Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Huntsville Health Care Center during CMS and state inspections, most recent first.
A resident with a diabetic foot ulcer requiring enhanced barrier precautions received care from two CNAs who did not consistently follow infection control protocols. The CNAs failed to sanitize hands before donning gloves, did not change gloves or perform hand hygiene between dirty and clean tasks, and did not wear gowns as required. Both staff acknowledged awareness of the protocols, and facility leadership confirmed that training and policies were in place, but these were not followed during the observed care.
A resident with hemiplegia and other complex medical needs, who required two-person assistance for bed mobility and ADL care, was left unattended by a CNA during incontinence care. The CNA left the resident on her side to retrieve supplies, resulting in the resident rolling off the bed and later being diagnosed with a femur fracture. The deficiency was due to failure to follow the care plan's supervision and assistance requirements.
The facility did not develop or implement comprehensive care plans addressing ADL assistance needs for three residents with significant physical and cognitive impairments. One resident with hemiplegia and other conditions experienced a fall during peri-care when left unattended, and her care plan lacked required ADL interventions. Two other residents, both dependent on staff for various ADLs due to dementia, fractures, or muscle weakness, also had care plans that failed to specify their assistance needs, despite staff providing help as needed.
A resident with hemiplegia and high care needs was left unattended during peri-care when a CNA left to get supplies, resulting in the resident rolling off the bed. The resident was later found to have a femur fracture after being sent to the hospital for a change in condition. The facility did not report the incident as an allegation of neglect to the state agency as required by policy, and leadership interviews revealed confusion and conflicting accounts about the event.
Two CNAs failed to follow enhanced barrier precautions and proper hand hygiene while providing care to a resident with a diabetic foot ulcer. The CNAs did not wear gowns as required, and one did not sanitize hands before donning gloves. Both failed to change gloves or perform hand hygiene when moving from dirty to clean tasks, despite being trained on infection control protocols. Facility leadership confirmed these actions did not align with established policies.
Three residents who required total or maximal assistance with transfers were observed using mechanical lift slings with faded and worn straps. Staff interviews revealed inconsistent inspection practices, with some unaware that color fading was a sign of sling wear requiring removal from service. Facility policy and manufacturer guidelines required removal of slings with signs of wear, including fading, but this was not consistently followed, resulting in the continued use of unsafe slings.
A Nurse Manager failed to remove and dispose of contaminated PPE inside a resident's room after providing direct care to a resident with complex medical needs and Enhanced Barrier Precautions. Instead, the Nurse Manager exited the room wearing the PPE and discarded it in a hallway trash can, contrary to facility policy and standard infection control practices. Staff interviews confirmed the correct procedures were not followed.
A resident with severe cognitive impairment and mobility issues was found to have an emergency call light cord in the bathroom positioned three feet above the floor, making it inaccessible if the resident were to fall. Staff interviews confirmed the inaccessibility, and facility policy required the call system to be reachable from the floor.
A shared restroom and a resident room on one hallway were found with significant maintenance and cleanliness issues, including damaged walls, dirty floors, and a broken dresser that could not be properly cleaned. Staff interviews confirmed awareness of the problems but revealed gaps in reporting and addressing these deficiencies, resulting in an environment that did not meet required standards for safety and sanitation.
The facility's kitchen operations failed to meet food safety standards, with staff not wearing hair nets properly, improper labeling and storage of food items, and inadequate sanitation practices. Observations included exposed hair, unlabeled and expired food, and unsanitary handling of food and utensils. Staff interviews confirmed these deficiencies, highlighting risks of cross-contamination and foodborne illnesses.
The facility failed to maintain a safe environment by not removing worn mechanical lift slings from service and not obtaining physician orders for mechanical lift transfers. Observations showed residents using slings with faded colors, loose strings, and tears, despite staff awareness of the risks. The facility's policy and manufacturer guidelines require the removal of such slings, but this was not followed, leading to a deficiency.
The facility failed to implement its policies to prevent abuse, neglect, and exploitation by not conducting a timely criminal history check for the DON. The DON was hired without the required background check, which was only completed over a month later. This oversight was acknowledged by HR, who was responsible for conducting these checks, and confirmed by the Administrator, highlighting a lapse in following the facility's procedures.
A resident with a feeding tube was at risk due to the facility's failure to properly label feeding tube bags. The bags lacked essential information such as the time they were hung and staff initials, which could lead to the resident receiving old or expired feed. Interviews with staff revealed that the nursing team was responsible for labeling, but the process was not followed correctly, posing a risk to the resident's health.
The facility failed to maintain clean oxygen concentrator filters for two residents, leading to dust buildup. One resident with COPD and another with CHF were found with dusty filters, despite care plans requiring regular cleaning. Staff interviews revealed confusion over cleaning responsibilities, with conflicting accounts from nursing and maintenance staff.
A facility failed to maintain an effective infection control program when a CNA did not sanitize or wash her hands after changing gloves during incontinent care for a resident with multiple medical conditions. Despite the presence of an RN who followed hand hygiene protocols, the CNA's oversight posed a risk of infection transmission. Interviews with staff highlighted awareness of the importance of hand hygiene, but the facility's policy was not adhered to in this instance.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper practices observed during care provided to a resident with a diabetic foot ulcer requiring enhanced barrier precautions (EBP). Two CNAs provided incontinent care to the resident without consistently following EBP protocols. Specifically, one CNA did not sanitize her hands before donning gloves, and both CNAs failed to change gloves and perform hand hygiene when moving from contaminated to clean tasks. Additionally, neither CNA wore a gown as required by EBP policy for high-contact care activities, despite signage and care plan instructions indicating the need for gown and glove use. The resident involved had a history of cerebral infarction with right-sided hemiplegia and type 2 diabetes, and was totally dependent on staff for toileting hygiene, with a documented open wound on the left foot. During the observed care episode, the CNAs performed multiple tasks, including cleaning the resident after a bowel movement and changing briefs, but did not change gloves or sanitize hands between dirty and clean tasks. One CNA also touched clean items, such as linens and the resident's cap, with contaminated gloves. Both CNAs acknowledged during interviews that they were aware of the EBP requirements and hand hygiene protocols but failed to follow them during the care episode. Interviews with facility leadership confirmed that staff had received training on infection control, hand hygiene, and EBP, and that policies required hand hygiene before and after glove use, as well as the use of gowns and gloves for residents on EBP during high-contact care. Documentation showed that at least one CNA had attended recent in-service training on these topics. Despite this, the observed failures in infection control practices placed residents at risk of exposure to infectious diseases due to improper adherence to established protocols.
Failure to Provide Required Two-Person Assistance Results in Resident Injury
Penalty
Summary
A deficiency occurred when a resident, who was assessed as requiring the assistance of two staff members for bed mobility and ADL care, did not receive the required level of supervision and assistance. The resident had a medical history including hemiplegia/hemiparesis due to cerebral infarction, pain, peripheral vascular disease, and hypertension. According to the records, the resident was dependent for toileting hygiene and required substantial to maximum assistance for rolling in bed. During an episode of incontinence care, only one CNA was present, despite the care plan indicating a two-person assist was necessary. The CNA providing care was unable to find another staff member to assist and proceeded to provide care alone. During the process, the resident had a large bowel movement, prompting the CNA to leave the resident unattended on her side to retrieve additional supplies from a cart located at the doorway. While unattended, the resident attempted to reach for an item on her bedside table and subsequently rolled off the bed. The resident was found on the floor, and although initial assessments did not reveal injuries, she later exhibited altered mental status and was sent to the hospital, where imaging revealed a fracture of the left femur near the knee. Interviews and record reviews confirmed that the CNA was aware of the two-person assist requirement but did not adhere to it due to the unavailability of additional staff at the time. The incident was not initially recognized as a fall by facility leadership, and the injury was only identified after the resident was transferred to the hospital. The failure to provide adequate supervision and assistance as outlined in the resident's care plan directly led to the resident sustaining a significant injury.
Failure to Develop and Implement Comprehensive ADL Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that addressed the activities of daily living (ADL) assistance needs for three residents. For one resident with hemiplegia, pain, peripheral vascular disease, and hypertension, the care plan did not include her ADL assistance requirements, despite documentation in the MDS indicating she required extensive assistance from two staff for bed mobility and was dependent for toileting hygiene. An incident occurred where this resident, while receiving peri-care from a CNA, rolled off the bed when left unattended as the CNA left to get supplies, resulting in a fall. Subsequent assessments and hospital imaging revealed a femoral fracture, though the timing and location of the injury were disputed. Another resident with a history of wedge compression fracture, dementia, and anxiety was also found to have a care plan that did not address her ADL assistance needs, despite being dependent on staff for personal hygiene, bathing, and requiring maximum assistance with toileting and dressing as documented in her MDS. Observations confirmed that she relied on staff for assistance during daily activities. A third resident, diagnosed with dementia, falls, and muscle weakness, similarly had a care plan that failed to address her substantial to maximum assistance needs for lower body dressing and bathing, as well as moderate assistance for upper body dressing and footwear, and touch assistance for toileting and eating. Interviews and observations confirmed that staff provided assistance as needed, but the care plan did not reflect these requirements. The DON acknowledged responsibility for care plans and stated they were developed collaboratively and reviewed at least quarterly or with changes in resident needs, but the care plans in question did not include the necessary ADL interventions.
Failure to Timely Report Alleged Neglect Following Resident Injury
Penalty
Summary
The facility failed to report an allegation of neglect to the state agency for one resident who required extensive assistance for bed mobility and was dependent for toileting hygiene. During peri-care provided by a CNA, the resident, who had hemiplegia and other significant medical conditions, was left unattended when the CNA left the bedside to obtain additional supplies. While unattended, the resident attempted to reach for an item on her bedside table and rolled off the bed. The CNA found the resident on the floor after hearing her scream and notified the nurse, who performed an assessment and found no immediate injuries or abnormal vital signs at that time. Subsequent documentation indicated that the resident was monitored with neuro checks and was stable until the following day, when she was found to be lethargic and only responsive to painful stimuli. The resident was then sent to the hospital for evaluation, where imaging revealed a fracture of the left femur near the knee. The facility's Director of Nursing and Administrator were uncertain about the timing and location of the injury, as the x-ray did not specify the age of the fracture, and there were conflicting accounts regarding whether the injury occurred at the facility or the hospital. Despite the incident and the resident's significant change in condition, the facility did not report the allegation of neglect to the state agency as required by their own policy, which mandates reporting all alleged violations within specified timeframes. Interviews with facility leadership confirmed that the event was not reported because they did not initially consider it a fall or neglect, and there was confusion about the details of the incident and the resulting injury.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during the provision of care to a resident with a diabetic foot ulcer requiring enhanced barrier precautions (EBP). The resident, who had a history of stroke, hemiplegia, and type 2 diabetes, was totally dependent on staff for toileting and hygiene and was always incontinent of urine and bowel. Physician orders and the care plan specified the use of gown and gloves for EBP during high-contact care activities, such as providing hygiene and changing briefs. On the observed date, both CNAs entered the resident's room to provide incontinent care. One CNA sanitized her hands before donning gloves, while the other did not perform hand hygiene prior to gloving. Neither CNA wore a gown as required by EBP protocols, and both failed to change gloves or perform hand hygiene when moving from dirty to clean tasks during care. Specifically, one CNA continued to use the same gloves after cleaning the resident's perineal area and then handled clean items, such as a new brief and bed linens, without changing gloves or sanitizing hands. Interviews with the CNAs revealed that they were aware of the EBP requirements and hand hygiene protocols but failed to follow them, citing forgetfulness. Facility records confirmed that both CNAs had received training on infection control, EBP, and hand hygiene. Facility leadership, including the DON, ADON, and IP, acknowledged the lapses in protocol and confirmed that the observed care did not meet the facility's infection control policies.
Failure to Remove Worn and Faded Mechanical Lift Slings from Service
Penalty
Summary
The facility failed to ensure that the environment remained as free from accident hazards as possible for three residents who required mechanical lift assistance for transfers. Observations revealed that the mechanical lift slings used for these residents had faded and light-colored straps, indicating wear and possible improper laundering. The colored connection tabs on the slings, which are essential for safe use, were no longer bright and had become uniformly light blue, rather than their original distinct colors. Record reviews showed that all three residents had significant physical and/or cognitive impairments, requiring total or maximal assistance with transfers using mechanical lifts. The facility's policy and manufacturer guidelines both required that slings be inspected for damage, including rips, tears, fraying, and color fading, and that any slings showing such signs be immediately removed from service. However, interviews with staff revealed a lack of awareness regarding the need to inspect for color fading, with some staff only checking for physical damage such as rips or tears. Laundry and nursing staff were both responsible for inspecting slings, but there was inconsistency in understanding and following the inspection protocols, particularly regarding faded straps. The deficiency was further evidenced by direct observations of residents sitting in wheelchairs with faded slings in use, and by staff interviews confirming that faded slings were not previously recognized as a hazard. The facility's own policy and the manufacturer's instructions explicitly stated that faded or improperly laundered slings are unsafe and should be removed from use, but this was not consistently implemented, resulting in the continued use of worn and faded slings for resident transfers.
Failure to Follow PPE Disposal Protocols During Resident Care
Penalty
Summary
A deficiency occurred when a Nurse Manager failed to follow proper infection prevention and control procedures while providing care to a resident with multiple complex medical conditions, including hemiplegia, muscle wasting, cognitive impairment, and a history of cerebral infarction. The Nurse Manager performed direct care involving a PICC line for the resident, who was dependent on staff for activities of daily living and had orders for Enhanced Barrier Precautions (EBP). After completing care, the Nurse Manager exited the resident's room wearing contaminated personal protective equipment (PPE), including a gown and gloves, and removed the PPE in the hallway, disposing of it in a trash can on the medication cart across the hall, rather than in the designated trash can inside the resident's room as required by facility policy. Interviews with staff, including the Nurse Manager, CNA, RN, medication aide, ADON, and Administrator, confirmed that the facility's policy and standard infection control practices require staff to remove and dispose of PPE inside the resident's room and perform hand hygiene before exiting. The Nurse Manager acknowledged not following these procedures and stated a misunderstanding about the disposal requirements. Other staff members consistently described the correct process and the importance of proper PPE use and disposal to prevent the spread of infection. Facility policy specifically directs that a trash can be positioned inside the resident's room for PPE disposal prior to exit.
Inaccessible Emergency Call Light in Bathroom
Penalty
Summary
The facility failed to ensure that the emergency call light system in a resident's bathroom was accessible to the resident while on the floor. During observation, the call light cord in the bathroom was found to be approximately three feet above the floor, making it inaccessible if the resident were to fall. The resident, who had severe cognitive impairment, muscle weakness, difficulty ambulating, and a history of falls, required supervision or touch assistance for toilet use. The resident reported using the restroom with minimal assistance and would call for help if needed. Interviews with facility staff, including an LVN and the Director of Maintenance, confirmed that the call light cord's length could prevent a resident from reaching it in the event of a fall. The facility's policy required that the call system be accessible to residents at each toilet and bathing facility, including for those lying on the floor. The deficiency was identified through observation, interview, and record review, and was specific to one resident reviewed for call light accessibility.
Failure to Maintain Sanitary and Safe Resident Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in one of four hallways reviewed, specifically in the 200 hallway. Observations revealed that the shared restroom for two rooms had multiple holes in the sheetrock wall beside the toilet, a dirty and discolored floor with no visible wax or coating, and black-brown debris around the base of the toilet that had been caulked over. Additional dirt and dust were present on the wall beneath the sink, and a section of the ceiling showed flaking texture from prior water damage. These conditions were directly observed and confirmed by staff interviews, indicating a lack of timely maintenance and cleaning in the restroom area. In a resident room on the same hallway, a dresser was found with a broken top, exposing particle board and loose vinyl trim, making it impossible to properly clean and disinfect the surface. Staff interviews confirmed the dresser had been damaged during care activities and was not suitable for use, but there was uncertainty among staff about reporting or addressing the issue. The Director of Maintenance was unaware of the needed repairs, and the facility's policy requires resident rooms to be equipped with functional furniture and maintained for comfort and sanitation.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. On multiple occasions, staff members, including the Dietary Aide (DA) and Dietary Manager (DM), did not wear hair nets effectively, leaving hair exposed. Additionally, the facility did not ensure that food items in refrigerators, freezers, and the dry pantry were properly labeled, dated, or discarded after their expiration dates. Containers of oil and sugar were not sealed properly, and frozen items like green beans and egg and cheese omelets were not stored correctly, with some being placed under a dripping pipe. Further observations revealed that the facility did not maintain proper sanitation practices. The food processor was not sanitized between pureeing different food items, and staff members were seen handling food without washing their hands between tasks. This lack of hygiene extended to the handling of utensils and the failure to change gloves appropriately. The facility's dry storage area contained expired items, and the refrigerator held uncovered and expired produce, such as celery and bell peppers, as well as undated and unlabeled beverages. Interviews with staff members, including the Maintenance Director and Dietitian, confirmed these deficiencies. The Maintenance Director attributed the dripping pipe to condensation from propped open freezer doors during deliveries. The Dietitian acknowledged the risks of cross-contamination and foodborne illnesses due to improper food storage and handling practices. The DM admitted to the oversight in labeling and dating food items and recognized the potential for contamination from improper hair net use and inadequate hand hygiene.
Failure to Remove Worn Mechanical Lift Slings and Obtain Physician Orders
Penalty
Summary
The facility failed to ensure the residents' environment was free from accident hazards by not removing worn and damaged mechanical lift slings from service. Observations revealed that several residents, including those with severe cognitive impairments and total dependency on mechanical lifts for transfers, were using slings that were faded, had loose strings, and in some cases, torn areas. These slings were not in good condition, as required by the facility's policy and manufacturer guidelines, which state that slings showing signs of wear should be immediately removed from use. Additionally, the facility did not obtain physician orders for mechanical lift transfers for the residents reviewed. This lack of documentation was noted for residents who were totally dependent on mechanical lifts, as indicated in their comprehensive care plans. The absence of physician orders for such critical equipment use could lead to improper handling and increased risk of injury during transfers. Interviews with staff, including a laundry aide and CNAs, confirmed that they were aware of the signs of wear on the slings and the potential risks associated with using damaged equipment. However, despite this awareness, the facility did not ensure that these slings were removed from service, as evidenced by the continued use of worn slings observed during the survey. The facility's policy and manufacturer guidelines clearly state that worn, frayed, or ripped slings should be discarded to prevent accidents, yet this was not adhered to, resulting in a deficiency in maintaining a safe environment for residents.
Failure to Conduct Timely Criminal History Check for DON
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation, specifically in the case of the Director of Nursing (DON). Upon review, it was found that the facility did not complete a criminal history check for the DON at the time of hire, which is a requirement according to the facility's policies. The DON was hired on April 8, 2024, but the criminal history check was not conducted until May 21, 2024. This oversight was identified during a record review and interviews with the Human Resources (HR) staff and the Administrator. The HR staff, who was responsible for conducting background checks, acknowledged the lapse and stated that she was not assigned HR duties until January 2024, despite starting at the facility in October 2023. She admitted to not knowing why the criminal history check for the DON was not completed as required. The Administrator confirmed that background checks are the responsibility of HR and should be completed within two days of an offer letter and before employment begins. The failure to conduct the criminal history check as per the facility's policy could potentially place residents at risk for abuse, neglect, and exploitation.
Failure to Properly Label Feeding Tube Bags
Penalty
Summary
The facility failed to ensure proper labeling of feeding tube bags for a resident who was dependent on enteral feeding. The resident, who had a history of hemiplegia, end-stage renal disease, and autistic disorder, was observed with a feeding tube bag that lacked essential labeling information such as the time it was hung and the initials of the staff member responsible. This oversight was noted during an observation where the feeding bag contained approximately 500 ml of formula, and the water bag was also missing a label. The lack of proper labeling could lead to the resident receiving old or expired feed, posing a risk to their nutritional status and overall health. Interviews with facility staff, including an LVN, ADON, DON, and the Administrator, revealed that the nursing staff were responsible for labeling the feeding bags. The LVN admitted to not labeling the bags correctly, acknowledging the potential risks of incorrect feedings or expired feedings. The ADON and DON confirmed that both feeding and water bags should be labeled with specific details, including the time and staff initials, to prevent the risk of administering old feedings. The facility's policy on feeding tube care emphasized the importance of adhering to clinical standards to prevent complications, which was not followed in this instance.
Failure to Maintain Oxygen Concentrator Filters
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents, as evidenced by the presence of dust buildup on the external filters of their oxygen concentrators. Resident #17, who has a history of COPD, congestive heart failure, myasthenia gravis, and pneumonia, was observed with a thick layer of dust on his oxygen concentrator's filter. Despite having a physician's order to clean the filter weekly, the resident could not recall the last time it was cleaned, indicating a lapse in the facility's adherence to the care plan. Similarly, Resident #34, who suffers from congestive heart failure and requires supplemental oxygen, was found with a dusty filter on his oxygen concentrator. Although the resident mentioned that he cleaned the filter himself every two weeks, the facility staff was responsible for this task according to the care plan. The resident's reliance on self-cleaning suggests a gap in the facility's maintenance routine. Interviews with facility staff revealed confusion and miscommunication regarding the responsibility for cleaning the oxygen concentrator filters. LVN A believed that maintenance was responsible for cleaning the filters, while the Maintenance Supervisor stated that he cleaned the filters monthly without keeping a log. The Director of Nursing and the Administrator provided conflicting information about the frequency and responsibility for cleaning the filters, highlighting a lack of clear protocol and oversight in ensuring the residents' respiratory equipment was maintained according to professional standards.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA C during the provision of incontinent care to Resident #12. During the care, CNA C did not sanitize or wash her hands after changing gloves, which is a critical step in preventing the transmission of infections. This oversight occurred despite the presence of RN B, who was also involved in the care process and adhered to hand hygiene protocols by sanitizing her hands between glove changes. Resident #12, who was involved in this incident, had significant medical conditions, including hemiplegia and hemiparesis following a cerebral infarction, gastrostomy status, end-stage renal disease, and autistic disorder. The resident was dependent on staff for all activities of daily living and was always incontinent of bowel and bladder, necessitating regular and careful personal care to prevent infections. Interviews with CNA C, the ADON, the DON, and the Administrator revealed a recognition of the importance of hand hygiene and the risks associated with non-compliance. CNA C acknowledged the lapse in hand hygiene, citing the absence of sanitizer and the inability to leave the resident unattended as reasons for the oversight. The facility's policy on hand hygiene, which emphasizes its role in preventing infection spread, was not followed in this instance, highlighting a deficiency in the facility's infection control practices.
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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 Huntsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Focused Care At Huntsville | 0.8 mi | ★★★★★ | 2 | 0 |
| Mrc Creekside | 2 mi | ★★★★★ | 5 | 0 |
| Willis Nursing And Rehabilitation Lp | 18.8 mi | ★★★★★ | 9 | 0 |
| River Pointe Of Trinity Healthcare And Rehabilitat | 19.1 mi | ★★★★★ | 1 | 0 |
| Trinity Rehabilitation & Healthcare Center | 19.8 mi | ★★★★★ | 37 | 3 |
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