Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Momentous Health At Sidney during CMS and state inspections, most recent first.
The facility failed to provide ordered speech therapy services for two residents with dysphagia and post‑cerebral infarction speech and swallowing deficits. Both had physician orders to continue existing speech therapy plans of care under a new provider, with one to receive therapy twice weekly and the other three times weekly over a defined certification period, targeting improved swallow function, diet tolerance without aspiration signs, and better communication and speech intelligibility. Medical records for each resident showed only a single 23‑minute speech therapy session during that entire period. A therapy regional manager confirmed that services under the new contractor started after the prior contractor was terminated, that these two residents received speech therapy only once, and that available telehealth speech therapy was not utilized.
The facility did not ensure coffee was available to all residents as listed on the menu and failed to post menus for resident review. Several residents reported not receiving coffee with breakfast, and staff confirmed that menus were not displayed, requiring residents to ask about daily meal options.
Staff did not consistently don required protective gowns while providing high-contact care to a resident on Enhanced Barrier Precautions for wounds, despite facility policy and posted instructions. Multiple staff, including nurses and CNAs, were observed on several occasions wearing gloves but not gowns during direct care activities.
Staff did not perform required hand hygiene between handling food trays and making direct contact with multiple residents during meal service. An Activities Director delivered meals, touched food and residents without washing or sanitizing hands or using gloves, as confirmed by staff interviews and facility policy review.
A resident with multiple chronic conditions, who was cognitively intact and required assistance with daily living, was not provided shaving care as requested during bathing. Despite the resident's request and facility policy requiring assistance with shaving based on resident preference, staff did not perform the shaving, resulting in the resident having long hair on her legs and underarms and feeling dissatisfied with her appearance.
A resident with multiple chronic conditions alleged that an LPN acted abusively by taking away her meal and requiring her to eat in her room, causing her distress. A CNA witnessed the incident and reported it to the DON, but the allegation was not documented or reported to the state agency as required by facility policy. The Administrator confirmed the failure to report.
A resident with multiple chronic conditions reported that an LPN took her meal away in a manner she felt was abusive, and a CNA who overheard the incident described the LPN's tone as rude and disrespectful. Although the CNA reported the incident to the DON, the Administrator was unaware and no investigation was conducted, in violation of the facility's abuse prevention policy.
A resident with multiple chronic conditions who required assistance for toileting was not changed for over eight hours, resulting in her being found heavily soiled with urine and a wet pad. Staff confirmed the lapse in care, and the resident expressed that she was not changed as frequently as needed, contrary to facility policy.
A resident with CHF, hypertension, and diabetes was not provided the ordered amount of fluids, consistently receiving less than the prescribed 2,000 ml per day over an extended period. The care plan called for assistance and supervision with fluid intake, but the resident frequently reported thirst and did not always receive fluids when requested. Staff and dietary review confirmed the resident was under the fluid restriction amount, and required documentation and reporting of intake variations were not adequately performed.
The facility failed to maintain kitchen sanitation and proper food storage, affecting 38 residents. Observations revealed debris on the ice maker, a brownish-red substance inside the ice machine, and significant ice build-up in a freezer, preventing movement of the inner basket. Food items were not dated or labeled, and the produce cooler contained a rotten tomato. The Dietary Manager confirmed these issues, which violated facility policies requiring sanitary maintenance and proper labeling of food.
The facility did not ensure the Medical Director or their designee attended a required quarterly QAPI meeting, as revealed by attendance logs and confirmed by the DON. The absence was noted for a meeting intended to monitor and revise the QA/QI program, which is crucial for maintaining quality care standards.
The facility failed to maintain a licensed nursing home administrator (LNHA) with a valid license, affecting all 39 residents. Administrator #280's license expired, and there was a period without a licensed LNHA until Administrator #285 temporarily filled the role. This lapse was identified through BELTSS verification and staff interviews.
The facility failed to complete quarterly MDS assessments within the required timeframes for three residents. One resident with dementia had an assessment due on a specific date but completed later, requiring substantial assistance with daily activities. Another resident with schizoaffective disorder and diabetes had a delayed assessment, needing assistance with daily tasks. A third resident with vascular diseases also experienced a delay, despite being cognitively intact. The MDS Nurse confirmed these delays, violating CMS guidelines.
A facility failed to transmit MDS assessments for a resident with chronic conditions to CMS as required. The resident's assessments, including an annual, a significant change, and two quarterly MDS assessments, were not sent. An MDS Nurse confirmed the oversight, which is against the CMS RAI 3.0 User Manual requirements for Medicare/Medicaid-certified facilities.
A resident with peripheral vascular disease and venous insufficiency did not receive prescribed TED hose or ACE wraps, as observed over two days. Despite physician orders, the resident's lower extremities were not properly covered, confirmed by an LPN. The facility lacked a policy to ensure adherence to physician orders, leading to a deficiency in care.
The facility failed to obtain ordered laboratory tests for three residents, affecting their care. A resident with multiple diagnoses did not receive a lipid panel as ordered. Another resident with cognitive impairment had no documentation of required tests being completed. A third resident with heart disease and diabetes had missing lab results. The issue arose from a change in laboratory providers, and the facility lacked a policy for obtaining lab values.
A facility failed to maintain proper infection control practices during wound care for a resident with multiple medical conditions. An LPN did not perform hand hygiene after removing soiled dressings and before applying new gloves, despite the facility's policy emphasizing the importance of hand hygiene in preventing infections.
A facility failed to ensure proper infection control when a staff member touched a resident's genitalia without gloves during care. The resident, who required full assistance, reported the incident, which was confirmed by video surveillance. The facility's policy requires gloves to be worn during such interactions.
Failure to Provide Ordered Speech Therapy Services
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered speech therapy services for two residents requiring specialized rehabilitative care. One resident, admitted with diagnoses including dysphagia, dementia, and rheumatoid arthritis, had an MDS indicating severe cognitive impairment and a need for supervisory support with eating, positioning, and transferring, while remaining independently mobile in a manual wheelchair. Physician orders directed continuation of the resident’s existing speech therapy plan of care under a new provider effective 02/01/26, with a treatment plan calling for speech therapy twice weekly for four weeks during the certification period 02/01/26–02/28/26. The short-term goals included tolerating a mechanical soft diet without signs or symptoms of aspiration and performing oral-motor strength exercises to improve swallow function. Record review showed only one 23‑minute speech therapy session on 02/20/26, with no other speech therapy visits documented during the certification period. The second resident, admitted with a history of cerebral infarction, dysphagia following cerebral infarction, and other speech and language deficits following cerebral infarction, had an MDS showing moderately impaired cognition, a need for supervisory support with eating, and dependence on staff for positioning and transferring, while also being independently mobile in a manual wheelchair. Physician orders similarly required continuation of this resident’s speech therapy plan of care under a new provider effective 02/01/26, with a plan of treatment specifying speech therapy three times weekly for four weeks during the same certification period. Short-term goals included improving communication and speech intelligibility and tolerating a regular texture diet without signs or symptoms of aspiration. Documentation revealed only one 23‑minute speech therapy session on 02/20/26, with no additional visits recorded. In an interview, the Therapy Regional Manager stated that rehabilitative therapy services began on 02/02/26 after termination of the previous therapy contractor, confirmed that both residents received speech therapy only on 02/20/26, and acknowledged that although telehealth speech therapy was available, it was not used.
Failure to Provide Coffee and Post Menus for Resident Review
Penalty
Summary
The facility failed to ensure that coffee was available to residents as indicated on the facility's weekly menu, and did not make menus available for resident review. Observations revealed that coffee, which was supposed to be offered daily with breakfast, was not provided to all residents on the morning in question due to insufficient supply. Interviews with residents confirmed that some were not offered coffee and had to drink hot chocolate instead. The Dietary Manager acknowledged that only one pot of coffee was available and that additional coffee had to be purchased after breakfast. The Dietary Manager was unaware that some residents did not receive coffee as requested. Additionally, the facility did not have weekly or daily menus posted or displayed in the dining or common areas for residents to review. Both staff and residents confirmed that menus were not accessible, and residents had to ask staff or kitchen personnel about the meals being served each day. The weekly menu, created by a contracted food service company, did not specify which vegetables or desserts would be served, only listing them as alternates or assorted options. This deficiency had the potential to affect all residents receiving meals from the kitchen.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Staff failed to follow proper infection control practices for a resident who was under Enhanced Barrier Precautions (EBP) due to wounds. The resident, who had quadriplegia, a history of pressure ulcers, an indwelling urinary catheter, and incontinence of stool, required staff to don both gowns and gloves before providing high-contact care, as indicated by signage in the room and facility policy. Multiple video recordings over several days showed various staff members, including nurses and CNAs, providing direct care to the resident while wearing gloves but not donning the required protective gowns. These observations were verified by the facility's Administrator and DON during a review of the footage. The facility's policy on Transmission Based Precautions clearly stated that both gowns and gloves were required for high-contact care activities such as hygiene, linen changes, and wound care. The failure to adhere to these procedures was identified through medical record review, direct observation, staff interviews, and review of facility investigation materials.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
Staff failed to perform proper hand hygiene during meal service, as observed when the Activities Director delivered breakfast trays to six residents without washing or sanitizing hands between rooms or after touching potentially contaminated surfaces. The Activities Director also handled food items, such as buttering and applying jelly to toast with bare hands, and touched residents directly without using gloves. These actions were observed during a single meal service and involved multiple instances of moving between residents and handling both food and residents without appropriate hand hygiene. Interviews with the Activities Director, a CNA, the Director of Operations, and the Administrator confirmed that staff should have washed or sanitized their hands between residents and used gloves when directly handling food. Facility policy review indicated that all staff are required to comply with CDC hand hygiene guidelines, including performing hand hygiene before direct contact with residents. The deficiency was identified during a complaint investigation and affected six residents out of those reviewed for handwashing.
Failure to Provide Requested Shaving Care Compromises Resident Dignity
Penalty
Summary
A deficiency was identified when a resident, who was cognitively intact and required assistance with activities of daily living, was not provided shaving care as requested. The resident had a history of chronic medical conditions including COPD, diabetes, CVA, seizure disorder, anxiety, depression, bipolar disorder, and asthma. During an observation of incontinence care, it was noted that the resident had long hair under her arms and on her legs. The resident reported that she had asked to have her legs and underarms shaved during her last shower, but this was not done by the assigned CNA. Staff interviews confirmed that the CNA responsible for the resident's last shower did not perform shaving, stating that shaving was only done if time permitted and that she would not ask the resident about shaving even if hair was observed. This was despite the facility's policy, which required assistance with shaving to be provided as needed according to resident preference. Documentation on the shower sheet also indicated that shaving was not completed. The failure to provide requested shaving care resulted in the resident experiencing a lack of dignity and respect for her personal preferences.
Failure to Report Resident Abuse Allegation to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse made by a resident was reported to the state agency as required. A cognitively intact resident with multiple medical diagnoses, including COPD, diabetes, CVA, seizure disorder, anxiety, depression, bipolar disorder, and asthma, reported that after winning a meal through a facility lottery, an LPN took her meal away in the dining room and directed her to eat in her room. The resident described the LPN's actions as abusive, particularly the act of snatching the meal, and stated that this caused her significant distress. A CNA who witnessed the interaction described the LPN's tone as rude and disrespectful, though did not see the meal being physically taken away. The CNA later reported the incident to the DON, who stated she would look into it and clarified that residents could eat any meal in the dining room. Despite the resident's allegation and the CNA's report to the DON, the incident was not documented in the progress notes, nor was it reported to the state agency as required by facility policy. The Administrator confirmed during interview that she was unaware of the allegation and acknowledged that it should have been reported. Facility policy mandates immediate reporting of all allegations of abuse to the Administrator and the state agency within 24 hours, but this procedure was not followed in this case.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure an investigation was completed following an allegation of abuse involving a resident with multiple medical conditions, including COPD, diabetes, CVA, seizure disorder, anxiety, depression, bipolar disorder, and asthma. The resident, who was cognitively intact and required varying levels of assistance for daily activities, reported that after winning a meal through a facility lottery, an LPN took her meal away in the dining room and directed her to eat in her room. The resident described the LPN's actions as upsetting and abusive, particularly the manner in which the meal was taken from her. A CNA who overheard the interaction described the LPN's tone as rude and disrespectful, and later reported the incident to the DON, who stated she would look into it. Despite the report made to the DON, the Administrator confirmed that she was unaware of the allegation and that no investigation had been conducted. Review of the facility's abuse prevention policy indicated that all allegations of abuse should be immediately reported to the Administrator and the state, and that an investigation should be completed within five working days. The lack of investigation and failure to follow reporting protocols constituted a deficiency in responding appropriately to alleged violations.
Failure to Provide Timely Incontinence Care
Penalty
Summary
Staff failed to provide timely incontinence care for a resident with multiple medical diagnoses, including COPD, diabetes, CVA, seizure disorder, anxiety, depression, bipolar disorder, and asthma. The resident was cognitively intact and required partial to moderate assistance for toileting, bed mobility, and transfers, and was frequently incontinent of bladder and always incontinent of bowel. According to the care plan, staff were to assist with cleansing and changing after each incontinence episode. Documentation showed the last check and change occurred at 2:54 A.M. From 9:32 A.M. to 11:26 A.M., no staff entered the resident's room to provide care. At 11:26 A.M., the resident was observed to be heavily soiled with urine, with a wet pad and noticeable odor. A CNA confirmed the resident had not been changed since 2:54 A.M. and acknowledged that care should have been provided every two hours. The resident also stated she would like to be changed every two hours, but this did not occur that morning. Facility policy required assistance with toileting and maintaining hygiene when residents could not do so independently.
Failure to Follow Fluid Restriction Order for Resident with CHF
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a fluid restriction order for a resident with congestive heart failure, hypertension, and diabetes was properly followed. The physician's order specified a 2,000 ml fluid restriction in a 24-hour period, with specific allocations for dietary and nursing departments, and required documentation of intake every shift. Medical record review showed that the resident was consistently provided with less than the ordered amount of fluids, being shorted 1,000 ml for 25 days and 700 ml for 44 days. The care plan identified a risk for fluid imbalance and included interventions for assistance and supervision with fluid intake, but these were not effectively implemented. Interviews revealed that the resident frequently expressed thirst and sometimes did not receive fluids when requested. Staff confirmed that the resident regularly asked for water and that requests were reported to nursing, but fluids were only provided if the resident was not over the fluid limit. The registered dietician verified that the resident had been under the fluid restriction amount on all reviewed days. Facility policy required nursing to evaluate and document fluid intake for residents at risk for nutritional problems and to report variations, but this was not adequately done, resulting in the deficiency.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey. The ice maker had debris on the outside and a brownish-red substance inside the ice dispensing chute. Additionally, a small chest freezer designated for residents' private foods had a significant ice build-up, preventing the inner basket from being moved. The freezer contained various food items, including breakfast sandwiches and tater tots, which were not dated or labeled with resident names. The produce cooler also had ice build-up and contained tomatoes, one of which was visibly rotten, and others with soft indents. The Dietary Manager confirmed these observations, acknowledging the debris on the ice maker, the substance inside the ice machine, the ice build-up in the freezer, and the lack of proper labeling on food items. The facility's policies require foods brought in from outside to be dated and labeled with the resident's name and mandate that all kitchen areas and equipment be maintained in a sanitary manner, free of debris. The policy also requires supervisors to inspect freezers monthly for excess condensation and ensure they are clean and sanitized regularly.
Medical Director's Absence from QAPI Meeting
Penalty
Summary
The facility failed to ensure that the Medical Director or their designee attended the quarterly Quality Assurance and Performance Improvement (QAPI) meetings as required. This deficiency was identified through a review of the facility's QAPI attendance logs, staff interviews, and policy review. Specifically, the Medical Director or their designee did not attend the quarterly meeting held on April 23, 2024. The Director of Nursing (DON) confirmed the absence of documentation to verify the attendance of the Medical Director or their designee at this meeting. The facility's policy, dated May 1, 2024, mandates that the QAPI committee, which includes the Medical Director/Physician among other key staff members, meets at least quarterly to monitor and revise the Quality Assurance/Quality Improvement (QA/QI) program. This program is essential for maintaining standards of quality care and improving service delivery and resident outcomes.
Failure to Maintain Licensed Nursing Home Administrator
Penalty
Summary
The facility failed to ensure that a licensed nursing home administrator (LNHA) with a valid license was providing supervision and leadership. This deficiency was identified through a review of the online verification system of the Board of Executives of Long-Term Services and Supports (BELTSS), the Administrator job description, and staff interviews. It was confirmed that Administrator #280, who had been serving as the LNHA of record, had an expired license during a specific period. This lapse in licensure had the potential to affect all 39 residents residing in the facility. Administrator #280 confirmed that she was notified by a BELTSS representative about the expiration of her LNHA license. During the period when her license was expired, Administrator #285, employed by the facility corporation, served as the LNHA. However, there was a gap when no licensed LNHA was serving, which was from the expiration of Administrator #280's license until it was renewed. The facility's job description for the Administrator role clearly stated the requirement for a current state license as a Nursing Home Administrator, which was not met during this period.
Failure to Complete MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that quarterly Minimum Data Set (MDS) assessments were completed within the required timeframes for three residents. Resident #26, who has medical diagnoses including dementia and Alzheimer's disease, had an MDS assessment with an Assessment Reference Date (ARD) of 09/07/24, but it was not completed until 09/24/24. This resident was noted to have moderate cognitive impairment and required substantial assistance with daily activities. Similarly, Resident #2, with diagnoses such as schizoaffective disorder and type II diabetes mellitus, had an ARD of 08/23/24, but the assessment was completed on 09/09/24. Resident #9, diagnosed with peripheral vascular diseases, had an ARD of 08/25/24, with the assessment completed on 09/24/24. Both residents were cognitively intact but required varying levels of assistance with daily activities. The MDS Nurse confirmed these assessments were not completed within the 14-day timeframe as required by the CMS Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User Manual.
Failure to Transmit MDS Assessments to CMS
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) as required. This deficiency affected one resident, identified as Resident #94, out of 12 residents reviewed for MDS assessments. The facility's census at the time was 39. Resident #94 had been admitted with medical diagnoses including chronic obstructive pulmonary disease, diabetes mellitus, anemia, hypertension, and moderate protein calorie malnutrition. The medical record review revealed that there was no documentation to support the timely transmission of MDS assessments for this resident, specifically for an annual MDS assessment, a significant change MDS assessment, and two quarterly MDS assessments. An interview with MDS Nurse #255 confirmed that the MDS assessments for Resident #94, dated 12/16/23, 02/07/24, 05/01/24, and 07/30/24, were not transmitted to CMS. According to the CMS Long-Term Care Facility RAI 3.0 User Manual, all Medicare and/or Medicaid-certified nursing homes must transmit required MDS data records to the CMS Internet Quality Improvement Evaluation System (iQIES). The manual specifies that the required MDS records include comprehensive, quarterly, and PPS assessments mandated under the Omnibus Budget Reconciliation Act (OBRA) and Skilled Nursing Facility Prospective Payment System (SNF PPS).
Failure to Follow Physician Orders for Compression Garments
Penalty
Summary
The facility failed to adhere to physician orders for a resident with peripheral vascular disease and venous insufficiency, leading to a deficiency in treatment for skin conditions. The resident, who was cognitively intact and required varying levels of assistance with daily activities, had a care plan indicating the need for compression garments to prevent skin integrity impairment. The physician's order specified the application of black thrombo-embolic deterrent (TED) hose or all cotton elastic (ACE) wraps to the resident's lower extremities every morning, to be removed every evening. Observations on two consecutive days revealed that the resident was not wearing the prescribed TED hose or ACE wraps, with only a Tubigrip dressing on one leg and the other leg uncovered. Interviews with an LPN confirmed the absence of the required compression garments on both days, despite the existing physician order. Additionally, the facility administrator acknowledged the lack of a policy to ensure compliance with physician orders, contributing to the deficiency in care.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain laboratory testing as ordered by the physician for three residents, affecting their care. Resident #28, who was cognitively intact and had multiple diagnoses including chronic obstructive pulmonary disease and heart failure, had a physician order for a complete metabolic panel (CMP), lipid panel, and complete blood count (CBC) with differential to be obtained every six months. However, the last blood work results were from February 2024 and did not include a lipid panel. Resident #26, with moderate cognitive impairment and diagnoses such as dementia and Alzheimer's disease, had orders for a serum magnesium test annually and a CMP, hemoglobin A1c (HbA1c), and lipid panel every six months. There was no documentation that these tests were completed as ordered. Resident #11, who was moderately cognitively impaired and had conditions like atherosclerotic heart disease and type two diabetes mellitus, had orders for a CMP, CBC with differential, thyroid stimulating hormone (TSH), and thyroxine (T4) to be obtained every six months. However, there was no documentation of these tests being completed in April 2024. The Director of Nursing (DON) revealed that the issue arose when the facility switched laboratory providers, and the new provider could not access the laboratory orders from the electronic medical records, leading to missed tests. The facility did not have a policy on obtaining laboratory values as ordered, contributing to the oversight.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to appropriately perform hand hygiene during dressing changes for a resident, which compromised infection control practices. The resident, who was cognitively intact and dependent on staff for various activities, had multiple medical conditions including quadriplegia and neuromuscular dysfunction of the bladder. The resident had specific physician orders for wound care, including cleansing and dressing changes for the suprapubic catheter site and wounds on the sacrum and ischium. During an observation, an LPN and an STNA performed wound care on the resident. Although they initially washed their hands and wore gloves, the LPN did not perform hand hygiene after removing soiled dressings and before applying new gloves for each wound site. This was confirmed in an interview with the LPN. The facility's handwashing policy emphasized the importance of hand hygiene before and after handling dressings and gloves, which was not adhered to during the procedure.
Failure to Use Gloves During Resident Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during resident care, specifically in the use of gloves. A resident, who was cognitively intact and required full assistance for personal hygiene and transfers, reported that a female staff member touched his genitalia with ungloved hands while providing care. This incident was corroborated by video surveillance, which showed the staff member touching the resident's genital area without gloves and subsequently apologizing for the oversight. The facility's policy on Peri Care, dated 05/01/22, mandates that staff perform hand hygiene and apply gloves prior to resident contact. The incident involved a State tested Nurse Aide (STNA) who was identified by the Administrator and the Director of Nursing during a review of the video surveillance. This deficiency was investigated under Complaint Number OH00155648.
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Illustrative
What surveyors actually found near you
We read the 84 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Nursing homes near Sidney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shelby Skilled Nursing And Rehabilitation | 1.4 mi | ★★★★★ | 1 | 0 |
| Fair Haven Shelby County | 2 mi | ★★★★★ | 2 | 0 |
| Ohio Living Dorothy Love | 2.7 mi | ★★★★★ | 0 | 0 |
| Ayden Healthcare Of Piqua | 10.1 mi | ★★★★★ | 0 | 0 |
| Piqua Manor | 11.4 mi | ★★★★★ | 3 | 0 |
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