she checked the state PASRR system before admission and confirmed the presence of a PASRR, but did not request a Level II evaluation at or after admission. She stated she was aware of the resident’s bipolar diagnosis and psychiatric referral but believed a Level II PASRR was only needed if the resident demonstrated behaviors, and she was not aware that a Level II evaluation was required when a resident was admitted with a mental health diagnosis and had only a Level I PASRR. The administrator also confirmed that no Level II PASRR request was made when the resident was admitted with a mental health diagnosis.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Failure to Assess and Respond to Post‑Fall Hip Pain and Mobility Decline
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess, recognize, and respond to a resident’s severe hip pain and functional decline following a reported unwitnessed fall. The resident had dementia, osteoporosis, and a history of femur fracture, and was previously able to transfer and ambulate with limited assistance. On the date of the unwitnessed fall, there was no nursing progress note, no documentation of a fall, no pain complaint, and no assessment of the lower extremities or of transfers, ambulation, or mobility. Nursing documentation on that date reflected a pain score of 0, and the nurse assigned to the resident did not recall any fall, pain, or assessment. The quarterly MDS showed severe cognitive impairment and a prior fall, but no pain assessment. On the following night, a nurse documented that the resident was having “a lot of pain” in her hip and placed a note in the doctor’s book, but did not call the on‑call provider, did not document administration of any pain medication, and did not record a pain score with the complaint. The nurse aide on that shift did not recall changes, but the nurse later reported that the aide had told her the resident was unable to ambulate, which was a change from baseline. The next day, another nurse documented in a late entry that the resident reported she had fallen the previous day, pulled herself up, and had not told anyone, and that the resident screamed in pain when moved. This nurse contacted the NP, who, according to the note, stated the resident complained of pain all the time; the nurse informed him that this pain was not typical. The progress note did not include a pain level, a lower extremity assessment, or documentation that the unwitnessed fall was communicated to the NP. The NP’s own note documented nonspecific hip pain, a sleepy and groggy presentation, and neuropathic/hip pain, but did not include an assessment of the legs or hips. The NP later stated he was unaware of the fall, did not assess the hips or legs, and did not inquire about changes in condition such as pain with movement or ambulation. Over the next several days, multiple nurses documented pain scores of 0 on the MAR despite intermittent administration of PRN acetaminophen and reports from nurse aides that the resident had significant pain with transfers, ambulation, and repositioning. Nurse aides reported that the resident, who had previously been able to get up and ambulate, now required increased assistance, had difficulty transferring and ambulating, and grimaced and winced in pain during movement. One aide kept the resident in bed and provided all care in bed due to pain with movement, while another aide did not report the pain to the nurse, assuming the nurse was already aware. There were no nursing progress notes on some days documenting any assessment of the lower extremities or of the resident’s ability to transfer, ambulate, or move, and some assigned nurses did not enter any assessment notes at all. A nursing supervisor received a Stop and Watch communication about hip pain, obtained an order for bilateral hip x‑rays, but did not complete a comprehensive assessment and did not document a pain level or lower extremity assessment. The x‑ray order was entered, and bilateral hip x‑rays were completed, but pain scores of 0 continued to be documented on the MAR by nursing staff, and the unit manager assigned for part of one day did not assess the resident. A nurse aide who assisted with the x‑ray reported that repositioning the resident in bed was difficult due to pain and observed grimacing and wincing. The x‑ray report later showed an acute left femoral neck fracture with displacement. The nurse who came on duty the next day found the x‑ray report on the fax machine, noted the fracture, and contacted the provider, after which the resident was sent to the emergency department. The hospital history and physical documented that the resident endorsed hip pain on arrival and was treated with analgesics and later underwent a left hip hemiarthroplasty. The NP and Medical Director both acknowledged that there was potential for complications when a fracture remained undiagnosed for several days while the resident continued to be moved, transferred, and assisted with ambulation. The DON confirmed that the facility’s investigation determined that a nurse had been informed of an unwitnessed fall and failed to report the incident, resulting in a delay in treatment, and emphasized the importance of thorough assessment and documentation.
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