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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Monterey Care Center during CMS and state inspections, most recent first.
A resident who left AMA had a pending urinalysis that later confirmed a UTI, but there was no documentation that the resident or their representative was notified of the abnormal results. Staff interviews confirmed that notification was expected, but no evidence of contact or attempts to notify was found in the record.
A resident with significant mobility and medical needs was transferred by a CNA using a mechanical lift without the required second staff member, contrary to the care plan and facility policy. During the transfer, the lift pad strap tore, causing the resident to fall and sustain dental injuries. Interviews confirmed the transfer was performed alone and that the lift equipment was not properly assessed prior to use.
A staff member was found preparing food without a beard restraint, in violation of the facility's policy requiring all food service employees to wear hair and beard restraints while working in food preparation and service areas. This lapse in sanitary practice was confirmed by both the staff member and the Dietary Manager, and had the potential to affect all residents except one who was NPO.
The facility's kitchen was found to be unsanitary, with a thick black buildup on the floor, food debris, and dust-like particles on the ceiling and shelves. The Dietary Manager confirmed these observations, which had the potential to affect all residents receiving food from the kitchen.
The facility did not implement a timely Water Management Program to prevent Legionella, affecting 108 residents. No evidence of testing or interventions was found before October 2024. The Administrator confirmed the absence of prevention measures, with a new Maintenance Director starting the plan in October 2024. The facility's policy outlined necessary control measures, but these were not documented or communicated before this date.
The facility failed to provide adequate nail care for four residents who were dependent on staff for assistance with ADLs. Observations revealed that these residents had long, dirty nails despite their care plans indicating the need for assistance. Interviews confirmed that the residents required help and did not refuse nail care, highlighting a lapse in the facility's responsibility to provide appropriate nail care.
The facility failed to provide adequate activities for residents in the memory care unit, especially during evenings and weekends. Four residents with cognitive impairments had limited engagement in activities, with observations showing them often unengaged in the lounge or dining room. The activity schedule was sparse, with few activities after 2:00 P.M. and minimal weekend offerings.
Two residents were left without breakfast while a newly admitted resident in the same room was served. Despite expressing hunger, the residents remained without meals as staff discussed responsibility but took no action. A CNA eventually served the meals, citing a delay due to assisting another resident.
The facility failed to provide proper bed hold notifications to two residents before hospital transfers. One resident with severe cognitive impairment was hospitalized after a fall, and another with minimal cognitive impairment was transferred due to PICC line complications. In both cases, the bed hold forms lacked the total number of days available, as confirmed by the Administrator.
The facility failed to apply TED hose as ordered for a resident with a history of venous thrombosis and embolism, and delayed urine collection and treatment for a UTI in another resident with Alzheimer's and other conditions. Observations confirmed the absence of TED hose, and treatment for the UTI was delayed due to issues with lab sample collection and processing.
A facility failed to assist a resident with the placement of hearing aids daily as ordered, affecting the resident's ability to hear. Despite a physician's order, there was no documentation of compliance, and the care Kardex lacked instructions. Observations showed the resident without hearing aids during surveyor visits, and the resident reported only one nurse and one aide knew how to place them properly. An LPN successfully placed the right hearing aid, but a CNA struggled with the left, requiring guidance. The facility's policy did not address hearing aid placement, and there was no evidence of staff education.
The facility failed to provide adequate pressure ulcer care for two residents. One resident was not given a bariatric extended bed as per their care plan, and another did not receive a comprehensive wound assessment upon admission. Additionally, staff were not educated on the appropriate settings for a low air loss mattress, leading to deficiencies in care.
The facility failed to implement timely and appropriate care to prevent contractures in two residents. One resident had a contracture of the left hand with no care plan or splint in place, despite recommendations. Another resident had contracted hands with no interventions documented, and staff confirmed the absence of care plans or physician orders addressing the issue.
A facility failed to implement fall interventions for a resident with muscle weakness, unsteadiness, and dementia. The care plan required grip strips on the floor by the bed, but an observation revealed their absence, confirmed by a Unit Manager. The facility's policy mandates a comprehensive care plan for fall management.
A resident with obstructive sleep apnea and COPD did not receive timely follow-up for sleep study results, leading to a deficiency in respiratory care. The resident was supposed to receive a CPAP machine, but the facility lost the sleep study results. The DON confirmed the sleep study device was sent to the pulmonologist, but the facility did not receive the results or follow up with the provider.
A facility failed to assess and address the PTSD triggers of a resident with a history of physical and sexual abuse. Despite the resident's intact cognition, their care plan lacked interventions to minimize re-traumatization risks. The DON confirmed the absence of a comprehensive assessment for stressors or triggers.
A resident with hypertension and other conditions was not monitored for blood pressure as ordered, despite receiving daily doses of Amlodipine Besylate. The care plan required blood pressure monitoring due to potential fluctuations, but this was not done from early to mid-November 2024. The oversight was confirmed by the DON.
A resident with multiple diagnoses, including dementia and dysphagia, was not served meals as prescribed by the physician. The resident was supposed to receive double entree portions, but an observation revealed that the lunch tray contained only one sandwich. The tray ticket did not reflect the physician's order, and a STNA confirmed the oversight.
The facility failed to provide necessary meal setup assistance and adaptive equipment for a resident with hemiplegia, resulting in difficulty accessing food and inadequate nutrition. Another resident did not receive required sippy cups, leading to spillage. The facility's policy on meal assistance and adaptive equipment was not followed.
The facility failed to accurately complete MDS assessments for several residents, leaving sections on cognitive patterns and mood incomplete. Staff interviews were not conducted when residents refused participation. Additionally, physical impairments were inaccurately documented, as confirmed by the DON.
Failure to Notify Former Resident of Post-Discharge UTI Diagnosis
Penalty
Summary
The facility failed to provide documented evidence of good faith efforts to notify a former resident of an active urinary tract infection (UTI) after the resident had left the facility against medical advice (AMA). The resident, who was cognitively intact and had an indwelling catheter, was admitted with diagnoses including retention of urine and presence of urogenital implants. During the resident's stay, intermittent confusion was observed, prompting a physician order for a urinalysis and culture. The urine sample was collected and sent to the laboratory, but before the results were available, the resident chose to leave the facility AMA. The laboratory results, which were received after the resident's departure, indicated a significant growth of Escherichia coli, confirming a UTI. Review of the medical record showed no documentation that the resident or their representative was notified of these abnormal results. Interviews with the Administrator, DON, and Unit Manager confirmed that there was an expectation to notify former residents of such findings, but no evidence of notification or attempts to contact the resident was found in the record. Facility policies required notification of changes in condition and post-discharge follow-up, but these were not followed in this case.
Failure to Provide Adequate Supervision and Equipment Assessment During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for transfers due to multiple complex medical conditions including bilateral leg amputations, multiple sclerosis, morbid obesity, legal blindness, and paraplegia, was transferred from a wheelchair to a bed using a mechanical lift by only one staff member. The resident's care plan specifically required two-person assistance for all mechanical lift transfers. Despite this, a CNA performed the transfer alone. During the transfer, the mechanical lift pad's strap tore, causing the resident to fall from the lift to the floor. As a result of the fall, the resident sustained dental injuries, including one missing tooth and another tooth broken in half. The resident was sent to the hospital for evaluation and returned with no other injuries noted, but required follow-up with an emergency dentist. Interviews with the resident, the CNA involved, and the DON confirmed that the transfer was conducted by a single staff member, contrary to the resident's care plan and facility policy, and that the mechanical lift pad failed during the process. The facility's policy required two staff members for mechanical lift transfers and proper assessment of lift equipment prior to use. The lack of adherence to these protocols directly contributed to the incident and resulting harm.
Failure to Enforce Beard Restraint Policy During Food Preparation
Penalty
Summary
A staff member was observed preparing lunch trays in the kitchen without wearing a beard restraint, as required by facility policy and professional food service standards. The staff member confirmed during the interview that he was not wearing the required beard restraint while preparing food for residents. The Dietary Manager also verified that the staff member was not in compliance with the policy, which mandates all food service employees to wear hair and beard restraints in food preparation and service areas. The facility's policy on employee sanitary practices, dated 06/26/20, specifies that all nutrition and food service employees must practice good personal hygiene and safe food handling procedures, including the use of hair and beard restraints to prevent hair from contacting exposed foods. This deficiency had the potential to affect all residents in the facility except one who was ordered nothing by mouth (NPO) and did not receive food from the kitchen.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a survey. The kitchen had an area in the center that was about an inch lower than the rest, containing cooking equipment such as the oven, fryer, and soup kettle. This area had a thick black buildup on the floor, which was supposed to be red tile, and was littered with food and other debris, including a dome lid, plastic utensils, and French fries. Additionally, there was a large amount of dirt-like material behind and around the soup kettle. These observations were verified by the Dietary Manager (DM). Further observations revealed that the ceiling throughout the kitchen had multiple spots with a thick buildup of dust-like particles and food splatter. Two racks with three to four shelves each were also noted to have a large amount of dust-like particles stuck to them and hanging from them. These racks contained items such as bowls, lids, stainless-steel cooking containers, and other food service items. The DM confirmed these observations as well. The facility's census was 108, with one resident identified as consuming nothing by mouth.
Failure to Implement Water Management Program for Legionella Prevention
Penalty
Summary
The facility failed to implement a timely and appropriate Water Management Program to prevent the spread of Legionella, potentially affecting all 108 residents. A review of the facility's Water Management Program logs showed no evidence of testing or interventions to prevent Legionella prior to October 2024. An interview with the Administrator confirmed the absence of water testing, flushing, or any other Legionella prevention measures before this date. The Administrator noted that a new Maintenance Director had started implementing the Water Management Plan in October 2024. The facility's policy, reviewed in December 2023, outlined control measures to reduce the growth and spread of Legionella, including routine testing of chlorine and water temperature levels, monitoring and flushing pipes, and checking decorative and water fountains for debris and biofilm. The CDC guidance on water management programs emphasizes identifying hazardous conditions and minimizing the growth and transmission of Legionella. It includes establishing a team, describing water systems, identifying growth areas, applying control measures, and ensuring the program's effectiveness. However, these steps were not documented or communicated in the facility's activities prior to October 2024.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for four residents who were dependent on staff for assistance with activities of daily living (ADL). Resident #104, diagnosed with bipolar disorder, secondary parkinsonism, and other conditions, required partial to moderate assistance with personal hygiene. Despite this, observations over several days revealed that her nails were long and dirty, with food caked under them. Interviews confirmed that she required assistance and did not refuse nail care. Similarly, Resident #95, with diagnoses including Alzheimer's disease and cognitive communication deficit, was observed with long, dirty nails. His care plan indicated a need for supervision or touching assistance with personal hygiene, yet his nails were neglected. Resident #91, suffering from conditions such as Alzheimer's disease and aphasia, was dependent on staff for personal hygiene. Observations showed her nails were long and dirty, with some dirt underneath, despite her care plan specifying the need for assistance. Lastly, Resident #75, with Alzheimer's disease and other cognitive impairments, was observed with excessively long and dirty nails. His care plan also required assistance with personal hygiene. Interviews with CNA #197 confirmed that these residents required assistance and did not refuse nail care, indicating a failure in the facility's responsibility to provide appropriate nail care as per their policy.
Insufficient Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide sufficient activities for residents in the memory care unit, particularly during evenings and weekends. This deficiency affected four residents who were reviewed for activities and had the potential to impact all 25 residents in the unit. The report highlights that the facility's activity schedule was limited, with few activities occurring after 2:00 P.M. and minimal engagement on weekends. Resident #95, diagnosed with Alzheimer's disease and other cognitive impairments, had a care plan indicating a need for cognitive stimulation and a preference for various activities. However, from October 20 to November 17, 2024, the resident had limited engagement in activities, with no independent or physical activities recorded and no activities on weekends. Observations showed the resident often sitting in the dining room or lounge with the television on but not engaged. Similarly, Resident #91, with Alzheimer's and memory problems, had a care plan encouraging socialization and mental stimulation. Despite this, the resident's activity records showed limited participation, with no physical activities and no weekend activities. Observations noted the resident facing a wall or a television without engagement. Other residents, such as #75 and #99, also experienced insufficient activity engagement, with records indicating a lack of weekend activities and minimal intellectual or physical activities.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to maintain resident dignity during dining experiences, affecting two residents during the annual survey. On the morning of the observation, two residents were found lying in bed without breakfast meal trays, while a newly admitted resident in the same room was already consuming breakfast. The two residents expressed hunger and a desire for a meal tray. Despite this, they remained without breakfast for an extended period. Three facility employees were observed discussing responsibility for one of the residents but did not take action to serve the meal. A registered nurse later confirmed the residents had not received their breakfast and promised to investigate. Eventually, a certified nurse assistant served the breakfast meal, explaining the delay was due to assisting another resident with dialysis preparation.
Failure to Provide Bed Hold Notifications
Penalty
Summary
The facility failed to provide proper bed hold notifications to residents prior to their transfer to a hospital, affecting two residents out of four reviewed for this requirement. Resident #15, who had severe cognitive impairment and multiple diagnoses including epilepsy and Alzheimer's disease, was sent to the hospital following a fall that resulted in a laceration. The Notification of Bed Hold form for this resident did not specify the total number of bed hold days available, which was confirmed by the Administrator during an interview. Similarly, Resident #39, who had minimal cognitive impairment and various medical conditions such as hallucinations and rheumatoid arthritis, was transferred to the hospital due to complications with a PICC line and abnormal lab results. The bed hold notification for this resident also lacked the total number of bed hold days, as verified by the Administrator. These deficiencies indicate a failure in the facility's process to inform residents or their representatives about bed hold policies during hospital transfers.
Failure to Apply TED Hose and Delay in UTI Treatment
Penalty
Summary
The facility failed to apply Thrombo-Embolic Deterrent (TED) hose as ordered by the physician for a resident with a history of venous thrombosis and embolism, chronic pain, and muscle weakness. Observations on multiple occasions revealed that the resident was without the prescribed TED hose while in the dining room and in their room. The Unit Manager confirmed the absence of the TED hose during these observations, indicating a failure to adhere to the physician's orders for managing the resident's edema. Additionally, the facility did not timely collect urine or treat a urinary tract infection (UTI) for another resident with Alzheimer's disease, dysphagia, dementia, and other conditions. Despite new orders to obtain a urinary analysis, there was a delay in collecting the urine sample, which was not obtained until several days later. The culture and sensitivity results were delayed, and treatment with Keflex was not initiated until over a week after the initial order. The Director of Nursing acknowledged the delay in treatment and attributed it to issues with laboratory sample collection and processing.
Failure to Assist Resident with Hearing Aids
Penalty
Summary
The facility failed to assist a resident with the placement of bilateral hearing aids daily as ordered, affecting one resident. The resident, who had medical diagnoses including dementia, unspecified bilateral hearing loss, and COPD, required assistance with activities of daily living and used hearing aids. Despite having a physician's order to assist the resident with hearing aids every day shift, there was no documentation of compliance, and the patient care Kardex lacked instructions for this assistance. Observations and interviews revealed that the resident did not have hearing aids in place during multiple surveyor visits and had difficulty hearing without them. The resident reported that only one nurse and one aide knew how to properly place the hearing aids, and staff did not offer assistance daily. During an observation, an LPN successfully placed the hearing aid in the resident's right ear, but a CNA struggled with the left ear, requiring guidance from the LPN. The facility's policy did not address the proper placement and use of hearing aids, and there was no evidence of staff education on this matter.
Deficiencies in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to ensure proper pressure ulcer prevention and care for two residents, leading to deficiencies in their treatment. Resident #43, who had diagnoses including hemiplegia and pressure ulcers, was not provided with a bariatric extended bed as per their care plan. The resident was observed lying in a regular-sized bed, which was confirmed by the Director of Nursing (DON) to be inappropriate as the bariatric bed was removed after hospice services ended and not replaced. This oversight was acknowledged by the DON, who confirmed the necessity of the bariatric bed to reduce pressure on the resident's feet. Resident #62, admitted with multiple pressure ulcers, did not receive a comprehensive wound assessment upon admission. The only assessment completed was a skin grid, which was not detailed. The resident's wounds were not fully assessed until three days post-admission by a wound physician. Additionally, there was a lack of education for the nursing staff regarding the appropriate settings for the resident's low air loss mattress, as confirmed by interviews with the Unit Manager, LPN, and DON. The facility's policy required a comprehensive skin evaluation upon admission, which was not adhered to in this case.
Failure to Address Contractures in Residents
Penalty
Summary
The facility failed to provide timely and appropriate care to prevent the development or worsening of contractures for two residents. Resident #43, who was admitted with diagnoses including hemiplegia and contracture of the left hand, had no care plan addressing the contracture. Despite an occupational therapy evaluation recommending a carrot splint, the resident declined therapy, and no physician orders for the splint were in place. Observations confirmed the absence of any splint or orthotic device, and interviews with staff verified the lack of a care plan to address the contracture. Resident #91, admitted with multiple diagnoses including Alzheimer's disease and rheumatoid arthritis, also had no care plan or physician orders addressing contractures. Observations revealed both hands were contracted into tight fists without intervention. Interviews with staff confirmed the absence of interventions for the contractures, and it was noted that the resident's husband did not want hand rolls or washcloths, although this was not documented in the medical record. The DON confirmed the presence of hand contractures since admission.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to ensure that fall interventions were in place according to the care plan for a resident. The resident, who was admitted with diagnoses including muscle weakness, unsteadiness on feet, and dementia, was assessed to be rarely/never understood. The care plan, initiated earlier, identified the resident as being at risk for falls and potential injury, with specific interventions such as grip strips to be placed on the floor in front of the bed. However, during an observation, it was noted that there were no grip strips present by the resident's bed. This was confirmed by an interview with the Unit Manager. The facility's policy on Fall Management Guidelines requires staff to implement a comprehensive care plan addressing fall management, including individualized interventions to minimize risk factors.
Failure to Obtain Sleep Study Results for Resident
Penalty
Summary
The facility failed to complete timely follow-up to obtain sleep study results for a resident, identified as Resident #13, who was diagnosed with obstructive sleep apnea and chronic obstructive pulmonary disease (COPD). Resident #13 was admitted to the facility with a history of dementia, anxiety disorder, and depression. The resident had an order to use a sleep study machine at bedtime, which was administered as ordered. However, there was no evidence in the progress notes of any follow-up to obtain the results of the sleep study, which was conducted in February 2024. Interviews revealed that Resident #13 was supposed to receive a Continuous Positive Airway Pressure (CPAP) machine but had not due to the facility losing the sleep study results. The Director of Nursing (DON) confirmed that the sleep study device was sent back to the pulmonologist for interpretation, but the facility never received the results. There was no evidence of routine follow-up with the outside provider to obtain the sleep study results or further instructions for Resident #13, leading to a deficiency in providing appropriate respiratory care.
Failure to Address PTSD Triggers in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the PTSD and minimize triggers and/or re-traumatization. This deficiency affected one resident, who was admitted with diagnoses including anxiety, cognitive communication deficit, depression, and suicidal ideations, and had an active diagnosis of PTSD related to a history of physical and sexual abuse. Despite having intact cognition, as evidenced by a Brief Interview for Mental Status (BIMS) score of 14, the resident's care plan did not address the cause of PTSD, potential triggers, or interventions to reduce the risk of re-traumatization. Additionally, there was no comprehensive social history or assessment conducted to identify stressors or triggers that could prompt recall of previous traumatic events. An interview with the Director of Nursing (DON) confirmed that the resident did not have a care plan addressing individual triggers or a current plan to manage those triggers. The DON also verified the absence of an assessment for stressors or triggers that could lead to re-traumatization.
Failure to Monitor Blood Pressure as Ordered
Penalty
Summary
The facility failed to ensure that a resident's blood pressure was monitored as ordered, which is a critical component of managing their medication regimen. The resident, who was admitted with diagnoses including senile degeneration of the brain, dementia, and hypertension, had a care plan that required monitoring of blood pressure due to fluctuations related to various conditions and medications. Despite having a physician's order to hold Amlodipine Besylate if the systolic blood pressure was below 110 mmHg, the resident's blood pressure was not assessed from November 1 to November 18, 2024, while the medication was administered daily. This oversight was confirmed by the Director of Nursing during an interview.
Failure to Provide Prescribed Double Entree Portions
Penalty
Summary
The facility failed to ensure that a resident in the memory care unit received meals as prescribed by the attending physician. The resident, who has a medical history including dementia, cognitive communication deficit, schizoaffective disorder, anxiety disorder, dysphagia, and hypertension, was ordered to receive a regular diet with double entree portions. However, during an observation, it was noted that the resident's lunch tray contained only one sandwich, contrary to the physician's order. A review of the resident's tray ticket confirmed that it did not indicate the need for double entrees, and an interview with a State tested Nursing Assistant verified the discrepancy between the physician's order and the meal provided.
Failure to Provide Meal Assistance and Adaptive Equipment
Penalty
Summary
The facility failed to provide appropriate setup assistance and adaptive equipment during meals for Resident #43, who was affected by hemiplegia and hemiparalysis following a cerebral infarction, resulting in muscle weakness and a contracted left hand. Despite the resident's need for assistance, as indicated in the care plan and physician's orders, the Certified Nurse Assistant (CNA) did not remove the lids from the bowls or position the over-the-bed table within easy reach. This left the resident struggling to access his meal, resulting in one of the fried eggs falling to the floor and the resident being unable to consume the second bowl's contents. The room was inadequately lit, further complicating the resident's ability to eat independently. Additionally, another resident, Resident #47, was observed without the required lids on his cups, leading to spillage and a wet gown. The meal ticket specified the need for sippy cups or cups with lids, which were not provided. The Registered Dietitian confirmed the necessity of these items to ensure proper nutrition and hydration. The facility's policy mandates assistance for residents needing help with eating and the provision of adaptive equipment as per physician's orders, which was not adhered to in these instances.
Inaccurate MDS Assessments in LTC Facility
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for six residents, affecting their care evaluations. For several residents, including those with dementia, Alzheimer's disease, and other cognitive impairments, sections of the MDS assessments, specifically Section C (Cognitive Patterns) and Section D (Mood), were left incomplete. In some cases, both resident and staff interviews were marked as 'not assessed,' indicating a lack of thorough evaluation. Interviews with MDS Coordinators and a Licensed Social Worker confirmed that these assessments were not completed as required, even when residents refused to participate, as staff interviews should have been conducted. Additionally, discrepancies were noted in the assessments of residents with physical impairments. For instance, one resident with bilateral hand contractures was inaccurately assessed as having no upper extremity impairments. This was verified through observation and confirmed by the Director of Nursing. These inaccuracies in MDS assessments highlight a significant deficiency in the facility's assessment process, impacting the accurate evaluation of residents' cognitive and physical conditions.
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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 Grove City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadow Grove Transitional Care | 2.5 mi | ★★★★★ | 0 | 0 |
| West Park Care Center Llc | 2.7 mi | ★★★★★ | 0 | 0 |
| Embassy Of Woodview | 2.7 mi | ★★★★★ | 7 | 0 |
| Columbus Healthcare Center | 4.2 mi | ★★★★★ | 25 | 0 |
| Scioto Rehabilitation & Care Center | 4.2 mi | ★★★★★ | 18 | 0 |
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