Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbors At Pomeroy during CMS and state inspections, most recent first.
A resident with colon cancer, chronic pain, and scheduled bowel meds had no care plan addressing constipation, despite receiving Colace and Lactulose on a routine basis and Norco PRN for pain. An RN confirmed the care plan did not include constipation even though the resident’s diagnoses and meds made it a documented medical problem.
Improper Medication Administration for Chronic Diarrhea: A resident with chronic diarrhea was receiving Lomotil scheduled for diarrhea and Glycolax scheduled for constipation, even though hospital discharge instructions called for Glycolax/Clearlax to be PRN for constipation. The resident continued to have loose stools, reported the issue was not being adequately addressed, and the MAR showed no PRN Imodium doses were given despite an active order.
Failure to Follow Fall and Safety Interventions: Two residents had ordered fall and safety interventions that were not in place as documented in their care plans and physician orders. One resident with dementia, epilepsy, and impaired mobility was observed with hot coffee without a lid, no visual cue to ask for assistance, and no padding on enabler rails for seizure precautions. Another resident with dementia, prior stroke, and unsteadiness was observed in bed with floor mats present but the bed not in its lowest position, despite a low-bed order and fall-risk care plan.
Medication Administered Outside Ordered BP Parameters: A resident with TIA, HTN, and severe cognitive impairment received metoprolol despite physician hold parameters requiring the dose to be withheld when DBP was below 80 mm Hg. The MAR showed multiple administrations when DBP readings were under the ordered limit, and the Regional Nurse confirmed the medication should not have been given.
Therapeutic Diet Menu Not Fully Followed for Renal Resident: A resident on a renal diet did not receive all items listed on the therapeutic menu during lunch. Staff substituted buttered noodles for a baked potato as ordered, but removed cornbread from the tray and did not replace it with an allowed bread item such as a dinner roll or slice of bread. The dietary manager confirmed the omission, and the resident stated she did not receive the bread substitute and would have liked it to help fill her up.
Failure to provide ordered meal assistive devices: A resident with Parkinsonism, dementia, and mildly impaired cognition had orders for weighted utensils, a plate guard, and a sippy cup with meals, and the care plan called for adaptive equipment. During breakfast, a CNA gave the resident juice in a glass with a straw because he was shaky, and no sippy or spouted cup was observed. An RN confirmed the order for a sippy cup with all meals.
A certified medication aide/tech who had not completed required training administered narcotic medication and insulin to two residents with complex medical histories. Facility records, interviews, and policy review confirmed the aide/tech was not qualified to give these medications, in violation of facility policy requiring administration by licensed or legally authorized staff.
Thirteen residents were taken on an outdoor outing during high temperatures, resulting in two residents becoming unresponsive and requiring hospitalization for heat stroke. Despite complaints of discomfort and visible signs of overheating, staff continued the outing and did not adequately address the risks posed by the heat or consult with a physician regarding the residents' participation. The bus used for transportation was not properly cooled, and residents were exposed to excessive heat for extended periods, leading to actual harm.
A facility failed to develop a baseline care plan for a resident's orthotic splint, despite physician orders to monitor the splint and check skin integrity. The resident, with multiple diagnoses including osteoarthritis and Kienbock's disease, reported discomfort and tightness from the splint, which was observed to cause edema. The facility's policy required such a plan, but it was not implemented, leading to a deficiency.
The facility failed to update care plans for two residents regarding ADL and palliative care. One resident required extensive assistance with ADLs, but the care plan was not revised to reflect this need. Another resident's care plan did not accurately reflect their current hospice provider. These deficiencies were confirmed through interviews with facility staff.
A resident with multiple medical conditions and a self-care performance deficit did not receive the required nail care as per physician orders. Despite a standing order for weekly nail trimming, observations and interviews confirmed that the resident's nails were long, jagged, and dirty, indicating non-compliance with the facility's nail care policy.
The facility failed to provide routine palliative care visits for a resident with a terminal prognosis and did not adequately monitor another resident's orthotic splint, leading to increased edema. The palliative care visits were missed due to external factors, while the splint was not adjusted despite the resident's complaints of tightness and swelling. These deficiencies were identified through observations, record reviews, and interviews.
Two residents in the facility did not receive routine podiatry services, leading to deficiencies in their care. One resident, with a complex medical history, was not seen by a podiatrist during scheduled visits, resulting in long and curving toenails. Another resident, diagnosed with neurocognitive disorder, also did not receive podiatry services since admission, with observations showing long and thick toenails. The facility's policy on nail care was not followed, and there was a lack of documentation regarding consent or refusal of podiatry services.
The facility failed to implement fall prevention interventions for three residents, leading to deficiencies in care. A resident was found without non-skid socks and a bed in the lowest position, another was missing an anti-rollback bar on their wheelchair, and a third had an unpadded footboard despite orders. Staff interviews revealed a lack of awareness of these interventions.
The facility failed to timely address pharmacy recommendations for two residents, leading to deficiencies in medication management. A resident's GDR was not justified by the physician, and another resident's medication adjustment was delayed beyond policy guidelines. Staff confirmed the lack of timely response, contrary to facility policy.
A facility failed to obtain physician-ordered laboratory testing for a resident with severe cognitive deficits and multiple diagnoses, including Alzheimer's and dementia. Despite a pharmacy recommendation and a physician's order to check the resident's A1C yearly due to the risk of adverse metabolic effects from antipsychotic and antidepressant medications, no A1C results were found in the medical record. The DON confirmed the absence of these results.
The facility failed to notify the local Ombudsman of transfers for two residents, one with complex medical issues and another with multiple sclerosis and cellulitis, to the emergency room. Despite documentation of the transfers and provision of bed hold policies, there was no evidence of Ombudsman notification, confirmed by facility staff.
Care Plan Did Not Address Constipation
Penalty
Summary
Resident #55’s comprehensive care plan did not address constipation despite multiple related factors documented in the record. The resident was admitted with diagnoses including malignant neoplasm of the colon, morbid obesity, chronic pain, and muscle weakness. Her active physician’s orders included Colace 100 mg twice daily for constipation, Lactulose 15 ml once daily for constipation, and Norco 7.5-325 mg every six hours as needed for chronic pain. The medication administration record for July 2026 showed she was receiving Colace and Lactulose on a scheduled basis and Norco as needed. Review of the resident’s active care plans showed no care plan in place for constipation, even though she had a known diagnosis that placed her at risk for constipation and was receiving stool softeners and laxatives on a scheduled basis. During interview, RN #184 confirmed the active care plans did not address constipation and acknowledged that, given the resident’s diagnoses and the medications used to treat constipation, the resident should have had an active care plan for that medical problem.
Improper Medication Administration for Chronic Diarrhea
Penalty
Summary
The facility failed to ensure a resident received medications in accordance with physician orders to properly manage his chronic diarrhea. Resident #9, who had diagnoses including malignant neoplasm of the prostate and need for assistance with personal care, was receiving Lomotil 2.5 mg/0.025 mg by mouth three times daily for chronic diarrhea and Glycolax 17 grams by mouth once daily for constipation after returning from the hospital. The resident also had an order for Imodium 2 mg as needed for loose stools, to be given after each loose stool up to a maximum of eight tablets in 24 hours. Review of the resident’s records showed the hospital discharge instructions directed Clearlax/Glycolax 17 grams to be taken once daily as needed for constipation, but the facility transcribed and administered it as a scheduled daily medication. The resident’s bowel movement record documented diarrhea 13 times in the prior 30 days, including multiple episodes after his return from the hospital, and he reported on interview that he continued to have diarrhea and felt it was not being adequately addressed. Staff confirmed the resident was receiving both a scheduled antidiarrheal and a scheduled laxative, acknowledged the laxative order should have been PRN, and verified the MAR did not show any PRN doses of Imodium had been given.
Failure to Follow Fall and Safety Interventions
Penalty
Summary
The facility failed to ensure fall prevention interventions were in place for two residents with identified fall risks. One resident had diagnoses including dementia, epilepsy, and difficulty walking, and her care plan included interventions to encourage use of a cup with a lid for hot liquids and a visual cue to ask for assistance. However, observations showed a cup of coffee without a lid at the bedside and later during breakfast, and there was no sign in the room as a visual cue to ask for assistance. The same resident also had an order for padding to enabler rails related to seizure precautions, but observations on multiple days showed no padding on the enabler rails, and staff confirmed it was not in place. Another resident with diagnoses including dementia, anxiety disorder, history of stroke, diabetes, hypertension, osteoporosis, muscle weakness, unsteadiness on feet, and irritable bowel syndrome had a care plan and physician order for a low bed while in bed, with floor mats at bedside. Observations showed the resident in bed with floor mats present, but the bed was not in its lowest position on more than one occasion. During interview, the RN confirmed the resident was at risk for falls, had fallen in the past when trying to self-transfer, and acknowledged the bed was not in the lowest position during the observations.
Medication Administered Outside Ordered Blood Pressure Parameters
Penalty
Summary
The facility failed to ensure that medications were administered within physician-ordered parameters for one resident. Resident #4 was admitted with diagnoses including transient cerebral ischemic attack and hypertension, and the quarterly MDS indicated severe cognitive impairment and hypertension. The physician ordered metoprolol succinate ER 50 mg, 0.5 tablet by mouth daily for hypertension, with instructions to hold the medication if systolic blood pressure was less than 100 mm Hg, diastolic blood pressure was less than 80 mm Hg, or heart rate was less than 60 beats per minute. Review of the July 2026 MAR showed the medication was administered on multiple occasions when the resident’s diastolic blood pressure was below 80 mm Hg, including readings of 77, 68, 75, 72, 76, 70, 72, and 77 mm Hg. During interview, the Regional Nurse confirmed the metoprolol was not held according to the ordered parameters and should not have been administered.
Therapeutic Diet Menu Not Fully Followed for Renal Resident
Penalty
Summary
The facility failed to ensure a resident on a renal diet received all food items included on the therapeutic menu. Resident #71 was admitted with end stage renal disease and dependence on renal dialysis, and her active physician’s order specified a renal (chronic kidney disease 5) diet. During lunch tray line observation, her meal ticket identified the renal diet, and staff substituted buttered noodles for a baked potato as listed on the renal menu. However, the resident was not provided cornbread, and although a dietary aide initially placed a piece of cornbread on the tray, it was removed and not replaced with another permitted bread item. The facility’s therapeutic diet spreadsheet showed that residents on the renal diet were to receive buttered noodles in place of a baked potato and were not to receive cornbread, but should have been given a dinner roll or a slice of bread instead. The dietary manager confirmed the resident did not receive the required bread substitute and acknowledged the aide removed the cornbread without replacing it with an allowed bread item. The resident stated she did not receive a dinner roll or slice of bread with lunch and would have liked one to help fill her up.
Failure to Provide Ordered Meal Assistive Devices
Penalty
Summary
The facility failed to ensure Resident #33 had assistive devices in place for meals. Resident #33 was admitted with diagnoses including Parkinsonism, dementia, and a need for assistance with personal care. The MDS showed mildly impaired cognition, and the physician orders included a regular diet with level three texture, thin liquids, weighted utensils and a plate guard with each meal, a sippy cup with each meal, and double bread for breakfast. The care plan also identified the resident as at risk for altered nutritional status and included interventions to provide adaptive equipment. During breakfast observation, a CNA was assisting Resident #33 and stated the resident had a glass of juice with a straw to make it easier because he was shaky. No sippy cup or spouted cup was observed in use during the meal. An RN confirmed the resident had an order for a sippy cup or cup with spouted lid for all meals as an assistive device. The facility policy stated assistive devices are to be provided for residents who need them.
Unqualified Staff Administered Narcotics and Insulin
Penalty
Summary
Certified Medication Aide/Tech #3 administered narcotic medication and insulin to two residents without being qualified or trained to do so. One resident, with multiple diagnoses including diabetes, cerebrovascular disease, and cognitive impairment, received hydrocodone-acetaminophen, a class II narcotic, on two occasions as documented in the medication administration record and controlled drug log. Another resident, with a history of diabetes, COPD, hemiplegia, and other conditions, received insulin aspart via Flex pen on two separate occasions, also administered by the same unqualified staff member. Documentation confirmed that the aide/tech had not completed the required training and was not authorized to administer these medications at the time of administration. Interviews with facility staff, including the administrator and a registered nurse, confirmed that the aide/tech was unqualified to administer narcotics and insulin. Review of the personnel file showed no evidence of completed training or qualification for medication administration. Facility policy requires that medications be administered by licensed nurses or staff legally authorized to do so, which was not followed in these instances. The deficiency was identified through review of records, interviews, and policy documents, affecting two residents out of 32 with narcotic and/or insulin orders.
Failure to Prevent Heat Stroke During Outdoor Activity
Penalty
Summary
The facility failed to provide adequate and proper interventions to prevent heat stroke during an outdoor activity, resulting in actual harm to residents. Thirteen residents were taken on a planned outing to the zoo on a day when the outside temperature reached 88 degrees Fahrenheit with a heat index of 90. Despite some residents expressing discomfort and complaints of being hot, the outing continued as scheduled, and residents remained outside and on a bus for extended periods. The bus used for transportation was not pre-cooled, and after leaving the zoo, residents stayed on the warm bus while meals were provided at a fast-food restaurant. The bus was described as being very hot inside, and residents were exposed to high temperatures for several hours. Two residents became unresponsive during the return trip, requiring emergency medical intervention. One resident was found to have a temperature of 105.7 degrees Fahrenheit and was transferred to the hospital, placed on a ventilator, and treated for heat stroke. Another resident was also unresponsive with a temperature of 104 degrees Fahrenheit and was admitted to the hospital for heat stroke. Both residents had significant medical histories, including cerebral infarction, hemiplegia, chronic obstructive pulmonary disorder, and other chronic conditions. Other residents on the outing also experienced symptoms of overheating, with some refusing assessment or treatment by EMS, and several being recommended for emergency room evaluation but declining. Staff interviews and documentation revealed that the decision to proceed with the outing was made despite prior discussions about the high temperature and concerns raised by staff. There was no evidence that the physician was consulted regarding the appropriateness of the outing for the residents given the weather conditions and their medical statuses. The facility did not ensure that outdoor activities were planned and provided to meet the safety and total care needs of the residents, and interventions such as increased fluids, sunblock, and access to shaded or air-conditioned areas were ineffective in preventing harm. The lack of adequate planning and response to residents' needs during the outing directly resulted in heat-related illnesses and hospitalizations.
Failure to Implement Baseline Care Plan for Orthotic Splint
Penalty
Summary
The facility failed to develop and implement a baseline plan of care for a resident's orthotic splint, which was necessary to address the resident's immediate needs upon admission. The resident, who was admitted with multiple diagnoses including osteoarthritis, osteonecrosis, and Kienbock's disease, had a right orthotic brace that was not addressed in the nursing admission evaluation. Despite the presence of physician orders to monitor the splint and check skin integrity, these instructions were not incorporated into a baseline care plan. The resident reported discomfort and tightness from the orthotic splint, which was observed to cause edema around the brace. The Senior Director of Nursing confirmed that the baseline plan of care did not include the necessary instructions for managing the orthotic splint, as required by the facility's policy. This oversight affected the resident's care and highlighted a deficiency in the facility's adherence to its own policies for developing baseline care plans.
Failure to Update Care Plans for ADL and Palliative Care
Penalty
Summary
The facility failed to review and revise the care plans for two residents in the areas of activities of daily living (ADL) and palliative care. For Resident #5, the care plan did not reflect the resident's current need for extensive assistance with ADLs, despite documentation indicating this requirement from early January to early February 2025. The resident, who has a severe cognitive deficit and multiple complex medical conditions including cerebrovascular accident with hemiplegia and chronic obstructive pulmonary disease, was noted to require extensive assistance, yet the care plan was not updated to reflect these needs. This was confirmed during an interview with the Senior Director of Nursing. For Resident #46, the care plan did not accurately reflect the resident's current hospice care provider. The resident, who has a terminal prognosis and is receiving palliative care for conditions including severe morbid obesity and chronic respiratory failure, was documented to be under the care of Compass Palliative Care. However, an interview with a Registered Nurse revealed that the resident's current hospice provider was Buckeye Hospice. The facility's policy requires that comprehensive care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment, which was not adhered to in these cases.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was dependent on staff assistance, as per physician orders. The resident, who had a range of medical conditions including diabetes mellitus, polyneuropathy, and congestive heart failure, was admitted with a self-care performance deficit. The resident's care plan required staff assistance for personal hygiene, including nail care. Despite a physician's order for the resident's nails to be trimmed every Monday, the facility did not comply with this order. Observations and interviews revealed that the resident's nails were long, jagged, and dirty, indicating that they had not been trimmed as required. The resident confirmed that their nails were not cut on the specified date, and the Regional Director of Clinical also acknowledged the condition of the resident's nails. The facility's policy on nail care, which emphasizes routine cleaning and inspection during activities of daily living, was not followed, leading to this deficiency.
Failure to Provide Routine Palliative Care and Monitor Orthotic Splint
Penalty
Summary
The facility failed to ensure that a resident received routine palliative care visits. Resident #46, who had a terminal prognosis and was admitted to Compass Palliative Care with a diagnosis of COPD, had not received a visit from the contracted palliative care service since December 14, 2024. Despite being scheduled, the visits were missed due to a snowstorm and sickness at the provider's company, as revealed in an interview with the Director of Nursing. The facility's policy requires coordination with hospice staff to promote the resident's well-being, which was not adhered to in this case. Additionally, the facility failed to monitor another resident's orthotic splint, leading to increased edema. Resident #116, who had multiple diagnoses including osteoarthritis and Kienbock's disease, was at risk for impaired skin integrity due to a splint on the right hand. The resident's plan of care included monitoring the splint and skin integrity every shift. However, the resident reported that the brace felt tight and had not been adjusted, which was confirmed by RN #111. The resident's hand was observed to be swollen, with indents from the brace, indicating that the splint was too tight. The lack of routine palliative care visits for Resident #46 and inadequate monitoring of Resident #116's orthotic splint represent deficiencies in the facility's care. These issues were identified through observations, record reviews, and interviews, highlighting a failure to adhere to care plans and facility policies designed to ensure residents' well-being.
Failure to Provide Routine Podiatry Services
Penalty
Summary
The facility failed to provide routine podiatry services to two residents, leading to deficiencies in their care. Resident #24, who has a complex medical history including diabetes mellitus, polyneuropathy, and congestive heart failure, was not seen by a podiatrist during scheduled visits on 11/01/24 and 01/08/25. Despite having a care plan that addressed self-care performance deficits, there was no documented evidence that the resident refused podiatry care. Observations revealed that the resident's right great toenail was long and curving under, indicating a lack of routine nail care as per the facility's policy. Resident #50, diagnosed with neurocognitive disorder with Lewy Bodies and other conditions, also did not receive podiatry services since her admission. Her care plans did not address the need for podiatry care, and there were no physician's orders or consents for such services. Observations showed that her toenails were long and growing out diagonally, with the left great toenail being particularly thick. Interviews with staff confirmed that the resident was a total assist for ADLs and that podiatry services were not provided. The facility's policy on nail care, which includes routine cleaning, trimming, and filing, was not adhered to for these residents. The absence of podiatry services and lack of documentation regarding consent or refusal of such services contributed to the deficiency. Interviews with the Regional Director of Clinical Operations and other staff highlighted the oversight in ensuring that residents received necessary podiatry care, as evidenced by the condition of the residents' toenails.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for residents with a history of falls, affecting three residents. Resident #29, who had a history of falls and was at risk due to various medical conditions including dementia and muscle weakness, was observed in bed without the bed being in the lowest position as ordered. Additionally, the resident was not wearing non-skid socks, which were part of her fall prevention plan. The registered nurse interviewed was unaware of the specific fall prevention interventions in place for the resident and acknowledged the oversight. Resident #50, who had a history of falls and was at risk due to conditions such as neurocognitive disorder and a previous hip fracture, was observed in a wheelchair missing an anti-rollback bar, which was part of her fall prevention plan. The certified nursing assistant and registered nurse interviewed were unaware of the missing anti-rollback bar and the presence of disposable gloves in the resident's room, which were supposed to be removed as part of the fall prevention strategy. The oversight was confirmed during the survey. Resident #37, who had a history of skin injuries and was at risk due to conditions such as cerebrovascular accident and diabetes, was found to have a footboard that was not padded as ordered by the physician. The licensed practical nurse confirmed the absence of the padding, which was intended to prevent further skin injuries. The facility's failure to adhere to the prescribed interventions for fall and injury prevention was evident in the observations and interviews conducted during the survey.
Delayed Response to Pharmacy Recommendations in LTC Facility
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for two residents, leading to deficiencies in medication management. For Resident #5, the pharmacist recommended a gradual dose reduction (GDR) for several medications, including Remeron, Depakote, and Risperdal. The physician addressed the recommendation but did not provide a rationale for declining the GDR, and no progress note was documented to justify the decision. This oversight occurred despite the resident's complex medical history, which included conditions such as cerebrovascular accident, schizophrenia, and dementia. Resident #24 also experienced a delay in addressing a pharmacy recommendation. The pharmacist suggested a reduction in Omeprazole dosage, but the physician did not act on this recommendation until more than 30 days later, which was beyond the facility's policy timeframe. The resident's medical history included diagnoses such as diabetes mellitus, anxiety disorder, and major depressive disorder, and the resident was receiving multiple medications, including antianxiety and antidepressant drugs. Interviews with facility staff, including the Director of Nursing and the Regional Director of Clinical, confirmed the lack of timely response to pharmacy recommendations. The facility's policy required medication regimen reviews to identify irregularities and respond promptly to prevent adverse drug events, but this was not adhered to in these cases.
Failure to Obtain Ordered Laboratory Testing for a Resident
Penalty
Summary
The facility failed to obtain physician-ordered laboratory testing for a resident, leading to a deficiency. The resident, who was admitted with diagnoses including Alzheimer's disease, Crohn's disease, dementia, delusional disorders, hallucinations, unspecified psychosis, anxiety disorder, and depression, had a severe cognitive deficit as indicated by a Brief Interview for Mental Status score of 03. The resident had been receiving antipsychotic and antidepressant medications, which posed a risk of adverse metabolic effects. A pharmacy recommendation dated 07/25/24 advised checking a fasting lipid panel, fasting glucose level, and A1C yearly. Subsequently, a physician's order dated 07/29/24 was made to check the resident's A1C yearly. However, a review of the medical record revealed no A1C results, and the Director of Nursing confirmed the absence of these results during an interview on 02/06/25.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the local Ombudsman of resident transfers as required, affecting two residents. Resident #57, who had a complex medical history including acute on chronic respiratory failure, seizures, and diabetes, was transferred to the emergency room due to seizure activity and low oxygen saturation. Despite the transfer being documented in the resident's medical record and a bed hold policy being provided, there was no evidence that the local Ombudsman was notified of the transfer. The facility attempted to confirm notification with the Ombudsman's office but was unable to obtain confirmation. Similarly, Resident #65, who had diagnoses including multiple sclerosis and cellulitis, was transferred to the emergency room for an infection in the right lower extremity. The facility also failed to provide evidence that the Ombudsman was notified of this transfer. Interviews with the Senior Director of Nursing and the Regional Director of Operations confirmed the lack of notification to the Ombudsman for both residents' transfers.
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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 Pomeroy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Overbrook Center | 8 mi | ★★★★★ | 11 | 0 |
| Majestic Care Of Lakin | 11 mi | ★★★★★ | 8 | 0 |
| Arcadia Valley Skilled Nursing And Rehabilitation | 13 mi | ★★★★★ | 20 | 0 |
| Kimes Nursing And Rehab Llc | 15.5 mi | ★★★★★ | 52 | 2 |
| Ravenswood Village | 15.8 mi | ★★★★★ | 3 | 1 |
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