Fairfax Behavioral Health & Memory Care Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Fairfax, Oklahoma.
- Location
- 282 County Road 6300, Fairfax, Oklahoma 74637
- CMS Provider Number
- 375467
- Inspections on file
- 22
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 22
Citation history
Health deficiencies cited at Fairfax Behavioral Health & Memory Care Community during CMS and state inspections, most recent first.
A resident who was cognitively intact but required substantial/maximal assistance and two-person help for toileting and transfers sustained two separate left arm fractures when staff did not follow the care plan or facility transfer policy. On one occasion, a CMA used a one-person transfer to the bathroom despite the resident stating they needed two-person assistance, and the resident fell and fractured the left arm. On another occasion, two CNAs transferred the resident to a shower chair by lifting under the arms instead of using a gait belt or approved technique, and a pop was heard in the resident’s shoulder, followed by confirmation of a left humerus fracture. The DON later stated staff were to use gait belts and not lift residents under their arms.
A resident with dementia and impaired mobility, identified as at risk for falls, experienced multiple witnessed and unwitnessed falls over time, including events causing skin tears, facial laceration, bruising, and swelling. Although some fall-related interventions such as non-slip socks, proper fitting shoes, staff presence, frequent toileting, distraction with snacks, and use of a specialized chair were documented in incident notes or described by staff, these interventions were not incorporated into the resident’s care plan after an earlier post-fall entry. Staff reported relying on the EHR, room postings, charts, or verbal instructions to know interventions, while the DON acknowledged that care plans were supposed to be updated after each fall but that the subsequent interventions were not added and were only reflected in progress notes that CNAs could not access.
A resident with severe cognitive impairment, dementia, anxiety, a history of wandering, and an identified elopement risk was able to leave the facility and was later found at a nearby park despite existing care plan interventions and staff presence. The resident required hands-on assistance for ambulation and was frequently observed walking the halls with a CNA, who attempted but was unable to consistently redirect the resident to sit. Staff and the DON reported that the resident was supposed to have 1:1 supervision during waking hours, that only staff knew the exit door code, and that staff were instructed to check exit doors and keep residents engaged, yet the resident still eloped from the building, indicating a failure to provide adequate supervision to prevent elopement.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety and well-being.
A resident with diabetes and a below-the-knee amputation did not receive prescribed wound care for a toe, as the order was entered incorrectly and the treatment was not completed. The resident confirmed no treatment was being done, and both the ADON and DON acknowledged the lapse.
The facility did not ensure that food served was hot and palatable, as observed during a test tray review where meals were found to be inadequately heated and poorly prepared. Two residents with intact cognition reported dissatisfaction with the temperature and taste of the food, and similar concerns were raised during a resident council meeting. The dietary manager acknowledged attempts to serve hot, appealing meals.
A dietary aide was seen washing dishes without a beard guard, and a bulk sugar container with a broken lid was found in the kitchen. The dietary manager confirmed that staff should use hair restraints and that the container lid should have been replaced. Meals from this kitchen were served to 48 residents.
The facility did not follow the posted menu for two meal services, serving meals that did not include the required bread and providing a pureed meal that did not match the planned menu. Staff confirmed that bread was omitted and that frozen pureed items were used instead of pureeing the prepared meal.
A resident prescribed haloperidol for delusional and anxiety disorders did not have required side effect monitoring documented on the treatment administration record, despite facility policy and care plan directives. The DON confirmed that monitoring should occur every shift and be recorded, but no such documentation was found.
The facility did not transmit MDS assessment data to the State within the required 14-day period for four residents. The ADON/MDS coordinator, who had recently taken over responsibility for MDS assessments, reported being behind in completing and submitting the assessments on time, resulting in late transmissions.
A resident with an indwelling urinary catheter for urinary retention did not have the catheter use addressed in their care plan, despite facility policy and staff acknowledgment that it should have been included. The omission was confirmed through record review and staff interviews.
A resident with diabetes and a foot ulcer received wound care from an ADON who did not wear a gown, contrary to the facility's Enhanced Barrier Precautions (EBP) policy. No signage indicated EBP was in place, and both the ADON and acting DON were unaware or did not follow EBP requirements for wound care, as confirmed by observation and interviews.
The facility failed to provide a safe and comfortable environment due to the lack of hot running water in rooms on the 100 hall. A resident with arthritis reported pain from washing hands in cold water, and two other residents confirmed the absence of hot water for over a month. The maintenance supervisor stated the issue is due to a broken hot water tank, which will not be replaced until a government grant is received.
A resident with dementia was observed by staff inappropriately touching another resident, also with dementia, in their room. The residents were immediately separated, and an assessment showed no signs of trauma. The incident was reported to the physician, family, and police.
A resident with a history of aggressive behavior verbally and physically threatened another resident in the dining room, resulting in an abusive interaction. Despite staff training on abuse identification and reporting, the incident was not initially recognized as abuse until later acknowledged by the ADON.
A resident with vascular dementia and leg amputations was left unclothed in their room and had an uncovered catheter bag in public areas, despite the facility having dignity covers. The resident was unable to reposition themselves or call for help, and staff failed to ensure their dignity was maintained. An LPN acknowledged the availability of dignity covers, and the DON confirmed the importance of respecting resident rights.
The facility did not provide three residents the opportunity to develop or refuse an advance directive as part of their admission process. An LPN confirmed that one resident's advance directive was signed late, and two others were not documented as having been offered the opportunity. The DON stated that advance directives should be completed during admission.
The facility failed to ensure interdisciplinary team participation in care planning for several residents. The MDS Coordinator did not invite other care team members to meetings, and there was no documentation of these meetings. The DON acknowledged the meetings should have been documented and that the physician was only informed of issues as required.
The facility failed to educate residents on the risks and benefits of bed rails, obtain informed consent, inspect bed frames and rails, and attempt alternatives before use. Two residents with dementia and amputations were affected, with no documentation of necessary assessments or attempts at alternative measures. The DON confirmed the lack of documentation and alternative interventions.
The facility failed to maintain registered nurse coverage for eight hours daily, as required. PBJ reports and staffing schedules revealed missing RN hours on several dates across two quarters. Interviews indicated a lack of awareness and communication among staff, with the DON unaware of the issue and an LPN responsible for staffing unable to fill gaps effectively.
The facility experienced delays in administering medications to residents due to sudden staffing shortages. On two consecutive days, a significant number of residents received their morning medications hours later than scheduled. The issue arose when two CMAs quit unexpectedly, leaving the facility short-staffed, and administrative nurses were unavailable due to emergencies. The DON acknowledged the situation and confirmed that medications should have been administered on time.
A facility failed to provide a written notice of discharge to a resident and did not notify the ombudsman when the resident was discharged to a hospital. The DON admitted to not giving a notice of transfer and not reporting the discharges to the ombudsman. A resident was discharged four times to a hospital for medical reasons, but the required notifications were not made.
A resident with vascular dementia and leg amputations developed a pressure wound on the coccyx, which was not accurately documented in the MDS quarterly assessment. The MDS Coordinator admitted to the error, and the DON acknowledged the lack of peer review among MDS nurses, leading to the inaccurate assessment.
A resident with vascular dementia and recent leg amputation developed a new pressure ulcer, but the facility failed to perform a significant change assessment within the required timeframe. The MDS Coordinator admitted the oversight, noting the part-time nurse responsible for assessments was unsupervised. The DON acknowledged the need for timely and accurate assessments.
The facility did not have policies and procedures for obtaining feedback from staff, residents, and resident representatives. A review of QAPI and QAA records showed no documentation of a feedback program. The Administrator confirmed the absence of such a program, despite having a grievance process for residents.
A facility failed to maintain a functioning call light system for a resident with multiple diagnoses, including vascular dementia. The resident's call light was out of reach and not ringing at the front desk. Despite the facility's policy to provide alternative alert methods, no immediate intervention was implemented. The issue was identified on June 3, 2024, but a hand bell was only provided after the malfunction was discovered.
Unsafe Transfer Techniques Resulting in Repeated Arm Fractures
Penalty
Summary
The facility failed to ensure safe transfer techniques were used for a cognitively intact resident who required substantial/maximal assistance and two-person help for toileting and incontinence care, resulting in two separate left arm fractures. The resident’s care plan, dated 10/02/25, specified moderate to maximum assistance of two staff for toileting and incontinent care. On 11/30/25, a CMA used a one-person transfer to assist the resident to the bathroom; the resident began to fall and used their left hand to break the fall, after having told the CMA they needed two-person assistance. The resident was subsequently found to have an acute distal left arm fracture on x-ray and was sent to the hospital for stabilization. The CMA later stated they did not know the resident was a two-person transfer. On 01/09/26, two CNAs transferred the same resident to a shower chair by placing their arms under the resident’s arms, rather than using a gait belt or other approved technique. Both CNAs and an LPN reported that during this transfer they heard a pop in the resident’s left shoulder. A mobile x-ray on 01/10/26 showed an acute distal fracture of the left humerus, and the resident was again sent to the hospital for stabilization. The resident later stated they broke their left arm when two aides transferred them under their armpits to get into a shower chair. The DON stated staff were expected to use gait belts and not lift residents under their arms, indicating that the transfer methods used with this resident were inconsistent with facility policy and the resident’s care plan.
Failure to Update Fall Care Plan After Multiple Falls
Penalty
Summary
The deficiency involves the facility’s failure to update and revise a resident’s fall care plan after multiple falls, despite a policy requiring that interventions be reflected in the care plan and updated with revised or additional interventions. The resident, admitted with non-Alzheimer’s dementia and identified as at risk for falls due to weakness, impaired mobility, abnormal gait, and balance, initially had a care plan dated 08/20/25 with a post-fall intervention added on 11/02/25 for frequent checks while in their room. After that date, the care plan contained no additional interventions, even though the resident experienced numerous subsequent falls. Incident notes documented a witnessed fall without injury on 12/26/25 with interventions of non-slip socks and proper fitting shoes, an unwitnessed fall with a right elbow skin tear on 01/01/26 with no interventions documented, and another unwitnessed fall on 01/18/26 with no injuries or interventions documented. Further documentation showed the resident was seen in the emergency department on 01/20/26 for a fall resulting in a facial laceration repaired with tissue glue, facial bruising, and a knee injury, followed by monitoring for bruising and swelling to the right eye on 01/21/26. Additional unwitnessed falls occurred on 01/22/26, 01/24/26, and three times on 01/28/26, with no injuries or interventions documented for several of these events. On 01/29/26, the resident had two unwitnessed falls; one had non-slip socks as an intervention and the other resulted in a right elbow skin tear and bruising with an intervention to start Buspar for agitation. Observations showed the resident was unsteady, required hands-on assistance to walk, and was frequently ambulating in the halls with a CNA. Staff interviews revealed that CNAs and an LPN described various fall interventions (such as constant staff presence, snacks for distraction, frequent toileting, non-slip socks, and use of a specialized chair) and stated they relied on the electronic health record, room postings, charts, or verbal communication to know interventions. The DON stated care plans were to be updated after every fall but acknowledged that interventions after 11/02/25 were not on the care plan and that CNAs could not see progress notes where interventions were documented.
Failure to Adequately Supervise High-Risk Resident to Prevent Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to prevent elopement for one resident identified as an elopement risk. The resident had non-Alzheimer's dementia, delirium due to a psychological condition, anxiety disorder, a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive dysfunction, and a documented history of wandering. The care plan, initiated prior to the incident, identified the resident as an elopement risk with interventions including structured activities and diversions. Despite these identified risks and care plan interventions, the resident was able to leave the facility and was later found at a nearby park approximately 50 yards from the facility's back door, on the other side of a small hill. At the time of the elopement, eight direct care staff were on duty. Following the elopement, documentation and staff interviews showed that the resident was to have one-on-one supervision with staff during waking hours, and staff described interventions such as remaining with the resident, providing snacks, treats, and fidget items, and using distraction with activities and toileting. Observations on multiple days showed the resident walking up and down the halls with a CNA, unsteady on their feet and requiring hands-on assistance, and staff attempting to redirect the resident to sit in a chair without success. The facility’s elopement prevention policy stated it was the policy to protect residents from elopement, and staff reported that only employees had the door code and that they were educated to check exit doors when near them and keep residents engaged. Despite these measures and the resident’s known elopement risk and cognitive impairment, the resident had previously been able to exit the building and reach the nearby park, demonstrating a failure to provide adequate supervision to prevent elopement.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to follow physician orders for a resident with diabetes mellitus type 2 and a below-the-knee amputation, who was assessed as having moderate cognitive impairment. The physician's order directed that the resident's left great toe be cleansed with normal saline, patted dry, Betadine applied every shift, and left open to air twice daily for wound care. Review of the Treatment Administration Record (TAR) for July 2025 showed no documentation of wound care for the left great toe as of mid-month. The resident confirmed that no treatment was being performed on the toe, and facility staff, including the ADON and DON, acknowledged that the wound care order had been entered incorrectly and the treatment was not being completed as ordered.
Failure to Provide Palatable and Properly Heated Food
Penalty
Summary
The facility failed to ensure that food served from the kitchen was palatable and at an appetizing temperature for its residents. During a test tray observation, the food was found to be not hot, with the meatloaf described as dry and bland, mixed vegetables as soggy, potatoes as not well seasoned, and the brownie as undercooked; bread was also missing from the meal. Two residents with intact cognition reported that the food was not hot when served in their rooms and sometimes did not taste appealing, with one stating the food was not good. Additionally, concerns about food temperature and palatability were raised by multiple residents during a resident council meeting. The dietary manager acknowledged efforts to serve hot, palatable food.
Failure to Ensure Proper Food Storage and Staff Hygiene in Kitchen
Penalty
Summary
During a kitchen inspection, a dietary aide was observed washing dishes without wearing a beard guard, which is required as a hair restraint in food preparation areas. Additionally, a bulk sugar container with a broken lid was found in the kitchen. The dietary manager confirmed that staff are expected to wear hair restraints and that the broken lid should have been replaced. The administrator reported that 48 residents received meals prepared in this kitchen. No information was provided regarding the medical history or condition of the residents at the time of the deficiency.
Failure to Follow Posted Menu for Regular and Pureed Meals
Penalty
Summary
The facility failed to follow the posted menu for two observed meal services, affecting all 48 residents who received meals from the kitchen. During observation, the regular meal served included meatloaf, mixed vegetables, au gratin potatoes, and a brownie, but no bread was provided, despite the menu specifying 'bread of choice.' For the pureed diet, the meal included pureed meatloaf, pureed corn, pureed bowtie pasta, and banana pudding, which did not match the menu that called for a vegetable blend and bread. Staff interviews confirmed that bread was forgotten during lunch service and that the pureed meal did not follow the planned menu, as frozen pureed items were used instead of pureeing the prepared meal.
Failure to Document Psychotropic Medication Side Effect Monitoring
Penalty
Summary
The facility failed to ensure that side effect monitoring was completed and documented for a resident who was receiving psychotropic medication. According to facility policy, nursing staff are required to document the resident's response to antipsychotic medications and any side effects, including extrapyramidal symptoms or sedation, every shift. Record review showed that a resident with diagnoses of delusional disorder and unspecified anxiety disorder, and with intact cognition, was prescribed haloperidol daily. The resident's care plan specified monitoring for medication side effects every shift. However, review of the treatment administration records for two months did not show any documentation of side effect monitoring. The Director of Nursing confirmed that such monitoring should be documented in the treatment administration record and acknowledged that if it was not documented, it was not done.
Failure to Timely Transmit MDS Assessment Data
Penalty
Summary
The facility failed to transmit Minimum Data Set (MDS) assessment data to the State within 14 days after completion for four residents. According to the facility's policy, all MDS assessments must be completed accurately and submitted electronically to the Quality Improvement and Evaluation System (QIES) within mandated timelines. Record review showed that for four sampled residents, the assessments were completed but not transmitted within the required 14-day period. Batch transmittal forms confirmed that the submission dates for these assessments exceeded the 14-day window. The Assistant Director of Nursing (ADON)/MDS coordinator reported that they had recently assumed responsibility for MDS assessments and, despite assistance, were still behind in completing and submitting the assessments on time.
Failure to Address Indwelling Urinary Catheter in Care Plan
Penalty
Summary
The facility failed to develop a care plan addressing the use of an indwelling urinary catheter for one resident, despite having a policy requiring individualized care plans for each resident. Record review showed that the resident had diagnoses including unspecified retention of urine and dementia, and a physician's order documented the presence of a size 16 French indwelling urinary catheter. However, the resident's care plan did not include any information regarding the catheter. Interviews with the ADON and acting DON confirmed that catheter use should have been addressed in the care plan, and they were unable to explain why it was omitted.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
During a wound care observation, the Assistant Director of Nursing (ADON) was seen providing wound care to a resident with a history of diabetes mellitus and a foot ulcer without wearing a gown, as required by the facility's Enhanced Barrier Precautions (EBP) policy. There was no signage indicating that the resident was on EBP, despite the policy mandating the use of personal protective equipment (PPE) for residents colonized or infected with multidrug-resistant organisms (MDROs) in accordance with CDC guidance. The resident confirmed that staff did not wear gowns during wound care, and the ADON acknowledged not using EBP during the procedure. Additionally, the acting Director of Nursing (DON) stated they were unaware of the requirement to use EBP during wound care.
Facility Fails to Provide Hot Water in Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by the lack of hot running water in the rooms on the 100 hall. Observations and interviews revealed that residents have been without hot water for over a month due to a broken hot water tank. Resident #4, who suffers from arthritis, reported experiencing pain when washing hands in cold water. The maintenance supervisor confirmed the issue and stated that the hot water tank would not be replaced until a government grant is received in March. Resident #5 and Resident #6 also confirmed the absence of hot water in their rooms since their arrival and for over a month, respectively, expressing the inconvenience it causes for daily activities like washing hands and face.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving two residents with dementia. One resident, with a BIMS score of 11, was observed by staff with their hand on the pubic area of another resident, who had a BIMS score of 5. This incident occurred in the resident's room, and the two residents were immediately separated following the observation. A head-to-toe assessment was conducted on the affected resident, revealing no signs of trauma or injury. The incident was reported to the physician, family, and local police department.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving two residents. Resident #3, who has diagnoses including diabetes mellitus and hypertension, was observed in the dining room shouting obscenities and threatening Resident #8, who has diagnoses including schizophrenia and convulsions, with bodily harm. Resident #3 propelled their wheelchair into Resident #8's leg, causing a physical altercation. A nurse's note documented the incident, and RN #2 acknowledged that such behavior is common for Resident #3 and agreed that the interaction was abusive. The Assistant Director of Nursing (ADON) confirmed that staff receive training on identifying and reporting abuse, and acknowledged that the incident met the definition of abuse.
Failure to Maintain Resident Dignity in Dressing and Catheter Management
Penalty
Summary
The facility failed to uphold the dignity of a resident who required assistance with dressing and catheter management. The resident, who had vascular dementia and amputations of both legs, was observed lying nude from the waist down in their room after returning from the hospital. They were unable to reposition themselves or reach the call light for assistance, indicating a lack of staff attention to their needs. The resident expressed dissatisfaction with being left unclothed, although they could not recall the duration of this state. Additionally, the resident's catheter bag was repeatedly observed uncovered in public spaces, such as the dining room and hallway, despite the facility having dignity covers available. The catheter bag was noted to be partially or fully filled with urine during these observations. An LPN acknowledged the availability of dignity covers and stated they would instruct aides to use them. The DON later confirmed that all resident rights should be respected, and the resident should not have been left unclothed or with an uncovered catheter bag.
Failure to Offer Advance Directives
Penalty
Summary
The facility failed to provide residents the opportunity to develop or refuse the creation of an advance directive for three out of five residents reviewed. The facility's policy on residents' rights regarding advance directives was not dated but stated that every competent person has the right to determine their health care decisions, including life-sustaining treatment and organ donation. Resident #15's advance directive form was signed only after the survey began, despite being admitted earlier. For Residents #21 and #36, there was no documentation indicating they were offered the opportunity to develop an advance directive, although the facility had a document for this purpose during the admission process. The Director of Nursing stated that advance directives should be completed thoroughly during or before admission.
Failure to Ensure Interdisciplinary Team Participation in Care Planning
Penalty
Summary
The facility failed to ensure that the required interdisciplinary team (IDT) members participated in the planning process of resident care plans for six residents. The facility's policy stated that the comprehensive care plan should be developed by an IDT, including the attending physician, registered nurse, nurse aide, dietary staff representative, the resident and/or resident representative, and any other healthcare professional as identified by the resident's needs. However, a review of resident records found no documentation related to interdisciplinary team care plan meetings for the six residents reviewed. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the care plan meetings were not conducted as per the facility's policy. The MDS Coordinator admitted to not inviting other care team members to the care plan meetings and had no recollection of contacting the medical director regarding the results of the meetings. The DON stated that they believed the social services director attended the meetings, but acknowledged that the meetings should have been documented and that the physician was only informed of issues as required. The lack of documentation and participation of the required IDT members led to the deficiency identified during the survey.
Failure to Educate and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to ensure that residents were educated on the risks and benefits of using bed rails, obtain informed consent, inspect bed frames and bed rails prior to their application, and attempt alternatives to bed rails before their use. Specifically, two residents, one with vascular dementia and amputations of both legs, and another with dementia, were not provided with education or informed consent regarding the use of bed rails. Additionally, there was no documentation of bed frame and bed rail inspections or attempts to use alternative measures before resorting to bed rails. The Director of Nursing (DON) acknowledged the lack of documentation and stated that no alternative interventions to bed rails had been attempted for the residents in question. The facility's policy on the use of bed rails was undated and did not provide clear guidance on the necessary steps to ensure resident safety and informed consent. Observations confirmed that positioning bars and full bed rails were in use without the required assessments and documentation.
Failure to Maintain Registered Nurse Coverage
Penalty
Summary
The facility failed to maintain registered nurses on duty for eight hours each day, seven days a week, as required. This deficiency was identified through a review of the facility's Payroll Based Journal (PBJ) reports and staffing schedules for the first and second quarters of 2024. The PBJ reports documented missing registered nurse hours on several dates, including specific days in November and December 2023, as well as January and February 2024. The facility's staffing schedules corroborated these findings, showing no registered nurses were documented as having worked on the identified dates. Interviews with facility staff revealed a lack of awareness and communication regarding the staffing deficiencies. The Director of Nursing (DON) was unaware of any dates without registered nurse coverage, relying on an LPN responsible for staffing to fill any gaps. The LPN described a process for finding replacements, which included contacting on-call staff, those willing to work overtime, staffing agencies, and an on-call person. However, this process failed to ensure registered nurse coverage on the identified dates. The Human Resources representative confirmed the accuracy of the PBJ reports, indicating that the facility's staffing records were consistent with the reported deficiencies.
Medication Administration Delays Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure medications were administered within the ordered time frame, as evidenced by a review of medication administration records and staff interviews. On two consecutive days, a significant number of residents did not receive their morning medications at the scheduled time of 7:00 a.m. Instead, these medications were administered after 12:00 p.m. Specifically, on the first day, 23 out of 48 residents were affected, and on the second day, 13 out of 49 residents experienced delays. The facility's Time of Administration policy outlines specific time frames for medication administration, which were not adhered to during this period. The delay in medication administration was attributed to staffing issues, as two Certified Medication Aides (CMAs) quit suddenly, leaving the facility short-staffed. Normally, two CMAs would pass medications, but due to the sudden resignations, only one CMA was available. Additionally, administrative nurses who could have assisted were unavailable due to emergencies. The Director of Nursing (DON) acknowledged the staffing challenges and confirmed that the medications should have been administered on time, despite the unforeseen circumstances.
Failure to Notify Resident and Ombudsman of Hospital Discharge
Penalty
Summary
The facility failed to provide a written notice of discharge to a resident and did not notify the ombudsman office when the resident was discharged to a hospital. This deficiency was identified for one of the two residents reviewed for discharges and hospitalizations. The facility's policy and procedure for transfer and discharge required notification to the resident, their representative, and the ombudsman, with documentation of the reason for transfer or discharge in the resident's medical record. However, the Director of Nursing (DON) admitted that they had not given a notice of transfer to the resident when discharged to a hospital and had not reported the discharges to the ombudsman office. Resident #12 was discharged from the facility four times since admission, with progress notes documenting transfers to a hospital for medical reasons on specific dates.
Inaccurate MDS Assessment of Pressure Wound
Penalty
Summary
The facility failed to accurately assess and code a pressure wound in Section M of a Minimum Data Set (MDS) quarterly assessment for a resident. The resident, who had vascular dementia and amputations of both legs, developed a new wound on the coccyx, which was documented in progress notes as increasing in size and later as an open area upon return from the hospital. However, the quarterly MDS assessment inaccurately documented that the resident had no pressure ulcers, despite the presence of an open wound observed during wound care. The MDS Coordinator admitted to the error, stating they were focused on the resident's surgical wounds rather than the pressure wound when completing the assessment. The Director of Nursing (DON) acknowledged that they were responsible for checking the MDS nurses' work but noted that the two MDS nurses did not review each other's assessments. The expectation was for all assessments to be accurate and timely, which was not met in this instance.
Failure to Conduct Significant Change Assessment
Penalty
Summary
The facility failed to conduct a significant change assessment for a resident following the development of a new pressure ulcer and a partial leg amputation. The resident, who had vascular dementia and had undergone an above-the-knee amputation, developed a wound on the coccyx. Despite these significant changes in the resident's condition, the facility did not perform the required assessment within the 14-day period as stipulated by their policy. The MDS Coordinator acknowledged that a significant change assessment should have been conducted due to the amputation and the new pressure wound. However, it was revealed that the part-time nurse responsible for MDS assessments was not supervised, which contributed to the oversight. The Director of Nursing stated that they were responsible for checking the work of the MDS nurses and agreed that the assessments should have been completed accurately and timely.
Lack of Feedback Program and Policies
Penalty
Summary
The facility failed to establish policies and procedures for obtaining and using feedback from staff, residents, and resident representatives. A review of the facility's Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) records revealed no documentation of a program to gather feedback from these groups. During an interview, the Administrator acknowledged that while there was a grievance process for residents, there was no formal feedback program or associated policies and procedures in place.
Failure to Maintain Functioning Call Light System
Penalty
Summary
The facility failed to maintain a functioning call light system for one of the residents, identified as Resident #47, who was part of a sample of 12 residents reviewed for this issue. Resident #47 had multiple diagnoses, including vascular dementia, atherosclerotic heart disease, and bipolar disorder. The resident's care plan, revised in April 2024, specified that the call light should be kept within reach and marked with bright tape. However, during an observation on June 3, 2024, the call light was found to be out of reach, attached to a privacy curtain, while the resident was seated in a wheelchair. Additionally, the resident was unable to confirm if the call light was functioning properly. The Director of Nursing (DON) confirmed that the call light for Resident #47 was not ringing at the front desk and admitted that no alternative intervention had been implemented at that time. The facility's policy stated that in the event of a call light malfunction, alternative methods such as a bell or buzzer should be provided, and maintenance should be notified immediately. However, the Administrator acknowledged that although they were informed of the issue on June 3, 2024, and maintenance had looked into it, a part needed to be ordered. A hand bell was provided to the resident only after the malfunction was discovered, indicating a delay in implementing the alternative alert method as per the facility's policy.
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A resident filed multiple written grievances against a nursing staff member, including one that lacked any attached investigation report, and reported never receiving a response from administration. The facility’s policy required the administrator to investigate and respond to written grievances within ten days, but staff interviews showed confusion about where grievances should be placed, with some believing they should go to the administrator and others thinking they belonged in the DON’s office. The ADON acknowledged that grievances were left in various locations, did not consistently reach administrative staff, and that staff had not been in-serviced on grievance procedures. An LPN reported assisting the resident with a grievance and sliding copies under the administrator’s and ADON’s office doors, yet leadership later stated they were unaware of that grievance due to a systemic failure in grievance review.
The facility failed to maintain required RN coverage for at least 8 consecutive hours per day, 7 days a week, despite a census of 76 residents and a written staffing policy requiring such coverage. PBJ staffing data showed multiple days in a quarter with no RN hours recorded. The business office manager and corporate HR officer confirmed the accuracy of the PBJ data and that there was no RN coverage on those days, and the DON acknowledged awareness of the missing RN hours.
The facility failed to follow its abuse reporting policy and regulatory requirements after a resident alleged that an LPN punched them in the shoulder, pushed their walker, and later verbally abused and cursed at them, causing fear, shaking, and prolonged crying. Grievances documented the physical and verbal allegations and the resident’s emotional response, but there was no timely response to the grievances. The DON acknowledged not reporting the abuse allegations to the state survey agency or local police within the required 2-hour timeframe and not notifying the state nursing board about the LPN, citing misunderstanding of the reporting timeframes and requirements.
Surveyors found multiple failures in food storage, sanitation, and hand hygiene in the kitchen. Undated and unlabeled leftover foods, including pasta, sliced ham, and a white liquid, were stored in the refrigerator, and opened gallon containers of mustard and Ranch dressing had dried spillage on the outside, with one lid not properly secured. Stacked cups and plates were observed with water droplets between them on two occasions, indicating dishes were not air dried. A dietary aide was seen tossing salad without gloves, and leadership reported that the dietitian had not visited for about a year and that no one was clearly responsible for kitchen audits, despite facility policy requiring proper food handling and dishwashing sanitation.
Surveyors identified that the facility did not ensure a clean, safe, and homelike environment for residents, noting makeshift window coverings using bed sheets, cluttered rooms with items on the floor, an unmade extra bed, a TV placed on the floor, and a urine odor in one room. Facility-wide issues included chipped and peeled paint on door facings and walls, as well as dirt and dust buildup on baseboards, a box fan, and bent, dirty air return vents in a TV room. A housekeeper reported there was no scheduled cleaning log or check sheet, and that cleaning of fans and baseboards occurred only when residents asked or when staff had time, reflecting the lack of a structured cleaning routine.
The facility failed to provide enough nursing staff to meet residents’ daily care needs, as shown by multiple days with documented insufficient direct care staffing and incomplete bathing records for several residents whose care plans called for regular baths. CNAs reported that due to short staffing, incontinent care, baths, and showers were often delayed or left for the next shift and sometimes never completed, particularly for residents needing 2-person assistance. The DON acknowledged both staffing shortfalls and the absence of a reliable process to document and track completed baths, and was unsure how many scheduled baths were actually provided.
A resident with cerebral palsy and major depressive disorder sustained three superficial gluteal lacerations during a transfer with a mechanical lift, as documented in incident notes and followed by treatment orders to cleanse the wounds daily and as needed. Facility policy required ongoing assessment and timely revision of care plans when a resident’s condition changed, and the MDS coordinator stated that care plans should be updated the same day or the next day after such events. However, the resident’s care plan was not revised to include the new lacerations, resulting in a failure to update the care plan to reflect the new skin condition.
A resident with dysphagia, dementia, and a physician order for a mechanically soft diet without bread was incorrectly served a grilled cheese sandwich and salad instead of the ordered diet. Despite a care plan and policy requiring therapeutic diets to follow MD orders, dietary staff misread the diet card and, despite questioning the appropriateness of the meal, proceeded after confirmation from the cook. The resident subsequently experienced a choking episode during the meal, required emergency intervention, and was transported to the ED, where suctioning removed a small piece of lettuce and symptoms resolved.
A resident with dementia, moderately impaired cognition (BIMS 9), and a documented history of elopement and prior injury in the community was admitted after hospital records and a family member identified them as an elopement risk. The social worker later reported learning of the elopement history from hospital records and verbally informing nursing staff, but did not document this information or the notification. On the night of the incident, staff last observed the resident during night‑shift rounds around 3:30–4:00 a.m. and discovered the resident missing during early morning hours. A CNA and an LPN searched the building and surrounding area without success, noting the resident’s room window appeared secured with the screen in place and with no clear route of exit identified. The resident was ultimately found in the community near a public school several miles away and was assessed by an LPN on return with no injuries noted.
The facility failed to follow physician orders for sliding-scale insulin and required follow-up FSBS monitoring for two residents with diabetes. Both had orders specifying insulin doses for elevated FSBS ranges, with instructions to recheck FSBS after 2 hours and notify the MD if levels remained high. Records showed multiple elevated FSBS readings for each resident, but there was no documentation of repeat FSBS checks or MD notification as ordered. In interviews, an LPN and an RN confirmed that the orders required 2-hour rechecks and documentation, and the DON acknowledged that documentation of repeat FSBS and MD notification was not found.
Failure to Receive, Track, and Investigate Resident Grievances per Policy
Penalty
Summary
The facility failed to ensure grievances were received, tracked, and investigated by an identified grievance official in accordance with its grievance policy. Review of the grievance binder showed multiple grievances filed by Resident #23, including one dated 01/07/26 that had no investigation reports attached. The facility’s undated grievance policy stated that the administrator should inform the complainant of the findings of the investigation within ten days of receiving the written grievance report and outline actions to correct identified problems. Resident #23 reported having filed multiple grievances against a nursing staff member and stated they had not received any response from administrative staff regarding these grievances. Staff interviews revealed confusion and inconsistency regarding the handling and routing of grievance forms. CNA #1 stated that nursing staff were required to take written grievances directly to the administrator, while CNA #2 believed grievances were being placed in the DON’s office but was unsure. The ADON stated that grievances were being placed by staff in various locations throughout the facility and were not reaching administrative staff promptly, and acknowledged that staff had not received in-service training on grievances. The ADON, DON, and administrator reported they were unaware of the 01/07/26 grievance due to a systemic grievance review failure. LPN #1 stated they assisted Resident #23 with the 01/07/26 grievance, made two copies, and slid them under the office doors of the administrator and ADON, yet the grievance was still not received or acted upon by the designated administrative staff.
Failure to Maintain Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure required RN coverage for eight consecutive hours per day, seven days per week, for a census of 76 residents. The facility’s staffing policy dated 10/2023 stated that an RN must be on duty 8 hours a day, 7 days a week. Review of the PBJ Staffing Data Report dated 03/20/26 showed there was no RN coverage on multiple dates in quarter 1 of 2026, specifically 10/05/25, 10/12/25, 10/18/25, 10/19/25, 11/09/25, 11/15/25, 11/29/25, 11/30/25, 12/06/25, 12/07/25, 12/13/25, 12/14/25, 12/20/25, 12/21/25, 12/27/25, and 12/28/25. During interviews, the business office manager stated that the corporate human resource officer was responsible for inputting PBJ data and confirmed that the missing RN coverage reflected in the PBJ report was accurate. The corporate human resource officer further confirmed that there was no RN coverage on the listed dates. The DON acknowledged awareness of the missing RN hours for quarter 1 of 2026. No additional resident-specific clinical details were documented in relation to these staffing gaps.
Failure to Timely Report Alleged Abuse to State, Police, and Nursing Board
Penalty
Summary
The facility failed to follow its abuse policy and federal/state reporting requirements for allegations of abuse involving one resident. The facility’s undated Abuse Policy Procedure required that all allegations of resident maltreatment, including abuse and injuries of unknown origin, be promptly reported to the administrator and investigated, and that the administrator immediately report the allegation to the Oklahoma State Department of Health (OSDH) and local police, with reporting within two hours when the allegation involves abuse or results in serious bodily injury. A grievance form dated 01/07/26 documented that a resident reported an LPN had "slugged" them in the shoulder and that the resident was "shaking like a leaf." A second grievance form dated 03/16/26 documented that the same resident reported the LPN told them to "get my ass back on my own hall," after which the resident began crying. An employee disciplinary action form dated 03/19/26 referenced several residents’ concerns about the LPN’s communication style and emphasized the need for empathy, active listening, and professionalism, but the form contained no signatures. During interview on 03/26/26, the resident stated the LPN punched them in the left shoulder on 01/07/26 and, when the resident did not fall, pushed their walker into them. The resident reported discovering a dime-sized bruise on the left shoulder later that day while showering, and stated they were fearful of the LPN and shook with fear and anger. The resident also stated that on 03/16/26 the LPN cursed at them and denied them access to a different hall, causing them to become upset and cry all night, and that no one responded to their grievances until 03/25/26. The DON stated on 03/26/26 that they were not aware of the 01/07/26 abuse allegation until 03/25/25 and had not reported the 01/07/26 or 03/16/26 allegations to OSDH or local police because they believed they had 48 hours after discovery to report. On 03/30/26, the DON further stated they had not notified the Oklahoma Board of Nursing regarding the LPN because they did not know they were required to report before completing the investigation. These actions and inactions resulted in the facility’s failure to timely report alleged abuse to OSDH within two hours of discovery, to immediately notify local law enforcement, and to report the allegation to the Oklahoma Board of Nursing as required.
Food Storage, Sanitation, and Hand Hygiene Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service and kitchen sanitation practices affecting 76 residents served from the kitchen. During a kitchen tour, surveyors observed multiple improperly stored and unlabeled food items, including an undated, unlabeled bag of leftover pasta, an open undated half package of sliced ham, and an undated, unlabeled pitcher of white liquid in the refrigerator. They also observed undated opened gallon containers of mustard and Ranch dressing with dried spillage down the sides onto the labels, and in the case of the Ranch dressing, the lid was not secured properly. The facility’s policy required that food be stored, handled, prepared, and served to minimize the risk of foodborne illness, and that dishwashing machines be operated using specified sanitation methods. Additional observations showed that stacked cups and plates had water droplets between them on two separate days, indicating dishes were not air dried as required. A dietary aide was seen tossing salad in a large bowl without wearing gloves, and the CDM acknowledged the aide should have washed hands and donned gloves before touching food. The CDM also reported that the dietitian had not visited in approximately a year, resulting in no kitchen audits being available, and the administrator stated they did not know who was responsible for kitchen audits since the dietitian was not coming to the building. These observations demonstrated failures in labeling, dating, cleanliness of condiment containers, dishwashing and drying practices, and hand hygiene, contrary to the facility’s kitchen sanitation policy and professional standards.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, comfortable, and homelike environment for its 76 residents, as evidenced by multiple environmental deficiencies observed during facility tours. In several resident rooms, folded bed sheets were tacked over windows instead of appropriate window coverings, and one room was noted to be cluttered with items on the floor. Another room contained clutter on shelves and in corners, an unmade extra bed without linens, a television placed on the floor, and a noticeable urine odor. Throughout the facility, door facings and walls had chipped and peeled paint. Additional observations in the TV room included baseboard ledges with visible dirt and dust buildup, a box fan with dust and dirt collected on one side of the guard, and air return vent covers that were dirty and bent. A housekeeper reported there was no scheduled cleaning log or check sheet in place, and that fans were cleaned only when residents requested it and baseboards were cleaned when staff were able, indicating a lack of structured cleaning practices contributing to the unclean and non-homelike environment.
Insufficient Staffing Leading to Missed Bathing and Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ daily care needs, including scheduled bathing and incontinent care. The DON reported a census of 98 residents, and Quality of Care Monthly Reports documented multiple days with insufficient direct care staff for the resident census: 3 days in December 2025, 5 days in January 2026, and 1 day in February 2026. A bath list showed one resident was scheduled for baths on Mondays and Thursdays, but bath sheets documented baths only on 03/05/26, 03/19/26, and 03/24/26. Another resident was scheduled for baths every Tuesday, Thursday, and Saturday, but records showed baths only on 03/05/26, 03/14/26, 03/19/26, and 03/24/26. A third resident was scheduled for baths on Wednesdays and Saturdays, but documentation showed only a complete bed bath on 01/16/26 and 01/21/26 and a shower on 03/05/26. CNA interviews further described that residents did not receive incontinent care, baths, or showers as often as needed due to staffing shortages. One CNA stated that care tasks were sometimes left for the next shift, but because shifts were often short-staffed, the care was never completed. Another CNA reported that when staffing was low, residents requiring more than one person for transfers often did not receive baths or showers. The DON stated there were no additional bath sheets available, acknowledged there was not a good process for bath or shower sheet completion, and expressed uncertainty about how many baths were actually being provided, indicating a lack of reliable tracking of whether scheduled bathing was carried out.
Failure to Update Care Plan for New Skin Lacerations After Transfer Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s comprehensive person-centered care plan to reflect a new skin alteration following an incident during a mechanical lift transfer. The facility’s policy, revised in 12/2016, stated that assessments of residents are ongoing and care plans are revised as information about the residents and their conditions change. Resident #28’s care plan, initiated on 03/06/25, documented diagnoses including cerebral palsy and major depressive disorder. On 12/04/25 at 12:01 p.m., an incident note recorded that during a transfer using a mechanical lift, the resident stated that the chair pinched them, and upon transfer back to bed, three superficial lacerations were noted on the gluteal area. A subsequent incident note on 12/04/25 at 4:00 p.m. documented a new order to cleanse the lacerations with wound cleaner and pat dry daily and as needed until resolved. Despite these documented lacerations and treatment orders, a review of Resident #28’s care plan showed no documentation of the lacerations. On 03/26/26, the MDS coordinator stated that care plans were to be updated with falls or other changes the same day or the next day and acknowledged that the care plan should have been updated to include the lacerations but that they were not added. This lack of revision to the care plan to reflect the new skin condition constituted the cited deficiency.
Failure to Follow Physician‑Ordered Mechanically Soft Diet Resulting in Choking Episode
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a physician‑ordered mechanically soft diet without bread. The resident had medical diagnoses including cerebral infarction, dysphagia, and dementia, was severely cognitively impaired with a BIMS score of 5, and required a mechanically altered diet and set‑up assistance with eating. The resident’s care plan and physician order specified a mechanically soft texture diet with no bread due to dysphagia and cognitive deficits. On the date of the incident, the resident was served a grilled cheese sandwich and a side salad for the evening meal instead of the ordered mechanically soft diet without bread. The dietary staff did not follow the physician’s order or the care plan intervention to provide a mechanically altered diet with no bread. The facility’s policy stated that therapeutic diets would be served according to doctor orders, but this was not followed when the resident was given regular‑texture food items inconsistent with a mechanically soft diet. The cook who prepared the tray acknowledged misreading the dietary card, which resulted in the incorrect diet being provided, and the dietary aide who delivered the tray reported questioning whether a grilled cheese sandwich and salad were appropriate for a mechanically soft diet but relied on the cook’s confirmation that they were. The dietary manager and administrator stated that the cook and dietary aide had not received adequate training regarding therapeutic diets and that the staff should have recognized the meal items were not consistent with the ordered mechanically soft diet without bread. As a result of receiving the incorrect meal, the resident experienced a choking episode during dinner, was observed unable to move air effectively, required abdominal thrusts, and was sent to the hospital, where suctioning revealed a small piece of lettuce before the resident’s symptoms resolved.
Removal Plan
- Completed an immediate diet order audit for all residents to ensure no additional meals were served without verification of the residents’ ordered diet consistency.
- Implemented a monitoring tool to verify meal trays matched physician-ordered diets for all residents.
- Registered dietician observed dietary preparation processes and provided additional re-education as needed.
- Scheduled dining room nursing assignments to increase staff presence and supervision during meal service.
- Conducted a multi-disciplinary quality assurance meeting and completed a root cause analysis to determine contributing factors and identify improvements needed to prevent recurrence.
- Speech therapy assessed Resident #3 and added gravy/sauce to ground meat items to improve moisture and aid in swallowing and continued monitoring during meals to ensure safety with updated dietary modification.
- In-serviced dietary and nursing staff on the importance of following physician-ordered diets.
- Implemented a two-step meal tray verification policy requiring dietary staff to verify diet orders and tray accuracy during tray preparation and nursing staff to conduct a second verification prior to tray delivery to residents.
- Suspended dietary staff involved in the incident pending investigation.
Failure to Prevent Elopement of Cognitively Impaired Resident With Known Elopement History
Penalty
Summary
The deficiency involves the facility’s failure to prevent an elopement of a resident with moderately impaired cognition and a known history of elopement. The resident had been admitted with diagnoses including non‑traumatic brain dysfunction and dementia, and a BIMS score of 9 indicated moderately impaired cognition. Prior records from a community acute care hospital documented that the resident had previously eloped from another nursing facility, which then refused to accept the resident back. A family member reported during admission that the resident was an elopement risk, had memory problems from a motor vehicle accident, and had previously been hit by a car while walking in the community. The family member stated they informed staff of this history during the admission process. The social worker later stated they learned of the resident’s elopement history from hospital records after admission and reported it verbally to nursing staff during a morning meeting, but did not document either the information or the notification. On the night of the incident, staff last observed the resident between approximately 3:30 a.m. and 4:00 a.m. during night‑shift rounds. When a CNA reported for duty shortly before 7:00 a.m. and went to the resident’s room, the resident was not present. The CNA and an LPN searched the building and surrounding area but could not locate the resident, and the CNA reported that the window in the resident’s room remained secured with the screen in place, and they did not know how the resident exited the building. An incident report documented that staff discovered the resident missing at approximately 6:20 a.m., and that the resident was later found in the community near a local public school approximately 2.2 miles from the facility at about 8:40 a.m. An LPN stated they learned the resident was missing at about 8:00 a.m. and assessed the resident upon return, finding no injuries. The administrator stated they were unable to definitively identify how the resident eloped from the facility.
Removal Plan
- The administrator contacted the QAPI committee members and created a performance improvement plan which included continued inspections of points of possible egress from the facility, staff education on elopement was initiated, continued 1:1 monitoring of the resident until discontinued by their physician, and ongoing monitoring of elopement prevention procedures by the administration and QAPI committee.
- The maintenance supervisor inspected the locks and code pads to all doors that lead to the outside of the building.
- The maintenance supervisor checked to ensure each window remained locked and secure from being opened by residents.
- The resident was placed on 1:1 monitoring for high elopement risk.
- The facility completed mandatory staff training on elopement prevention for staff, with participation verified through training sign-in sheets and interviews.
Failure to Follow Sliding-Scale Insulin Orders and Document Required FSBS Rechecks
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for insulin administration and required follow-up blood glucose monitoring for two residents with diabetes. For Resident #1, a physician order dated 03/09/26 for Insulin Aspart specified that for finger stick blood sugar (FSBS) readings of 351–400, staff were to administer 10 units of insulin, recheck the FSBS in 2 hours, and, if still 400, notify the physician. The resident’s record showed multiple FSBS readings in the 360–401 range between 03/09/26 and 03/12/26, including 383, 401, 399, 390, 360, 384, 370, 366, and 383. However, there was no documentation that any repeat FSBS checks were performed 2 hours after these elevated readings or that the physician was notified as ordered. Resident #11 had a physician order dated 12/08/25 for Insulin Aspart that directed staff to administer 12 units of insulin for FSBS 401–450 and 15 units for FSBS 451–500, recheck the FSBS in 2 hours, and, if still greater than 400, notify the physician. The resident’s record showed FSBS readings of 411, 460, 481, 411, 429, 461, and 455 on various dates in March, all within or above the ranges specified in the order. As with Resident #1, there was no documentation of repeat FSBS checks or physician notification following these elevated readings. In interviews, an LPN and an RN confirmed that the sliding scale orders required a 2-hour recheck and documentation of the repeat FSBS and physician contact, and the DON acknowledged that they did not find documentation of repeat FSBS when blood sugars were over 351 for Resident #1 or over 400 for Resident #11.
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