Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Pine Valley Center For Rehabilitation And Nursing during CMS and state inspections, most recent first.
Improperly Labeled and Dated Food Items in Kitchen Storage: Surveyors found multiple food items stored in kitchen refrigerators, freezers, and coolers without required labels or open dates, including garlic, cabbage, chicken, salad, juices, bread, cereal, butter, carrots, sandwiches, and applesauce. The FSD acknowledged that items needed to be labeled with the food name and date opened/prepared, and stated the unlabeled items had been opened or prepared over the weekend.
Failure to Offload Heels for Residents at Risk for Pressure Ulcers: Three residents who were assessed as at risk for pressure ulcers had physician orders for heel offloading, but staff did not implement the orders. Two residents were observed in bed with both heels resting on the mattress, and one resident’s care plan did not include the ordered heel offloading intervention. Interviews showed staff were responsible for ensuring heels were offloaded, but this was not consistently done.
A facility failed to ensure ordered splints and braces were consistently applied for residents with contractures and limited ROM. Observations showed a resident with bilateral hand contractures not wearing carrot splints, a resident with a left-hand contracture without a left-hand roll brace, and a resident with a right-hand contracture without a resting hand splint. Staff interviews showed CNA and nursing staff were not consistently aware of the orders or whether the devices were in place, and the DON/rehab staff confirmed nursing was responsible for daily application.
A resident with severe cognitive impairment, dependence for ADLs, obstructive uropathy, an unstageable sacral PU, and adult failure to thrive did not have a quarterly MDS completed within the required 3-month timeframe after the annual comprehensive MDS. Facility policy stated the Assessment Coordinator is responsible for ensuring timely quarterly assessments, and the MDS Coordinator acknowledged the quarterly MDS should have been completed but was not documented.
A resident with nicotine dependence, paraplegia, and bipolar disorder was not coded as an active smoker on the annual MDS, even though the resident had signed a smoking contract and stated they were an active smoker. The MDS coordinator said the resident was incorrectly coded as a non-smoker and acknowledged the oversight.
A resident with CKD and cervical cancer had known hoarding tendencies, but the care plan did not address the behavior. Observations found multiple bags and bins of clothing piled around the room and blocking access to the sink, bathroom, and windows. The resident said they could not organize their belongings and did not trust staff to handle them. The Case Manager stated there was no care plan or set schedule in place to manage the hoarding, while the DON said staff would only remove items if they were unsafe.
Care plan not updated for bed rail use: A resident with CKD and cervical cancer had care plan interventions and a nursing assessment documenting bilateral bedrails for bed mobility and transfers, but the rails were later removed and the resident said they did not know why. Rehab staff said the latest eval supported bilateral bedrail enablers, while an LPN said the care plan may not have been updated to reflect the resident’s current mobility status; the DON stated the resident was no longer safe using bedrails and the order was discontinued.
An unlocked med cart was found unattended in the unit corridor near the nursing station with one drawer open. The assigned LPN was in the med room behind a closed door and not within eyesight of the cart, and stated the cart should have been locked to prevent access to the meds.
A resident with a history of anxiety, depression, and behavioral symptoms made an allegation of sexual abuse that was reported by a family member. The DON and Administrator delayed reporting the allegation to the Department of Health, citing the allegation's vagueness and the resident's history, and instead conducted an internal investigation before reporting, resulting in a failure to meet the required two-hour reporting timeframe.
A resident with severe cognitive and physical impairments was subjected to abuse by staff members who used excessive force during care. Video footage revealed instances of rough handling, including forceful gown removal and physical smacking. The resident was identified as high-risk for abuse due to their vulnerabilities.
A resident with severe cognitive impairment and physical disabilities was subjected to abuse by staff, as captured on video. Despite the evidence, the facility failed to report the incidents to local law enforcement, believing it was the family's responsibility. The facility only notified the Department of Health, neglecting their obligation under the Elder Justice Act.
The facility failed to conduct timely performance reviews and provide the required in-service education for two CNAs. One CNA had not been evaluated since 2021 and attended insufficient in-services, while the other had only one review since 2017 and attended only three in-services. Both CNAs had documented performance issues, yet the facility did not ensure compliance with regulatory requirements for evaluations and education.
The facility failed to adhere to infection control practices for two residents on enhanced precautions. Staff did not wear gowns during high-contact care activities, such as transferring and bathing, despite the presence of precaution signs and the residents having conditions like G-Tubes and Foley catheters. This was against the facility's infection prevention policy.
Improperly Labeled and Dated Food Items in Kitchen Storage
Penalty
Summary
Food was not stored in accordance with professional standards for food service safety, as twenty-five food items were found in the kitchen refrigerators, freezers, and food storage areas without proper identification or dating. The facility policy titled Food Storage, last revised May 2025, required containers to be legible and accurately labeled and dated, with all foods covered, labeled, and dated before refrigeration and leftovers checked for safe use by dates. During the kitchen inspection with the Food Service Director, surveyors observed multiple unlabeled or undated items in several storage areas. In the Meat Refrigerator, there was a 5 lb. container of peeled garlic with no opened date, a tray of cabbage open to air with no date prepared and no identification label, and a tray of chicken legs with no identification label. In the Meat Freezer, there was a tray of ground chicken with no date prepared and no identification label and a tray of cabbage open to air with no date prepared and no identification label. In the Two Door Cooler, surveyors found nine cups of salad with no date prepared and no identification label, two trays of juices with no identification label, two opened bags of bread with no opened date, one opened bag of Corn Flakes with no opened date and no identification label, and one pound block of butter opened with no opened date. In the Dairy Freezer, there was one bag of carrots with no opened date, three sandwiches with no identification label, and one container of apple sauce with no identification label. The Food Service Director stated the items needed to be marked with dates opened and identified, and said the unlabeled items had been opened or prepared during the weekend.
Failure to Offload Heels for Residents at Risk for Pressure Ulcers
Penalty
Summary
The facility did not ensure heel offloading was implemented for three residents who were assessed as at risk for pressure ulcers and had physician orders for heels to be offloaded. Resident #59 had diagnoses including hypertensive heart disease, sequelae of cerebral infarction, and spastic hemiplegia, and was documented as severely cognitively impaired, dependent for all care, and at risk for pressure ulcers. Although a physician order dated 10/01/2022 directed heels to be offloaded, the care plan did not include a heel offloading intervention. During multiple observations, the resident was found lying in bed with both heels resting on the mattress and no pillows in place to offload the heels. Staff interviews indicated the CNA was unaware the heels should be offloaded and the RN unit manager stated staff were responsible for ensuring heel offloading was done, but was not sure whether the resident had been checked that week. Resident #91 had diagnoses including sequelae of cerebral infarction, anxiety disorder, and dementia with behavioral disorder, and was documented as severely cognitively impaired, dependent for ADLs, and at risk for pressure ulcers. The care plan included turning and positioning and encouraging heel elevation in bed, and a physician order dated 02/10/2025 directed turning and repositioning and heels offloaded. During observations, both heels were resting on the mattress while the resident was in bed. Resident #100 had diagnoses including hemiplegia and hemiparesis, heart failure, and atrial fibrillation, and was documented as severely cognitively impaired, dependent for transfers, and at risk for pressure ulcers. A physician order dated 01/02/2025 directed turning and repositioning, heels offloaded, and an air mattress, but the care plan did not include a heel offloading intervention. During observations, the resident was lying in bed with both bare feet resting on the mattress and not offloaded.
Ordered hand splints and braces not consistently applied for residents with contractures
Penalty
Summary
The facility did not ensure that residents with limited ROM received ordered treatment and services to maintain or improve mobility and prevent further decrease in ROM. The deficiency involved four residents reviewed for positioning and mobility: one resident with severe cognitive impairment and bilateral hand contractures, one cognitively intact resident with a left wrist contracture, and two residents with spastic hemiplegia and upper-extremity contractures. The facility policy stated contracture management was intended to prevent decreased ROM, maintain skin and joint integrity, and optimize functional abilities through splints, orthotics, and positioning devices as tolerated. For the resident with bilateral hand contractures, OT recommended bilateral carrot splints to be worn except during hygiene, skin checks, bathing, and ROM exercises, and a physician order was written for both hands. However, multiple observations showed the splints resting on the resident’s chest, sheets, bedside chest, or not in use while the resident was in bed or in a geri-chair, and staff stated the resident was not wearing them. For the resident with a left-hand contracture, a physician order required a left-hand roll brace, but repeated observations showed the brace was not in place while the resident was in a wheelchair. The resident stated the brace was in the drawer and that they could not apply or remove it independently. For the resident with a right-hand contracture, a physician order required a right resting hand splint from 8:00 AM to 8:00 PM with skin checks every four hours, yet repeated observations showed the resident without the splint while in bed and with the contracted hand exposed. Staff interviews indicated CNA and nursing staff were not consistently aware of the splint orders, did not place the devices, and were unsure whether spot checks had been completed. A fourth resident was also identified in the deficiency statement as not receiving a left-hand carrot splint as ordered, and the Director of Rehabilitation stated nursing staff were responsible for applying the ordered devices daily.
Quarterly MDS Not Completed on Time
Penalty
Summary
The facility did not ensure that resident assessments were updated at least once every three months for Resident #44. Resident #44 had diagnoses including obstructive uropathy, an unstageable pressure ulcer of the sacral region, and adult failure to thrive. An annual MDS dated 06/28/2025 documented severe cognitive impairment, dependence for activities of daily living, and one pressure ulcer. However, there was no documented evidence that a quarterly MDS was completed in September or October 2025, even though the facility policy stated the Assessment Coordinator is responsible for ensuring the Interdisciplinary Assessment Team conducts timely resident assessments at least quarterly. During interview, the MDS Coordinator stated that a quarterly MDS should have been completed in September or October 2025 after the annual comprehensive MDS.
MDS Did Not Accurately Reflect Smoking Status
Penalty
Summary
The facility did not ensure that the Minimum Data Set 3.0 annual comprehensive assessment accurately reflected Resident #9’s status by failing to code the resident as an active smoker. Resident #9 had diagnoses including nicotine dependence, unspecified paraplegia, and bipolar disorder, and the record included a Resident Smoking Contract signed on 12/05/2024. The care plan documented monitoring compliance with the smoking contract, directing the resident to the designated smoking area, and completing a smoking screen to determine safety. However, the annual comprehensive MDS dated 10/22/2025 documented the resident as cognitively intact but did not indicate that the resident was an active smoker. During interview, Resident #9 stated they were an active smoker and had signed a smoking contract with the facility. The MDS Coordinator stated they completed the assessment, coded the resident as a non-smoker, and acknowledged this was an oversight and that the resident should have been coded as a smoker.
Lack of Care Plan for Hoarding Behavior
Penalty
Summary
The facility did not develop and/or implement a comprehensive person-centered care plan for Resident #13 that addressed known hoarding behavior, and the record contained no documented behavior care plan for that issue. Resident #13 had diagnoses of chronic kidney disease and malignant neoplasm of the cervix. The MDS 3.0 assessment documented that the resident was cognitively intact and did not display inappropriate behavior, and the comprehensive care plan initiated for behavior addressed episodes of refusing dialysis treatment, but not hoarding. During observations on 12/16/2025 and 12/18/2025, Resident #13's room contained six large clear plastic bags of clothing arranged around the room and piled on chairs, blocking access to the sink, bathroom, and windows. Several large plastic storage bins were also present on wire shelves. Resident #13 stated they were unable to put their clothing away and organize their belongings, and said staff used to help them go through their belongings but they did not trust staff to put items away for them. The Case Manager stated Resident #13 had hoarding tendencies, did not allow anyone to touch the clothing in the room, and that no staff member had been assigned since the former DON left to work with the resident on a regular schedule. The Case Manager also stated there was no care plan to address the hoarding behavior and no system in place to prevent it from increasing. The DON stated the resident had a noncompliance care plan and that staff would remove anything unsafe from the room.
Care Plan Not Updated for Bed Rail Use
Penalty
Summary
The facility did not ensure Resident #13’s plan of care was reviewed and revised to match the resident’s current bed mobility status. Resident #13 had diagnoses of chronic kidney disease and malignant neoplasm of the cervix, and the MDS 3.0 assessment documented the resident as cognitively intact and independent in rolling left and right in bed. The comprehensive care plan dated 08/28/2025 and last reviewed 09/10/2025 documented use of top bilateral bed rails for rolling, bed mobility, and transfers from bed, and another care plan documented bilateral 1/2 siderails to promote and assist with bed mobility. A nursing bed rail/grab bar assessment documented that the resident needed a bedrail to increase independence with bed mobility and transfers in and out of bed, and a physician order for siderails was initiated on 08/27/2025 and discontinued on 12/10/2025. During observation and interviews, Resident #13 stated the siderails had been removed and they did not know why. The Director of Rehabilitation stated the latest rehabilitation evaluation determined the resident should have bilateral bedrail enablers for mobility, and that nursing was responsible for a safety assessment to determine whether bedrails were appropriate. The Director of Rehabilitation also stated the last nursing assessment for bedrails was in 09/2025 and documented that the resident should have siderails, but they did not know why the bedrails were removed. An LPN stated they were responsible for updating resident care plans and that Resident #13’s bedrail intervention may not have been updated to reflect the resident’s most recent bed mobility status. The DON stated the resident previously used bedrails for bed mobility but no longer was safe using them and the order for bedrails was discontinued.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure drugs and biologicals were maintained in accordance with currently accepted professional standards for storage. During observation, the Three East High Side medication cart was found unattended in the unit corridor near the nursing station, unlocked, with one drawer left open. The cart’s assigned nurse, an LPN, was not near the cart, was not within eyesight of it, and was in the unit medication room behind a closed door. The facility policy titled Medication Storage, dated May 2025, stated that nursing staff are responsible for maintaining medication storage and that compartments containing drugs and biologicals must be locked when not in use. During interview, the LPN stated they knew the cart was supposed to be locked to prevent residents or other nurses from accessing the medications.
Failure to Timely Report Alleged Abuse to State Authorities
Penalty
Summary
The facility failed to ensure that all alleged violations of abuse were reported immediately, but not later than two hours, to the New York State Department of Health for one of three residents reviewed for abuse. On 9/23/2025 at approximately 2:00 PM, a family member reported that a resident alleged sexual abuse. However, the allegation was not reported to the Department of Health until 9/24/2025 at 11:18 AM, exceeding the required reporting timeframe outlined in the facility's Abuse Prevention Policy and Procedure. The policy mandates that all alleged violations involving abuse must be reported immediately, but no later than two hours after the allegation is made, if the events involve abuse or result in serious bodily injury. The resident involved had diagnoses including anxiety disorder, depression, and hypertension, and was documented as having intact cognition with behavioral symptoms that significantly intruded on others and put the resident at risk. During interviews, the DON and Administrator acknowledged awareness of the two-hour reporting requirement but stated that the allegation was not reported within the required timeframe because it was considered vague and confusing, and the resident had a history of accusations. The facility conducted an internal investigation within two hours and concluded that abuse did not occur, which contributed to the delay in reporting the allegation to the Department of Health.
Resident Abuse Due to Excessive Force by Staff
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by video footage showing multiple staff members using excessive force while providing care. The resident, who was readmitted with diagnoses including cerebral vascular accident, hemiplegia, and impairments to both upper and lower extremities, was severely cognitively impaired and dependent on staff for all activities of daily living. The resident was identified as a high-risk victim of abuse due to their inability to communicate needs effectively and vulnerability from cognitive and physical disabilities. The abuse incidents were captured on video, showing staff members handling the resident roughly and using unnecessary force. Specific instances included a CNA forcefully removing the resident's gown and wiping their face roughly, another CNA attempting to reposition the resident in bed by pulling and tugging on their upper body and head, and a resident assistant physically smacking and flicking the resident. These actions were reported to the Director of Nursing, who, upon reviewing the footage, suspended and subsequently terminated the involved staff members.
Plan Of Correction
Plan of Correction: Approved January 21, 2025 1. Resident #1 potential victim of abuse care plan was updated as a victim of abuse, which addresses ways to ensure that he does not become a victim of abuse including but not limited to redirecting him away from persons of concern, observing whereabouts of resident and intervening as needed and monitoring socialization. The three staff members have been terminated based on the findings of the investigation. The facility policy for Abuse reviewed/revised date was added along with the facility official letterhead. 2. The Director of Nursing or designee will audit by 1/31/25 to ensure all residents at risk to be a victim of abuse have care plans in place, updated, and accurate reflecting their potential to be a victim. Any findings of noncompliance will be corrected immediately. 3. The Director of Nursing or designee will educate by 1/31/25 all licensed nursing staff on the Care Plan policy. All facility staff will be educated on the Abuse Policy and Procedure by the Director of Nursing or Designee. The facility policy will change the Abuse education from upon hire and annually, to upon hire and quarterly going forward. 4. The Director of Nursing or designee will audit all potential to be a victim care plans monthly for 3 months to ensure that all residents have appropriate and up-to-date care plans in place, with any findings of noncompliance corrected immediately. The Administrator and Director of Nursing will review the Abuse policy and procedure quarterly. The Director of Nursing or Designee will audit staff Abuse education compliance weekly for 3 months then monthly thereafter. Any findings of noncompliance will be reported to QAPI quarterly. Responsibility: Director of Nursing or Designee
Failure to Report Abuse to Law Enforcement
Penalty
Summary
The facility failed to report incidents of staff-to-resident abuse to local law enforcement, as required by regulations. This deficiency was identified during a survey where it was found that multiple staff members, including Certified Nursing Assistants and Resident Assistants, used excessive force while providing care to a resident. The incidents were captured on video footage provided by the resident's family, which showed staff members handling the resident roughly and inappropriately. Despite the evidence of abuse, the facility did not report these incidents to local law enforcement, as they believed it was the family's responsibility to do so. The resident involved in the incidents had a history of severe cognitive impairment and was dependent on staff for all activities of daily living due to conditions such as a Cerebral Vascular Accident and Hemiplegia. The resident was assessed as a high-risk victim of abuse, with a care plan in place to protect them from such incidents. However, the care plan's goal of ensuring the resident's protection was not met, as evidenced by the abusive actions captured on video. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed a misunderstanding of the facility's obligations under the Elder Justice Act. The Director of Nursing acknowledged the abuse after reviewing the video footage and suspended the involved staff members but did not contact law enforcement, leaving the decision to the family. The facility only reported the incident to the Department of Health, failing to fulfill the requirement to notify local law enforcement, which constitutes a deficiency in their abuse reporting protocol.
Plan Of Correction
Plan of Correction: Approved December 23, 2024 The facility policy for Abuse reviewed/revised date was added along with the facility official letterhead. The Administrator reported the abuse on Resident #1 to the local police on 11/26/24 during the abbreviated survey. The facility Director of Nursing and Administrator have been re-educated during the abbreviated survey as well as by Regional Administrator on reporting regulations of the Elder Justice Act that requires reports to be made to at least one local law enforcement agency of jurisdiction. The facility Administrator and Director of Nursing will be re-educated by the Regional Administrator on the reporting requirements quarterly. All facility staff will be educated on the Abuse Policy and Procedure by the Director of Nursing or Designee. The facility policy will change this education from upon hire and annually, to upon hire and quarterly going forward. The Administrator will report education compliance to QAPI for 6 months. The Director of Nursing or Designee will audit staff Abuse education, which includes reporting requirements, compliance weekly for 3 months then monthly thereafter. Any findings of noncompliance will be reported to QAPI quarterly. Responsibility: Director of Nursing, Administrator or Designee
Deficiency in CNA Performance Reviews and In-Service Education
Penalty
Summary
The facility failed to ensure that a performance review of every nurse aide was completed at least once every 12 months, and that each nurse aide received no less than twelve hours of in-service education per year based on the outcome of these reviews. This deficiency was identified during a survey, which included staff interviews and a review of facility documentation. Specifically, the facility did not conduct timely performance reviews for two Certified Nursing Assistants (CNAs), nor did it provide the required in-service education hours. Certified Nursing Assistant #1 had not received a performance evaluation since May 4th, 2021, and had attended only nine in-services, which did not meet the required twelve hours of education. Additionally, Certified Nursing Assistant #4 had only one performance review on file dated July 6th, 2017, and had attended only three in-services since their hire date. The documentation revealed that Certified Nursing Assistant #1 had a history of verbal counseling in 2024 for issues such as failure to document and improper break time. Certified Nursing Assistant #4 had received warning notices for various infractions, including leaving a resident unattended in a bathroom. Despite these documented issues, the facility did not ensure that these CNAs received the necessary performance evaluations and in-service education to address and improve their job performance. This lack of compliance with regulatory requirements for performance reviews and education contributed to the identified deficiency.
Plan Of Correction
Plan of Correction: Approved December 23, 2024 The three staff members have been terminated based on the findings of the investigation. The facility will audit all current CNAs 12 hours of education and annual performance evaluations. Any CNAs not in compliance with the 12 hours of education or annual performance evaluation will be corrected. Education will be provided to the Director of Human Resources and all CNA staff that 12-hour education is required each year as well as annual performance evaluations. The facility will audit all CNAs 12 hours of education and annual performance evaluations weekly for 3 months, then monthly thereafter to ensure all 12 hours of education and annual performance reviews are in compliance. Any findings of noncompliance will be reported to QAPI. Responsibility: Director of Nursing and Director of Human Resources or Designee
Inadequate Infection Control Practices for Residents on Enhanced Precautions
Penalty
Summary
The facility failed to maintain proper infection control practices for two residents on enhanced precautions. Resident #1, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was observed being transferred by a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN) without wearing gowns, despite the resident having a G-Tube, Foley catheter, and a stage IV wound. Additionally, video reviews showed multiple instances where CNAs and Resident Assistants provided care to Resident #1, such as bed baths and catheter management, without wearing gowns, which was against the facility's infection prevention policy. Similarly, Resident #6, who was cognitively intact and had a urinary catheter, was also on enhanced barrier precautions. However, during a transfer from bed to chair, none of the staff members involved wore gowns, despite the presence of a precaution sign on the resident's door. These actions were in direct violation of the facility's infection control policy, which mandates the use of gowns and gloves during high-contact resident care activities to prevent the transmission of multi-drug resistant organisms.
Plan Of Correction
Plan of Correction: Approved December 23, 2024 The three staff members have been terminated based on the findings of the investigation. Licensed Practical Nurse #9, Certified Nursing Assistant #6, #7, #8 and Resident Assistant #15 were re-educated on Enhanced Barrier Precautions PPE requirements. The DON or designee will audit all residents who are currently EBP to ensure staff are following policy and procedure. Education has been provided to all facility staff on enhanced barrier precautions. The facility policy will change this education from upon hire and annually, to upon hire and quarterly going forward. The Director of Nursing or Designee will audit all residents who are currently EBP to ensure staff are following policy and procedure weekly for 3 months. Any noncompliance will be immediately corrected and reported to QAPI. The Director of Nursing or designee will audit staff education to ensure compliance weekly for 3 months then monthly thereafter. Any findings will be reported to QAPI. Responsibility: Director of Nursing and Infection Control Preventionist (ICP) or Designee
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Illustrative
What surveyors actually found near you
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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 Spring Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friedwald Center For Rehab And Nursing, L L C | 1 mi | ★★★★★ | 4 | 0 |
| Northern Metropolitan Res Health Care Facility Inc | 2.1 mi | ★★★★★ | 2 | 0 |
| Northern Manor Geriatric Center Inc | 2.1 mi | ★★★★★ | 0 | 0 |
| The Willows At Ramapo Rehab And Nursing Center | 5.2 mi | ★★★★★ | 17 | 0 |
| Nyack Ridge Rehabilitation And Nursing Center | 5.2 mi | ★★★★★ | 1 | 0 |
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