Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grove Park Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
Emergency trach supplies were not consistently at the bedside for residents with trachs, and staff could not identify key equipment or the correct inner cannula sizes. For two residents, an LPN could not locate or describe the Ambu bag and obturator, and one resident had the wrong inner cannula size at bedside. A separate resident’s PO for inner cannula changes did not specify the cannula size, and the RN/UM confirmed the order should have included it.
Failure to Preserve Resident Dignity, Privacy, and Autonomy: A resident who was his/her own responsible party was not allowed to leave on pass without an escort despite having a physician order, another resident was observed wearing a visible DNR wristband after admission, and a third resident was denied normal privacy when staff entered the room without knocking. The third resident also reported being drug tested after an overnight visit and not being told the screen could be refused, after which the resident said future visits were restricted.
A resident with dementia, MDD, and anxiety had a severely impaired BIMS score and a care plan addressing mood changes related to environmental factors. Surveyors observed the resident’s room with old food and trash on the floor, no blinds or curtains, no personal items displayed, a chipped baseboard, and no trash can. The family said they had been asking for curtains and a trash can for weeks, and staff reported they were not aware of the missing room items.
A resident with chronic respiratory failure, tracheostomy status, and persistent vegetative state was sent to the hospital after family reported facial swelling and an NP ordered further evaluation. The facility did not document providing the resident or RR with the required written transfer notice or bed hold notice, and the SSD confirmed the information was not sent to the RR.
Tracheostomy Care Training and Equipment Deficiencies: Three nurses did not demonstrate the knowledge and competency needed to care for residents with tracheostomies. One LPN could not recall emergency trach care training or what to do if a cannula became dislodged, another LPN did not know a resident’s trach size and found no Ambu bag or obturator in the room, and a third LPN had never heard of an Ambu bag or obturator. An RN identified the needed emergency supplies but could not state the resident’s trach size and did not check bedside supplies at the start of the shift.
A resident with chronic pain syndrome was given Ibuprofen 800 mg during med pass even though there was no active physician order for the medication. RN1 administered the dose after the resident complained of pain, while the EMR showed no order in place; LPN and DON both confirmed the medication was not ordered, and the DON stated the nurse should have contacted the physician for an order.
A nurse failed to follow infection control practices during medication administration for a resident with type 2 DM and contractures. The nurse handled gabapentin with bare hands, opened the capsule, and poured the contents onto other medication before giving it to the resident. The DON stated staff should not pick up medication with bare hands, and the nurse acknowledged gloves should have been used.
A resident with a history of substance abuse, who was receiving medication-assisted treatment and had intact cognition, reported ingesting a marijuana-infused brownie given by a visitor. The facility contacted the transportation company identified by the resident, but after the company denied knowledge of the individual, the facility ended its investigation without further follow-up, contrary to its own policy requiring thorough incident investigations.
The facility failed to treat residents with NPO orders with dignity by posting weekly menus in their rooms. Three residents with ongoing tube feeding and cognitive impairments were observed with menus, despite their dietary restrictions. The Recreation Director acknowledged placing menus without considering individual dietary needs, contrary to the facility's dignity policy.
The facility failed to provide bedtime snacks to residents, resulting in a gap of more than 15 hours between dinner and breakfast. Four residents reported not receiving snacks, and the Food Service Director confirmed the absence of a system to document snack distribution. The facility's policy required bedtime snacks, but there was no accountability or documentation to ensure compliance.
The facility failed to maintain proper kitchen sanitation practices, as observed by a surveyor. During a kitchen tour, the surveyor noted water splashing from the dishwasher onto meal trays placed on a drying rack. The trays were wet nesting and stacked together, which the Dietary Manager confirmed were used to serve residents' meals. The DM acknowledged that trays should not be stacked to ensure complete drying, and the LNHA confirmed the absence of a policy on tray drying.
A facility failed to accurately document the nutritional intake for a resident who was NPO, as the care plan incorrectly included goals for oral intake. The resident, with a history of dysphagia and gastrostomy, was receiving tube feeding, yet the RD's notes mistakenly aimed to maintain oral intake. The error was acknowledged by the RD, and facility leadership agreed that NPO residents should not have oral intake goals.
The facility failed to follow physician's orders and document the application of medical devices for three residents. A resident was observed without heel booties, another without a hand splint, and a third without heel booties, despite orders for their use. Staff interviews revealed a lack of awareness and documentation, and facility policies lacked guidance on documenting device application.
A resident with dysphagia, gastrostomy, and gastritis did not receive a timely nutritional evaluation after a 3-day calorie count, as required by the facility's policy. The RD, working remotely, delayed the assessment by 10 days, and missing meal percentage recordings were noted. The resident expressed dissatisfaction with food quality and had not seen the RD to address concerns.
A facility failed to document routine pain assessments for a resident with multiple diagnoses, including chronic osteomyelitis and pressure ulcers. Despite the resident's frequent requests for pain medication, there were no physician's orders for pain assessment or monitoring. An LPN confirmed that pain assessments were not completed every shift, contrary to the facility's policy requiring regular assessments for acute and chronic pain.
A facility failed to monitor and document side effects for a resident on psychotropic medication, as required by the Physician's Order. The resident, with severe cognitive impairment and on Olanzapine for symptoms like anxiety and depression, had no monitoring order in their eMAR. An LPN confirmed the absence of such an order, and the DON acknowledged this deficiency, which violated the facility's policy on psychoactive medication use.
A resident with severely impaired cognition was inaccurately assessed in the MDS, as it failed to reflect the administration of antipsychotic medication, despite evidence from medical records and staff confirmation. The MDS Coordinator acknowledged the error, and facility leadership recognized the inaccuracy.
Tracheostomy Emergency Supplies and Orders Were Incomplete
Penalty
Summary
The facility failed to ensure that emergency tracheostomy equipment was readily available at the bedside for residents with tracheostomies, that staff were trained to use the emergency tracheostomy equipment, and that primary care nurses knew the residents’ inner cannula sizes. This deficient practice was identified for Resident #174 and Resident #6, both of whom had tracheostomies and required respiratory-related care in the facility. The report states that this created an Immediate Jeopardy situation and that the facility’s Administration was notified on 02/17/26 at 10:05 PM. Resident #174 was admitted with chronic respiratory failure, tracheostomy status, and persistent vegetative state. The resident’s MDS coded the resident as comatose with persistent vegetative state/no discernible consciousness and requiring oxygen therapy, suctioning, and tracheostomy care. The physician orders included daily inner cannula changes, suctioning, trach care, oxygen as needed, and chest physiotherapy with suctioning after therapy. During observation, the resident’s bedside had a size 7.5 mm inner cannula and an Ambu bag, but no obturator and no size 8.0 mm inner cannula. The LPN caring for the resident stated she had not received additional trach training outside of nursing school and told the surveyor she had never heard of an Ambu bag or obturator. Resident #6 was admitted with malignant neoplasm of the larynx, COPD, and tracheostomy status. The resident’s MDS indicated the need for suctioning and tracheostomy care. Physician orders included daily inner cannula changes, suctioning, and trach care, but the order did not identify the inner cannula size. The hospital record showed the inner cannula size was 6.0 mm, yet during observation only a 5.0 mm inner cannula was on the windowsill, with no Ambu bag or obturator in the room and no crash cart on the floor. The LPN caring for the resident could not state the inner cannula size and confirmed the absence of the emergency trach equipment. The report also identified a separate deficiency for Resident #199, whose physician order for inner cannula changes did not specify the inner cannula size, and the RN/UM confirmed there should have been an order reflecting that size.
Failure to Preserve Resident Dignity, Privacy, and Autonomy
Penalty
Summary
The facility failed to treat three residents with dignity and respect in separate events involving resident autonomy, privacy, and room entry practices. R4, who had diagnoses of paraplegia and muscle weakness and was documented as his/her own responsible party with a BIMS score of 15, wanted to leave the facility on pass without a family escort. Although R4 had a physician order permitting a pass, the Social Services Director stated the facility required an escort and acknowledged this process may violate residents’ rights. R4 reported feeling helpless because there was no one who could help him/her. R62, who was admitted with hemiplegia and hemiparesis following cerebral infarction, dysphagia, cognitive communication deficit, and unspecified dementia, had a BIMS score of 00 indicating severe cognitive impairment. Observations showed R62 wearing a purple wristband marked DNR on the left wrist, making the resident’s code status visible to residents and visitors. Facility staff, including the ADON, RDCS, and an LPN, confirmed the wristband should have been removed at admission and that code-status wristbands were not part of the facility’s practices. R175, who was re-admitted with traumatic brain injury and bipolar disorder, stated that staff did not knock or announce themselves before entering the room, and this was directly observed when an AIT entered the room without knocking or announcing themselves. R175 also stated that after returning from an overnight family visit, the resident was drug tested and later told the resident could no longer have visitors or overnight visits after a positive result for fentanyl. R175 stated the resident did not know the drug screen could be refused, and the Ombudsman confirmed the resident’s complaint that the facility would not let the resident go out anymore. The record also showed an order for an overnight pass and a one-time urine drug screen related to substance abuse history.
Resident Room Not Maintained in Clean, Homelike Condition
Penalty
Summary
The facility failed to ensure one resident’s room was clean, in good repair, and maintained in a homelike condition. The resident, who was admitted with diagnoses of dementia, major depressive disorder, and anxiety disorder, had a quarterly MDS showing a BIMS score of 6 out of 15, indicating severely impaired cognition. The resident’s care plan identified a focus related to risk for mood changes from dementia and included interventions to assess for physical and environmental changes that may precipitate mood changes. During observations, the resident’s room was found to have old food and trash on the floor, no blinds or curtains on the window, no personal items displayed on the walls or furniture, a chipped baseboard near the right side of the door, and no trash can. The resident’s family member stated they had been asking nursing staff for curtains and a trash can for weeks after the resident was moved to the room. Staff interviews showed the CNA assisted the resident with dressing in the room or bathroom, while the RN/UM, housekeeping aide, and maintenance staff stated they were not aware of the missing curtains/blinds or trash can.
Missing Transfer and Bed Hold Notice
Penalty
Summary
The facility failed to ensure that a written transfer notice containing all required information and the bed hold notice were provided for one resident who was transferred to the hospital. The resident's EMR showed diagnoses of chronic respiratory failure, tracheostomy status, and persistent vegetative state. Nursing progress notes documented that the resident's family member reported swelling on the left side of the resident's face, and the NP ordered transfer to the hospital for further evaluation. A subsequent note stated the resident was being admitted for facial swelling. Review of the resident's EMR did not show documentation that the facility provided the resident and resident representative with a written transfer notice or the bed hold policy when the resident was transferred. During interview, the SSD stated that the resident went to the hospital on Friday and that the information was not sent to the resident representative by email when the SSD returned to work on Monday. The SSD also confirmed that the bed hold policy and transfer notice should have been provided in writing. The facility's policy required written notice to include the reason for transfer, effective date, location, appeal rights information, bed hold policy, and required agency contact information.
Tracheostomy Care Training and Equipment Deficiencies
Penalty
Summary
The facility failed to provide training for three nurses, including two LPNs and one RN, so they did not demonstrate the knowledge and competency needed to care for three residents with tracheostomies. During interviews, one LPN stated she could not remember what emergency equipment should be at the bedside of a resident with a tracheostomy and could not remember receiving in-service training on emergency tracheostomy care. The same LPN also stated she could not remember what she would do if a tracheostomy cannula became dislodged. Another LPN stated that emergency bedside equipment should include sterile water, an Ambu bag, split gauze, and a trach care kit, but did not know the size of one resident’s Shiley cannula. When the surveyor went to that resident’s room, the LPN confirmed there was no Ambu bag or obturator in the room and only one size 5.0 inner cannula was present. A third LPN stated she had never heard of an Ambu bag or obturator. An RN stated that emergency tracheostomy equipment should include an Ambu bag, inner cannulas, suction catheters, a suction machine, a trach care kit, and trach ties, but could not state the size of the resident’s cannula and said she did not check the supplies at the beginning of her shift even though she had received tracheostomy care training that morning. The regional director of clinical services confirmed that residents with tracheostomies should have the required emergency equipment at the bedside and in the room as outlined in policy.
Unordered Ibuprofen Given During Medication Pass
Penalty
Summary
The facility failed to ensure that one resident, who was readmitted with a diagnosis of chronic pain syndrome, did not receive an unnecessary medication during medication pass. During observation on 02/17/26 at 8:34 PM, RN1 administered Ibuprofen 800 mg by mouth to the resident because the resident complained of pain. However, review of the resident’s Order Summary Report dated 02/18/26 showed no evidence of an order for Ibuprofen 800 mg as of 02/17/26. Review of the resident’s blister package dated 01/07/26 showed Ibuprofen 800 mg, one tablet by mouth every 6 hours as needed for moderate to severe pain for 14 days. RN1 stated he/she was unaware the resident did not have an order. LPN2 confirmed the resident did not have a physician order for Ibuprofen, and the DON stated he/she would have expected RN1 to call the physician to obtain an order when the resident was having pain. The DON also confirmed there was no order for the Ibuprofen on 02/17/26. The facility policy stated medications shall be administered in a safe and timely manner, and as prescribed, and that the individual administering the medication must verify the right resident, right medication, right dose, right time, and right route before giving the medication.
Medication Administration Infection Control Lapse
Penalty
Summary
The facility failed to ensure that medication was administered in a manner to prevent possible cross contamination for one resident during medication pass. During observation on 02/17/26 at 8:34 PM, RN2 placed all of the resident’s medications into a medication cup except gabapentin 300 mg, which was placed in a separate cup. RN2 then picked up the gabapentin with a bare right hand, opened the capsule, and poured the contents onto the other medication using bare hands before administering the medications. The resident had diagnoses of type 2 diabetes mellitus and contracture of the right upper arm and right thigh. The DON stated that nurses are not expected to pick up medication with bare hands and may use a spoon or gloves instead, and RN2 stated that he/she should have used gloves rather than bare hands. The facility policy on administering medications states that staff shall follow established infection control procedures, including handwashing, antiseptic techniques, gloves, and isolation precautions, as applicable.
Failure to Fully Investigate Alleged Provision of Illegal Substance to Resident
Penalty
Summary
The facility failed to fully investigate and implement measures to address an allegation that a visitor provided an illegal, unapproved substance to a resident with a history of substance abuse. The resident, who had diagnoses including opioid dependence and was receiving medication-assisted treatment for addiction, reported to the facility that a friend working for a transportation company gave them a marijuana-infused brownie. The resident's cognitive status was assessed as intact, and their care plan documented their substance abuse history and ongoing treatment. Upon learning of the incident, the facility contacted the transportation company, which denied having a driver by the name provided by the resident. After receiving this denial, the facility ended its investigation without further action. The facility's policy required prompt initiation and documentation of investigations into accidents or incidents, but the investigation was not pursued beyond the initial inquiry with the transportation company.
Failure to Remove Menus for NPO Residents
Penalty
Summary
The facility failed to ensure that residents with a physician's order for NPO (nothing by mouth) were treated with dignity and respect. This deficiency was identified for three residents who had ongoing tube feeding and were observed with the facility's weekly menu posted in their rooms. The presence of these menus was inappropriate given their NPO status, as it disregarded their dietary restrictions and could potentially affect their dignity and self-esteem. Resident #141, #40, and #88 were all observed with menus posted in their rooms despite having medical conditions such as dysphagia, gastrostomy, and cognitive impairments that necessitated NPO orders. The Recreation Director admitted that their department placed menus in every resident's room without considering individual dietary restrictions. The facility's policy on dignity emphasized treating residents with respect and sensitivity, particularly those with cognitive impairments, which was not adhered to in these instances.
Failure to Provide Bedtime Snacks
Penalty
Summary
The facility failed to consistently provide nourishing snacks to residents when there was a gap of more than 15 hours between dinner and breakfast. This deficiency was identified during a group meeting with five alert and oriented residents, where four residents reported not receiving bedtime snacks. The Food Service Director (FSD) confirmed that while snacks were provided to the units, there was no accountability system in place to ensure that residents received their snacks, as there was no snack log or documentation available. The facility's policy on meal delivery times indicated a 15-hour gap between dinner and breakfast across all floors, which necessitated the provision of bedtime snacks. However, the Resident Council Meeting Minutes from previous months did not address the issue of food and bedtime snacks. During a meeting with the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), both acknowledged the lack of documentation for bedtime snacks, which was contrary to the facility's policy that required providing bedtime snacks to residents.
Inadequate Kitchen Sanitation Practices
Penalty
Summary
The facility failed to maintain appropriate kitchen sanitation practices, as observed during a surveyor's visit. During the initial tour of the kitchen, the surveyor, accompanied by the Dietary Manager (DM), observed two dietary staff cleaning dishes used during breakfast. When the DM turned on the dishwasher, a significant amount of water splashed towards the drying rack, where meal trays were placed. The DM acknowledged the water splash issue and indicated that the drying rack was used to dry meal trays. The surveyor noted that the trays were wet nesting and stacked together, which the DM confirmed were used to serve residents' meals. The DM admitted that the trays should not be stacked together to ensure they dry completely. The Licensed Nursing Home Administrator (LNHA) later confirmed that the facility lacked a policy and procedure regarding tray drying. The DM agreed that trays must not be stacked to allow for complete drying. This deficiency was discussed with the LNHA, Director of Nursing, Chief Nursing Officer, and the Regional Educator, but no further information was provided.
Inaccurate Documentation of Nutritional Intake for NPO Resident
Penalty
Summary
The facility failed to document the appropriate nutritional intake for a resident who was designated as NPO (nothing by mouth). This deficiency was identified during a survey when it was observed that the resident, who was receiving nutrition through a tube feeding machine, had a care plan that incorrectly included goals for oral intake. The resident had a medical history of dysphagia, gastrostomy, and muscle weakness, and was admitted with a physician's order for an NPO diet. Despite this, the Registered Dietitian's progress notes mistakenly included a goal to maintain oral meal and snack intake above 50%, which was not applicable to the resident's NPO status. The surveyor's review of the resident's medical records and interviews with facility staff confirmed the error in documentation. The Registered Dietitian acknowledged the mistake in the progress notes, stating that the resident did not take food or medication orally. The facility was unable to provide a policy regarding the accuracy of documentation, and during a meeting with the survey team, facility leadership agreed that residents with an NPO order should not have goals related to oral intake in their records.
Failure to Follow Physician's Orders and Document Device Application
Penalty
Summary
The facility failed to consistently follow physician's orders and document the application of medical devices for three residents, leading to deficiencies in care. Resident #51 was observed without heel booties on two separate occasions, despite having a physician's order for their use to prevent skin breakdown. The resident's electronic medical records did not reflect the order, and staff interviews revealed a lack of awareness and documentation regarding the application of the heel booties. Resident #45 was observed without a hand splint on two occasions, despite a physician's order for its use to manage hemiplegia and hemiparesis. Interviews with staff indicated that the splint was not applied as required, and there was a lack of documentation to confirm its use. The Director of Rehabilitation confirmed the order for the splint, and staff acknowledged the need for compliance with such orders. Resident #96 was also observed without heel booties, which were ordered for daily use while in bed. Staff interviews revealed that the heel booties were not consistently applied, and there was no documentation to confirm their use. The Director of Nursing acknowledged the oversight, and a review of facility policies showed a lack of guidance on documenting the application of such devices.
Delayed Nutritional Evaluation for Resident
Penalty
Summary
The facility failed to ensure a timely nutritional evaluation for a resident who was on a 3-day calorie count. This deficiency was identified for a resident with diagnoses including dysphagia, gastrostomy, and gastritis. The resident expressed dissatisfaction with the food quality and mentioned not having seen the Registered Dietitian (RD) to address these concerns, suspecting weight loss. The resident's cognition was intact, as indicated by a perfect score on the Brief Interview for Mental Status. A physician's order dated September 11, 2024, required a 3-day calorie count to observe meal and fluid intake, but the evaluation of this calorie count was delayed by 10 days after its completion. The RD, who works remotely, acknowledged the oversight in not completing the progress note within the expected timeframe of one to two days after the calorie count. The facility's policy required the dietitian to review daily caloric intake and assess the adequacy of caloric intake over the three-day period, initiating interventions if necessary. However, the RD's evaluation was not conducted in a timely manner, and the facility's leadership was aware of this delay. The surveyor noted missing meal percentage recordings for lunch and dinner on the last day of the calorie count, further contributing to the deficiency.
Failure to Document Routine Pain Assessments
Penalty
Summary
The facility failed to ensure routine pain level assessments were completed and documented for a resident, as per the facility's policy and standard of practice. This deficiency was identified during a survey when a resident, who was awake in bed, reported experiencing pain from a wound on their back and frequently requested pain medication. A review of the resident's electronic medical record revealed that the resident had been admitted with multiple diagnoses, including chronic osteomyelitis, open wound on the left lower leg, unstageable pressure ulcer in the sacral region, stage 3 pressure ulcer on the left heel, and paraplegia. The resident's cognitive status was assessed as intact, and they were on a pain medication regimen that included Morphine Sulfate ER, Oxycodone HCl, and Acetaminophen. Despite the resident's frequent requests for pain medication, there were no physician's orders to document pain assessment or monitoring. An interview with an LPN confirmed that the resident was alert, oriented, and able to verbalize pain, but pain assessments were not completed every shift. The facility's policy required pain assessments at least each shift for acute pain or significant changes in chronic pain levels, and at least weekly for stable chronic pain. The Licensed Nursing Home Administrator and Director of Nursing acknowledged the lack of pain assessment and monitoring during a discussion with the survey team.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to monitor and document potential side effects for a resident on psychotropic medication as per the Physician's Order. This deficiency was identified during a survey when a resident was observed in bed with eyes closed, and a review of their electronic medical record revealed that there was no order to monitor for side effects of the psychotropic medication. The resident, who had severe cognitive impairment and was on antipsychotic medication, was admitted with diagnoses including dementia, anxiety, and mood disorder. Despite being on Olanzapine for target symptoms such as anxiety and depression, there was no documentation or monitoring for side effects as required by the facility's policy. The surveyor's interview with an LPN confirmed that the electronic Medication Administration Record did not include an order for monitoring or assessing the psychotropic medication's side effects. The Director of Nursing acknowledged the absence of such an order during a meeting with the survey team. The facility's policy on psychoactive medication use mandates that nursing staff monitor and report side effects and adverse consequences to the attending physician, which was not adhered to in this case.
Inaccurate MDS Coding for Antipsychotic Medication
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for a resident, leading to a deficiency in the assessment of the resident's status. The resident, who was observed to have severely impaired cognition with a Brief Interview for Mental Status (BIMS) score of 7 out of 15, was taking antipsychotic medication as per the physician's order and the electronic Medication Administration Record (eMAR). However, the MDS inaccurately reflected that the resident did not receive antipsychotic medication, despite evidence to the contrary. The surveyor's review of the resident's medical records and interviews with the Licensed Practical Nurse (LPN) and the MDS Coordinator/Registered Nurse (MDSC/RN) confirmed the error in the MDS coding. The MDSC/RN acknowledged that the psychotropic medication should have been coded as 'yes' in the MDS, aligning with the Resident Assessment Instrument (RAI) manual guidelines. The facility's leadership, including the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), also recognized the inaccuracy in the MDS assessment during discussions with the survey team.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near East Orange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Orange Park | 0.4 mi | ★★★★★ | 13 | 0 |
| Park Crescent Healthcare & Rehabilitation Center | 0.9 mi | ★★★★★ | 12 | 0 |
| Sinai Post-acute Nursing & Rehab Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Brookhaven Health Care Center | 1.5 mi | ★★★★★ | 9 | 0 |
| Alaris Health At St Marys | 1.5 mi | ★★★★★ | 2 | 0 |
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