Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Mountain Villa Nursing Center during CMS and state inspections, most recent first.
The facility failed to develop comprehensive, person-centered care plans for two residents by omitting key medical issues. One resident receiving Eliquis (apixaban) twice daily for bilateral lower extremity arterial occlusion did not have this anticoagulant therapy addressed in the care plan, and another resident with a documented diagnosis of type II DM did not have diabetes addressed in the care plan. The DON, Administrator, and MDS nurse all stated that care plans are intended to outline resident needs and guide staff care, and acknowledged that conditions such as DM and medications such as anticoagulants should be included. The MDS nurse reported responsibility for creating and revising care plans quarterly and as needed, with input from floor nurses, and all interviewees noted there had been no recent in-services on care planning, despite facility policy stating that care plans are to guide daily care routines and be available to staff.
The facility failed to maintain an effective training program for all staff when a night-shift LVN had no documented completion of required annual trainings in compliance and ethics, abuse, neglect and exploitation, and restraint reduction since 2018. HR confirmed that all staff, including nurses and CNAs, were required to complete annual trainings together, but this LVN’s record lacked evidence of those trainings. The DON reported that night-shift nurses were given trainings to read and sign and that she was responsible for monitoring completion, while the Administrator acknowledged his responsibility for ensuring all staff, regardless of shift, were current on required education and stated that lack of training in restraint reduction and abuse/neglect could result in staff not knowing how to proceed in such situations.
The facility failed to ensure accurate reconciliation and documentation of controlled substances on one medication cart when an LVN signed the narcotic count sheet for a shift change without proper verification and without a second nurse’s signature, contrary to facility policy requiring two licensed nurses to perform and document a physical inventory at each shift change. The DON and an RN confirmed that nurses were responsible for completing narcotic counts only at shift change, that the DON audited the sheets periodically, and that signing ahead of time could lead to residents not having access to medications and to drug diversion, but neither could recall the last in-service on narcotic count procedures.
Surveyors found that a medication cart contained a blister pack of Sertraline 100 mg with outdated instructions directing staff to administer it with a 50 mg tablet for a total of 150 mg, while the current physician order and EMAR required a total daily dose of 125 mg using a 100 mg and a 25 mg tablet for a resident with anxiety, major depressive disorder, and severe cognitive impairment. The medication aide reported she was responsible for updating blister pack labels to match the EMAR and to apply labels directing staff to follow EMAR instructions, but admitted she failed to update this label after the order change due to being distracted. The DON confirmed that medication aides are responsible for updating blister packs, that red stickers are used to direct staff to the EMAR, and that cart audits occur, but could not specify audit frequency or recall the last in-service, and the facility’s medication storage policy referenced random QA checks that did not prevent the mislabeled medication from remaining in use.
A resident with severe cognitive impairment and a cardiac pacemaker did not have the device or related care needs included in her comprehensive care plan. Staff interviews revealed reliance on MDS triggers and verbal communication rather than ensuring all significant medical conditions were documented, resulting in the omission of the pacemaker from the care plan.
The facility failed to implement policies to prevent abuse, neglect, and exploitation of residents, as well as misappropriation of property. A CNA's file lacked the required Employee Misconduct Registry (EMR) documentation upon hire, despite the facility's policy mandating such checks. The Secretary responsible for running EMRs confirmed the absence of the document in the file.
Two residents with severe cognitive impairments experienced disrespectful treatment during meal times, with staff removing their trays before they finished eating. This led to one resident feeling hungry and another unable to complete meals due to staff prioritizing dish cleaning. The administration was unaware of these incidents, and the facility lacked a policy to ensure residents had sufficient time to eat.
The facility failed to create comprehensive person-centered care plans for four residents, omitting critical information such as DNR code status and specific care needs. This oversight involved residents with severe cognitive impairments and various medical conditions, potentially affecting their care and well-being. Interviews with the MDS Coordinator and DON revealed a lack of emphasis on the importance of these care plans.
The facility did not ensure RN coverage for at least 8 consecutive hours daily on several occasions, as required by policy. This deficiency was due to challenges in hiring additional RNs, as stated by the DON. The lack of RN presence led to potential discontinuity of care for residents, as acknowledged by the ADMN.
A facility reported a 12% medication error rate involving two residents. One resident received an incorrect dose of calcium and vitamin D due to confusion over medication directions. Another resident's blood pressure medications were withheld without proper documentation or physician notification, based on past instructions rather than current orders.
The facility did not follow the prescribed menu for residents on a pureed diet, failing to provide a dinner roll and ice cream as listed. This affected three residents with cognitive impairments and mechanically altered diets, potentially impacting their nutritional intake. Staff interviews revealed a lack of communication and oversight in ensuring menu compliance.
The facility was found deficient in food safety and hand hygiene practices. Observations revealed that food items in storage were not properly labeled or dated, and staff failed to perform hand hygiene or wear gloves while handling food. The Dietary Manager admitted to not enforcing these policies, and the Administrator and Dietician acknowledged the risk of cross-contamination and illness among residents due to these lapses.
The facility failed to maintain an effective infection prevention and control program, as observed in the actions of CNA B and LVN D. CNA B did not remove gloves or perform hand hygiene at appropriate times during incontinent care, while LVN D did not sanitize the insulin flex pen before use and failed to perform hand hygiene between glove changes during wound care. These actions were contrary to the facility's infection control policies, placing residents at risk for infections.
A resident with severe cognitive impairment and mobility issues was found without her call light within reach on two occasions, contrary to her care plan. The DON and ADMN acknowledged that staff oversight led to this deficiency, which could result in unmet needs for the resident.
The facility did not complete baseline care plans within 48 hours for two residents with severe cognitive impairments and multiple health conditions. The MDS Coordinator, responsible for these plans, was delayed due to additional duties, and both she and the DON did not perceive an impact on residents. This oversight contravenes the facility's policy requiring a preliminary care plan within 24 hours of admission.
Failure to Care Plan Anticoagulant Therapy and Diabetes Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents with significant medical needs. For one resident, an older female with a diagnosis of atherosclerotic heart disease and severe cognitive impairment (BIMS score of 4), records showed she had been prescribed Eliquis (apixaban) 2.5 mg orally twice daily for bilateral lower extremity arterial occlusion since February 2024. Despite this ongoing anticoagulant therapy being documented in the medication administration record and order summary, the resident’s care plan revised in September 2024 did not address her blood thinner medication prescription. For another resident, an older male with intact cognition (BIMS score of 15), the history and physical documented a diagnosis of type II diabetes mellitus, but his care plan revised in September 2025 did not address this diagnosis. In interviews, the DON, Administrator, and MDS nurse each stated that the purpose of the care plan is to detail resident needs and guide staff in providing care, and all acknowledged that diagnoses such as diabetes and medications such as anticoagulants should be included in the care plan. They also reported that the MDS nurse is responsible for creating and revising care plans quarterly and as needed, that floor nurses are expected to communicate updates, and that there had been no recent in-services regarding care plans. Facility policy states that the care plan is to be used in developing residents’ daily care routines and must be available to staff responsible for providing care or services.
Failure to Ensure Required Annual Staff Training for Night-Shift LVN
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, as evidenced by missing required annual trainings for one of six staff reviewed, an LVN working night shift. Review of this LVN’s personnel record showed that annual training did not include evidence of training consistent with their expected role, specifically in the areas of compliance and ethics, abuse, neglect and exploitation, and restraint reduction. Record review further showed that the LVN’s last annual trainings in these topics were completed in September 2018, with no subsequent documentation of completion. In interviews, HR staff confirmed that all staff, including nurses and CNAs, were required to complete annual trainings and that this LVN’s required trainings had not been completed since 2018. HR stated that staff usually complete annual trainings together at one time and referred to the LVN’s direct supervisor for why this was not done. The DON stated that the LVN was a night shift nurse and that trainings for night shift nurses were left for them to read and sign, and that she was responsible for ensuring nursing staff completed annual trainings by reviewing who had signed. The Administrator stated he was responsible for ensuring staff were up to date with annual trainings, acknowledged that all staff were required to complete them regardless of shift, and noted that night shift nurses were harder to reach. He stated that staff not being up to date on trainings such as restraint reduction and abuse and neglect could lead to staff not knowing how to properly proceed in events involving restraint or identifying abuse and neglect. The facility’s Staff Development Program policy required all personnel to participate in initial orientation and regularly scheduled in-service training classes.
Failure to Accurately Reconcile and Document Controlled Substances
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of drugs and biologicals, and failed to maintain an established system for accurate reconciliation of controlled substances on one of two medication carts (East Wing). Record review of the Controlled Substance Shift Change Audit Record for the East Wing medication cart dated 12/03/25 showed only one nurse’s signature documented for the 2:00 PM shift change. During interview, the LVN who signed the form stated she had signed it at the 2:00 PM shift change but could not explain why it appeared to have been signed ahead of time. The facility’s policy required a physical inventory of all Schedule II controlled medications at each shift change or when keys were rendered, to be conducted by two licensed nurses and documented on the controlled substances accountability record or verification of controlled substances count report. In interviews, the DON stated that nurses were responsible for performing the narcotic count and signing the form during the change of shift only after the count was completed, and acknowledged that signing ahead of time posed a risk for drug diversion and residents not having access to their medications. The DON was unable to recall the last in-service regarding narcotic counts and stated she monitored the count sheets up to twice weekly. An RN similarly stated that the narcotic count sheet was used by nurses to ensure accuracy of medications counted during shift change, that the DON was responsible for auditing the sheets as often as possible, and that signing the count sheet ahead of time could result in residents not having medications available and posed a risk of drug diversion. The RN was also unable to recall the last in-service on this process.
Mislabeled Sertraline Blister Pack Not Updated to Match EMAR Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically on one medication cart used by a medication aide. For one resident, a male with a history of anxiety and major depressive disorder and severe cognitive impairment (BIMS score of 4), the physician’s order and EMAR reflected a current dose of Sertraline 125 mg daily, consisting of a 100 mg tablet plus a 25 mg tablet. The resident’s care plan directed nursing staff to administer Sertraline as ordered by the physician, and the MAR for the month confirmed that the resident had been receiving 125 mg per the current order. However, during observation of the medication cart, the blister pack label for the resident’s Sertraline 100 mg still instructed staff to give one 100 mg tablet with a 50 mg tablet for a total dose of 150 mg, which did not match the current EMAR instructions. During interviews, the medication aide stated that medication aides and nursing staff were responsible for updating blister pack labels to match the EMAR, and that she had been trained to notify the floor nurse when blister pack instructions and EMAR orders did not match so the nurse could reconcile the medications. She also stated she was trained to add a label directing staff to refer to the EMAR for the most current physician orders, and that she audited her cart one to two times per week, while nurses also audited carts but she was unsure of their frequency. The medication aide acknowledged she failed to update the Sertraline label earlier in the week because she became distracted with other duties and could not recall the last in-service on medication labeling. The DON confirmed that medication aides were responsible for updating blister packs to reflect EMAR instructions, that a red sticker was used to direct staff to the EMAR, and that medication aides audited carts weekly with nurses auditing less frequently, though she could not provide a specific timeframe or recall the last in-service. The facility’s medication storage policy referenced random quality assurance checks and corrective action when problems are identified, but did not prevent the mislabeled Sertraline blister pack from remaining on the cart.
Failure to Include Cardiac Pacemaker in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting the presence of a cardiac pacemaker from the care plan for one resident. The resident, an elderly female with severe cognitive impairment and a documented diagnosis of a cardiac pacemaker, did not have this device or its associated care needs reflected in her comprehensive care plan, despite it being listed in her medical records and MDS assessment. The care plan dated 3/1/25 did not mention the pacemaker, and staff interviews confirmed that this omission was not identified or addressed. Interviews with nursing staff, including an LVN, DON, and ADON, revealed that the care planning process relied heavily on MDS triggers and verbal communication among staff, rather than ensuring all significant medical devices and conditions were documented in the care plan. The LVN was unaware of the omission, and both the DON and ADON acknowledged that the pacemaker was not included because it was not triggered by the MDS, despite recognizing the importance of including it for continuity of care. The facility's policy required comprehensive care plans with measurable objectives and timetables, but this was not followed in the case of the resident with a pacemaker.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified during the review of the employee files for a Certified Nursing Assistant (CNA A). The facility did not have CNA A's Employee Misconduct Registry (EMR) on file upon hire, which is a critical component of the screening process to ensure the safety and well-being of residents. The facility's Abuse and Neglect policy, which was not dated, requires all personnel to be screened before hiring, including criminal history records, background checks, and reference checks. Additionally, the policy mandates that the licensing board be contacted for all licensed personnel to determine if any sanctions have been assessed against the applicant's license, and that all nurse aides' conduct be verified through the EMR. However, a review of CNA A's employee file revealed that while her criminal background check dated the same day as her hire showed no findings, there was no EMR noted in her file. An interview with the Secretary responsible for running EMRs upon hire revealed that although she had run CNA A's EMR, it was not found in the file, and the Administrator was responsible for ensuring its completion and filing.
Failure to Respect Resident Meal Times
Penalty
Summary
The facility failed to treat two residents with respect and dignity, as observed during meal times. Resident #32 experienced having his meal tray removed before he finished eating, despite expressing his dissatisfaction. This occurred during both breakfast and lunch, leading to the resident feeling hungry. A CNA witnessed these actions and reported that the resident was left without sufficient food. Additionally, Resident #3, who ate in his room, reported that staff would remove his meal tray before he finished, citing the need to clean dishes. This resulted in him not completing his meals, and he expressed his concerns to staff without any resolution. Both residents had severe cognitive impairments, as indicated by their BIMS scores. The facility's administration was unaware of these incidents until the survey, and the dietician emphasized the importance of allowing residents ample time to eat to ensure they receive necessary nutrition. The facility admitted to not having a policy in place to address this issue, which could potentially impact the residents' quality of life and nutritional intake.
Failure to Develop Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for four residents, which did not address their specific medical, nursing, mental, and psychosocial needs. Resident #2's care plan lacked documentation of her DNR code status and the use of a fall mat, despite her severe cognitive impairment and history of falls. Resident #27's care plan also omitted her DNR code status and did not include PASRR services, which are essential for her diagnoses of type 2 diabetes, paranoid schizophrenia, and major depressive disorder. Resident #28's care plan was not resident-specific or person-centered, failing to address his intact cognition and specific needs related to his osteoarthritis. Similarly, Resident #36's care plan was not tailored to his severe cognitive impairment and other diagnoses, such as visual hallucinations and insomnia. The care plan did not specify the necessary assistance for activities of daily living, such as bathing and showering, which he required due to his self-care performance deficit. Interviews with the MDS Coordinator and the DON revealed a lack of understanding and importance placed on comprehensive care plans. The MDS Coordinator believed that code status did not need to be included in the care plans, as it was already in the orders and flagged in the electronic chart. The DON expressed that care plans were merely paperwork and did not believe the missing information affected the residents. This oversight in care planning could potentially place residents at risk of not receiving appropriate care and services to maintain their well-being.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, seven days a week, on five specific dates within a 91-day review period. This deficiency was identified through a review of the facility's Direct Care Staff Daily Report, which showed no evidence of RN coverage on the specified dates. Interviews with the Director of Nursing (DON) revealed that while she was on call during weekends and could be contacted if needed, there were instances when no RN was physically present. The DON attributed the lack of coverage to difficulties in hiring additional RNs. The Administrator (ADMN) confirmed the expectation of having 8 hours of RN coverage daily and acknowledged the potential impact on residents, citing discontinuity of care as a concern. However, the ADMN did not provide a specific reason for the failure to maintain the required RN coverage. The facility's policy, dated June 26, 2024, mandates 7-day RN coverage, yet the facility did not adhere to this policy on the identified dates, placing residents at risk due to the absence of an RN to manage healthcare needs and oversee direct care staff.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 12% due to three errors out of 25 opportunities. This involved two residents, one of whom received an incorrect dose of calcium and vitamin D, while the other had blood pressure medications withheld without proper documentation or physician notification. These errors were identified through observations, interviews, and record reviews. For the first resident, the medication administration error involved the incorrect dosage of calcium and vitamin D. The resident was supposed to receive two tablets of Citracal Maximum Oral Tablet 315-6.25 mg-mcg twice a day, but the medication aide administered two tablets of a different dosage, Calcium 630mg - Vitamin D 12.5mcg, crushed and mixed with water. The medication aide admitted to the error, citing confusion over the directions and the availability of the medication. The second resident's issue involved the withholding of blood pressure medications, amlodipine besylate and olmesartan medoxomil, without documented hold parameters or physician orders. The medications were held based on a blood pressure reading and past instructions from a nurse practitioner, but without current orders specifying such actions. The facility's Director of Nursing stated that the medications were held per nursing judgment, and the physician was not notified, as the facility did not frequently contact doctors for such issues.
Failure to Follow Prescribed Menu for Pureed Diets
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents on a pureed diet, specifically for three residents who were observed during lunch meals. These residents, who were on a high-calorie, pureed texture diet, did not receive the dinner roll and ice cream as listed on the menu for two consecutive days. This oversight was noted during observations and interviews, where it was confirmed that the menu items were not provided on the pureed diet trays. The residents involved had varying levels of cognitive impairment and were on mechanically altered diets due to their nutritional needs. Their care plans emphasized the importance of maintaining adequate nutritional status, with interventions to provide and serve the diet as ordered. However, the facility's failure to include the menu items as prescribed could potentially impact the residents' nutritional intake, as noted by the facility's administration and dietician. Interviews with staff, including a CNA and the dietician, revealed a lack of communication and oversight in ensuring that residents received all items listed on the menu. The dietician emphasized the importance of serving everything on the menu to maintain a balanced diet and nutritional value, even for residents with lower cognitive abilities. The facility's policy on therapeutic diets highlighted the need to serve diets according to doctor's orders and the resident's needs, which was not followed in this instance.
Food Safety and Hand Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. The deficiencies included the lack of proper labeling and dating of food items in the kitchen's freezer, refrigerator, and dry storage areas. Specific items such as beneprotein powder, orange juice, ReaLemon juice, chicken noodle soup, mixed vegetables, milk, apples, jalapenos, lemons, broccoli, celery, bell peppers, cucumbers, lettuce, tomatoes, and bread were found without received or opened dates. This oversight was acknowledged by the Dietary Manager (DM), who admitted to not enforcing the dating policy, believing it unnecessary due to the quick usage of products. Additionally, the facility failed to ensure proper hand hygiene practices among staff handling food. An observation noted that a dietary aide did not perform hand hygiene or wear gloves while preparing food for resident lunch service. The DM admitted to not providing in-service training for handwashing, relying instead on posted instructions. The Administrator (ADMN) and Dietician both expressed expectations for compliance with hand hygiene policies, acknowledging the risk of cross-contamination and potential illness among residents due to these lapses. Interviews with the DM, ADMN, and Dietician revealed a lack of monitoring and enforcement of food safety and hand hygiene policies. The DM was unable to specify how often staff were monitored for compliance, and the ADMN admitted unfamiliarity with kitchen policies. The Dietician emphasized the importance of proper training and monitoring to prevent cross-contamination. The facility's policy and procedure manual, as well as external food safety guidelines, were reviewed, highlighting the necessity of proper food labeling, storage, and hand hygiene to prevent contamination and ensure resident safety.
Infection Control Deficiencies in Staff Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two staff members, CNA B and LVN D, during observed care procedures. CNA B did not remove gloves or perform hand hygiene at the appropriate times while providing incontinent care to a resident. After assisting the resident with changing clothes and removing a soiled brief, CNA B left the resident's room with gloved hands and trash, only removing the gloves and performing hand hygiene after disposing of the trash in the shower room. LVN D was observed administering insulin using a multi-dose flex pen without sanitizing the rubber tip of the pen before attaching a new needle. During wound care, LVN D failed to perform hand hygiene between glove changes while treating wounds on a resident's ankles. Although LVN D acknowledged the oversight, she attributed it to nervousness from being observed. The facility's Director of Nursing (DON) expressed expectations for proper sanitization and hand hygiene practices, noting that failure to follow these procedures could lead to infection risks. The facility's policies on hand hygiene, insulin administration, and incontinent care were reviewed, revealing specific guidelines that were not adhered to by the staff. The policies emphasized the importance of handwashing and sanitizing procedures to prevent the spread of infections. Despite these guidelines, the observed deficiencies in infection control practices placed residents at risk for unnecessary infections.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident, specifically by not ensuring that the resident's call light was within reach. This deficiency was identified during observations and interviews conducted by surveyors. The resident in question, an elderly female with severe cognitive impairment and mobility issues, was observed on two separate occasions with the call light hanging on the wall at the foot of her bed, out of her reach. The resident's care plan explicitly stated that the call light should be within reach and that she required prompt assistance. Interviews with the Director of Nursing (DON) and the Administrator (ADMN) revealed that the nursing staff and CNAs were responsible for ensuring call lights were accessible to residents. Both the DON and ADMN acknowledged that the failure to place the call light within reach could result in unmet needs for the resident. The DON attributed the oversight to staff forgetting to check the call light placement, while the ADMN emphasized the importance of monitoring staff to prevent such failures. The facility's policy on call lights also stipulated that each resident should have a call light within reach.
Failure to Develop Timely Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for two residents, which is a requirement to ensure effective and person-centered care. Resident #46, a male with severe cognitive impairment and multiple diagnoses including chronic kidney disease and Type 2 diabetes, did not have a baseline care plan completed. Similarly, Resident #198, also with severe cognitive impairment and conditions such as Alzheimer's disease and prostate cancer, lacked a baseline care plan. This oversight was identified through record reviews and interviews. The MDS Coordinator, responsible for completing these care plans, attributed the delay to her additional duties of working the floor, which took precedence over her care planning responsibilities. The Director of Nursing (DON) acknowledged the MDS Coordinator's role in care plan completion but did not provide a reason for the failure. Both the MDS Coordinator and the DON expressed that they did not perceive an impact on residents due to the absence of baseline care plans. The facility's policy mandates a preliminary care plan within 24 hours of admission, which was not adhered to in these cases.
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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 El Paso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nazareth Living Care Center | 2.1 mi | ★★★★★ | 19 | 0 |
| Mountain View Health & Rehabilitation | 2.6 mi | ★★★★★ | 31 | 2 |
| Grace Pointe Wellness Center | 3.2 mi | ★★★★★ | 22 | 0 |
| The Montevista At Coronado | 5 mi | — | 0 | 0 |
| Franklin Heights Nursing & Rehabilitation | 5.6 mi | ★★★★★ | 9 | 0 |
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