Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mount Vernon Healthcare Center during CMS and state inspections, most recent first.
Unsafe and Unclean Facility Environment: Surveyors observed trash and debris in the parking lot, a wobbly front gate not secured in the concrete, and multiple resident rooms that were cluttered and had strong urine and body odor. The Administrator acknowledged the gate issue and stated clutter and deep cleaning concerns had already been identified in QAPI and were being addressed through ongoing room rotation and decluttering efforts.
Failure to Assess and Reevaluate Continued Use of a Mitten Restraint: A resident with dementia, trach status, and total ADL dependence wore a right-hand mitten restraint for safety after pulling out the trach tube. Staff followed the order to release the mitten every 2 hours, but the chart lacked an initial assessment and ongoing re-evaluation for continued restraint use, and the DON could not locate the original assessment.
Failure to provide routine grooming and nail care was identified for a resident who was totally dependent for ADLs, nonverbal due to trach status, and had advanced dementia, a contracted left hand, and a mitten restraint on the right hand. Surveyors observed long fingernails on both hands, no left-hand splint despite care plan and orders, and an odor in the room; the record showed bed baths but no documentation of hair washing or nail trimming, while staff gave conflicting statements about who provided nail care.
Failure to Apply Ordered Hand Splint: A resident with advanced dementia, trach status, and a contracted left hand was ordered to wear a left resting hand splint for 6 hours daily to maintain ROM and prevent worsening contractures. Staff observed the resident in bed without the splint in place, and interviews showed a CNA and an LPN believed nursing staff were responsible for applying it because they document the task, while the DON stated physician orders were expected to be followed.
An LPN provided trach care and suctioning for a resident with trach status, advanced dementia, COPD, dysphagia post stroke, and chronic respiratory failure, but did not explain the procedure, assess lung sounds before or after suctioning, or check oxygen saturation. The DON stated the facility expected nurses to follow its trach and suction policy and the Lippincott procedure standard for tracheostomy suctioning.
A dietary aide was observed packaging and dating salads in the kitchen without a hair net or beard guard. The aide stated he forgot to put on the beard guard, and the DON stated the facility expected all staff to wear appropriate head and beard coverings at all times in the kitchen. Facility policy required authorized personnel to wear appropriate head covering and to have facial hair properly restrained.
Surveyors found that kitchen staff failed to follow facility policies requiring all refrigerated foods to be covered, labeled, dated, and used within specified time frames. During a kitchen tour, they observed uncovered and undated cucumbers with white spots, cut green and red peppers with visible white spots and older storage dates, undated butter in an open wrapper, and pork chops leaking into a wet cardboard box. The Regional District Dietary Supervisor confirmed these findings, acknowledged that products should have been used before expiration, and stated there was no procedure or schedule for dietary staff to routinely check stored foods’ expiration dates, despite written policies and a food storage and retention guide specifying proper storage and time limits for animal, plant, and dairy products.
The facility failed to inform cognitively intact, registered-voter residents about a state election or assist them with voting, resulting in missed opportunities to exercise their right to vote. One resident reported waiting for an absentee ballot that never arrived and stated that no election information was provided, while two other residents said they were not approached about voting or made aware that voting was occurring, though they would have liked to participate. Staff interviews showed that no absentee ballots were issued, no voting opportunities were offered, and there was confusion between the Activities staff, SSD, and the Administrator about who was responsible for coordinating resident voting and election notifications.
Two cognitively intact, bedbound residents with multiple comorbidities, including CVA with hemiplegia, ESRD on dialysis, major depressive disorder, and mobility limitations, had documented preferences and care plans for in-room, one-to-one activities such as reading, chess, music, TV/movies, religious study, and conversation, yet reported that no staff had ever come to their rooms to engage them in such activities. Activity calendars were posted out of their visual range, and observations showed activity staff inviting other residents to group programs while not inviting these residents or providing alternative in-room activities. The Activities Director stated that residents needing one-to-one activities should receive twice-weekly 30-minute visits with documentation, but no activity records existed for these two residents, contrary to the facility’s policy that activities be geared to each resident’s needs and interests.
A resident with a history of cerebrovascular disease, hemiplegia, dysphagia, and GERD had a physician order for a daily 81 mg chewable aspirin. Instead, an LPN crushed an 81 mg delayed-release (enteric-coated) aspirin tablet, mixed it with applesauce, and administered it, contrary to the specific order for a chewable form and despite facility policy and manufacturer guidance not to crush enteric-coated medications. The DON confirmed that this type of aspirin should not be crushed, and facility policy required following manufacturer "do not crush" recommendations.
A resident with neuromuscular bladder dysfunction using an external catheter and urinary drainage bag was repeatedly observed with the drainage bag dragging on the floor after care by a CNA. Later, an LPN, when asked to check the resident’s positioning, lifted the drainage bag above bladder level, causing urine to back up in the tubing, then placed the full bag on the bed while repositioning the resident. During repositioning, the bag fell to the floor and the LPN stepped on it before directing that it be placed in a basin. These actions did not follow facility policy requiring the collection bag to remain dependent to the bladder to prevent urine from flowing back to the resident.
Surveyors found that medications in a medication room refrigerator were not maintained according to expiration-date requirements, including five expired bags of Fetroja IV antibiotic that remained in active storage and an opened Tuberculin vial that was not dated. An LPN reported that he was responsible for removing the Fetroja when new medication arrived but admitted he did not remove or return the expired bags to the pharmacy, and he did not know when the Tuberculin vial had been opened. The DON confirmed that medications should be removed when expired and that vials are to be dated when first opened, while facility policy addressed dating opened medications but did not specify procedures for handling expired medications.
Two residents on contact isolation or Enhanced Barrier Precautions (EBP) did not receive care in accordance with posted PPE requirements and facility policy. One resident with MRSA and multiple antimicrobial-resistant infections had contact isolation and EBP signage and an isolation cart with PPE at the door, yet an LPN entered and remained in the room without donning a gown or gloves, despite acknowledging the resident’s contact isolation status. Another resident on EBP related to a condom catheter had door signage directing staff to wear gowns and gloves for direct care, but a CNA twice provided dressing assistance and peri-care while wearing only gloves and no gown, later stating he had forgotten to don the gown. The DON confirmed the first resident should have been on contact isolation with gowns and gloves used upon room entry, and the Infection Preventionist confirmed that EBP was not appropriate for the first resident and that staff are expected to use gowns and gloves for residents on EBP during direct care, consistent with the facility’s EBP policy.
Unsafe and Unclean Facility Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents. Survey observations found trash and debris in the parking lot, including two face masks and one pair of used purple latex gloves, with litter throughout the parking lot and on the grass. The front entrance wrought iron gate was wobbly and not secured in the concrete on one side, creating an unsafe condition at the entrance. The Administrator was informed of the gate concern and acknowledged it was an issue. Inside the facility, several resident rooms were observed to be cluttered with personal property and items such as shopping bags under a bed, towels, wash cloths, and hospital gowns on a chair. Multiple rooms had signs indicating deep cleaning was scheduled, and some rooms had strong odors of urine, while one room also had a strong odor of body odor. During interview, the Administrator stated that clutter in resident rooms had already been identified in a QAPI meeting and that deep cleaning and decluttering were ongoing processes, with rooms being rotated on the deep cleaning schedule.
Failure to Assess and Reevaluate Continued Use of a Mitten Restraint
Penalty
Summary
The facility failed to ensure one resident was free from physical restraint use without proper assessment and re-evaluation for continued need. The resident was admitted with diagnoses including dysphagia post stroke, COPD, tracheostomy status, gastrostomy tube, dementia, neuromuscular dysfunction of bladder, chronic respiratory failure, generalized anxiety disorder, major depressive disorder, and GERD. The most recent MDS coded the resident with a BIMS score of 00 out of 15, and the resident was described as nonverbal due to trach status, totally dependent for all ADLs, bedbound, and contracted in the left hand. The resident wore a mitten restraint on the right hand because of incidents of pulling out the tracheostomy tube. During observation, the resident was seen in bed with the right hand mitten in place, and the clinical record showed an order to apply the mitten to the right hand and release it for 10 minutes every 2 hours as tolerated. The ADL/behavior monitoring documentation showed the mitten was used for safety, with each daily block documented as no behavior for April, May, and June 2026. Staff were observed following the order to remove the restraint every 2 hours for 10 minutes. Review of the record found no assessment or re-evaluation of the continued need for restraint use. When the DON and Administrator were asked for documentation of the initial evaluation and subsequent re-evaluation, the DON reported the resident had been in the facility since 2019 and the initial assessment could not be located. The record contained documentation of the resident pulling out the trach, but there was no formal assessment or re-evaluation for continued restraint use as required by facility policy.
Failure to Provide Routine Grooming and Nail Care
Penalty
Summary
Failure to provide necessary grooming and personal hygiene services was identified for a resident who was admitted with diagnoses including dysphagia post stroke, COPD, tracheostomy status, gastrostomy tube, dementia, neuromuscular dysfunction of bladder, chronic respiratory failure, generalized anxiety disorder, major depressive disorder, and GERD. The resident’s most recent MDS coded a BIMS score of 00 out of 15, and she was described as nonverbal due to trach status, unable to make needs known because of advanced dementia, totally dependent on staff for all ADL care, bedbound, and contracted in the left hand. She wore a mitten restraint on the right hand because of prior incidents of pulling out her tracheostomy tube. During observations, the resident was seen in bed with long fingernails on the left hand, no splint to the left hand despite care plan and orders, and later with long fingernails on both hands when the DON examined her hands. She was observed dressed in a t-shirt and incontinent brief, with a sheet not covering her legs, and an odor was noted in the room. The DON stated podiatry cuts her nails and later said the unit manager cuts the resident’s fingernails, while the clinical record showed 2 bed baths per week for April, May, and June 2026 with no documentation of hair washing or nail trimming. Facility policy stated routine nail hygiene and hair hygiene are part of regular grooming care.
Failure to Apply Ordered Hand Splint
Penalty
Summary
The facility failed to ensure that a resident received the ordered left hand splint for 6 hours per day to maintain range of motion and prevent worsening of contractures. The resident was admitted with diagnoses including dysphagia post stroke, COPD, tracheostomy status, gastrostomy tube, dementia, neuromuscular dysfunction of bladder, chronic respiratory failure, generalized anxiety disorder, major depressive disorder, and GERD. The most recent MDS coded the resident with a BIMS score of 00 out of 15, indicating she could not be evaluated. She was nonverbal due to trach status, had advanced dementia, was totally dependent on staff for all ADL care, and was bedbound with a contracted left hand. The clinical record included an order to wear the left resting hand splint from 10:00 AM to 4:00 PM every day and evening shift, with skin checks and removal for hygiene. During observations, the resident was seen in bed without the left hand splint in place, while the right hand mitten restraint remained on due to prior trach pulling. Staff interviews showed a CNA stated the nurse was supposed to put the splint on because the nurse signs it off in documentation, and an LPN stated nurses put the splints on and off because they are responsible for chart documentation. The DON stated the facility expectation was that physician orders are followed and splints are put on as ordered by the physician.
Tracheostomy Care and Suctioning Not Performed per Standard
Penalty
Summary
The facility failed to ensure that tracheostomy care was provided in accordance with standards of practice for one resident. The resident was admitted with diagnoses including dysphagia post stroke, COPD, tracheostomy status, gastrostomy tube, dementia, chronic respiratory failure, and other conditions. The resident had advanced dementia, was nonverbal due to trach status, totally dependent on staff for all ADLs, bedbound, and had a contracted left hand. She wore a mitten on her right hand because of prior incidents of pulling out her tracheostomy tube. During observation, an LPN performed trach care and suctioning by assembling equipment, performing hand hygiene, donning PPE, turning on suction, removing and cleaning the inner cannula, and inserting the suction cannula 4-6 inches into the trach before withdrawing it with suction applied. The LPN did not explain the procedure, assess lung sounds before or after suctioning, or check the resident's oxygen saturation. The DON stated the facility expected nurses to follow the trach and suction policy and procedure each time they suction and provide trach care, and identified the professional standard as Lippincott Procedures for tracheostomy suctioning.
Improper Hair and Beard Covering During Food Preparation
Penalty
Summary
The facility failed to prepare food in accordance with professional standards for food service safety for all residents receiving food from the kitchen when a dietary aide packaged and dated salads without wearing a hair net or beard guard. On 6/3/26 at 9:00 a.m., the dietary aide was observed packaging and dating salads in the kitchen without a hair net or beard guard. At 9:05 a.m., the dietary aide stated that he forgot to put on the beard guard. At 9:15 a.m., the Dietary Manager stated that the facility expected all staff to use appropriate head and beard coverings at all times in the kitchen. The facility policy, Authorized Kitchen Personnel Policy, stated that all authorized personnel must wear appropriate head covering while in the kitchen or production area, including facial hair properly restrained. On 6/4/26 during the end of day meeting, the Administrator was made aware of the concerns.
Failure to Label, Date, and Properly Store Refrigerated Food Items
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage practices when touring the kitchen refrigerator with the Regional District Dietary Supervisor (RDDS). They observed 18 uncovered cucumbers with white spots and soft texture stored in an uncovered, undated cardboard box; cut green peppers in a one‑pound plastic bag with visible white spots and dated 04/07/26; and cut red peppers in a one‑pound plastic bag with visible white spots and dated 04/07/26. They also found a half‑pound of butter in an open wrapper on a shelf with no date on the package, and six pork chops in a plastic bag inside a cardboard box where the corner of the box was wet from apparent leakage from the pork chop bag, with a date of 04/12/26. The RDDS confirmed these observations and stated that the dates on the food items represented storage dates. The RDDS further stated that butter should have been kept in closed packaging and dated by staff, and confirmed that all products should have been used before they expired. The RDDS also acknowledged there was no procedure or schedule in place for dietary staff to routinely check stored foods’ expiration dates. Review of the facility’s “Dining Services Policy and Procedure Manual – Food Storage: Cold Foods” showed that all food was required to be stored wrapped or in covered containers, labeled and dated, and arranged to prevent cross‑contamination. A separate “Food Storage and Retention Guide” indicated that animal and plant foods were to be kept up to seven days and butter/dairy products for one to three months. These observations and statements demonstrated that the facility did not follow its own policies for labeling, dating, covering, and timely use of stored food items.
Failure to Inform and Assist Residents With Voting in State Election
Penalty
Summary
The facility failed to honor residents' rights to self-determination and to exercise their right to vote by not informing or assisting registered voters with a special state election. Three cognitively intact residents, each identified on the facility’s list of registered voters, were not notified of the election or provided any opportunity to vote. One resident, with a BIMS score of 15/15, reported being aware that voting was occurring and had been waiting for an absentee ballot that never arrived, stating that the facility had not offered any information about the election and that he felt his right to vote was being denied. Another resident, with a BIMS score of 14/15, stated he was a registered voter, had seen commercials about the upcoming elections, but no staff approached him about voting and that he would have voted if asked. A third resident, also cognitively intact with a BIMS score of 14/15, reported not being made aware that voting was occurring and stated she would have liked to vote. Staff interviews confirmed that no arrangements were made to inform residents of the election or facilitate voting. The Activity Leader initially was unsure whether an election was occurring and later acknowledged that, to her knowledge, no information had been given to residents. The Activities Director, who maintained the list of registered voters and stated that most residents typically voted via absentee ballots, confirmed that no absentee ballots were issued and no other voting opportunities were offered, and indicated that voting activities were the responsibility of the Social Service Director (SSD). The Administrator stated that none of the registered voters had expressed interest in participating in the election and acknowledged that no arrangements were made to inform residents of the upcoming election. The SSD, in turn, stated that the Activities Director was responsible for resident voting, demonstrating confusion and lack of coordination regarding responsibility for ensuring residents could exercise their right to vote.
Failure to Provide Individualized One-to-One Activities for Bedbound Residents
Penalty
Summary
The facility failed to provide a program of activities to meet the individual needs and documented preferences of two cognitively intact, bedbound residents. One resident had diagnoses including cerebrovascular infarction with right-sided hemiplegia/hemiparesis, diabetes mellitus, neuromuscular bladder dysfunction, and major depression. His Activity Preferences Interview showed he preferred afternoon activities in his room or activity room and enjoyed audiobooks, reading/writing, TV/movies, radio, computer use, news, and religious activities/bible study. His care plan stated he was self-directed for activities and would participate in activities of choice or one-to-one. However, he reported that he did not attend activities outside his room because he was bedbound, could not read the posted activity calendar, and that no activity staff had ever come to his room to offer one-to-one activities. He stated he would like someone to play chess with him or read to him and that staff only entered his room to provide care, without spending time engaging him in activities. The second resident had diagnoses including end stage renal disease with dialysis, peripheral vascular disease, right above-knee amputation, and major depressive disorder, and was also cognitively intact. Her Activity Preferences Interview documented preferences for music, TV/movies, radio, reading books, cooking, computers, religious studies, keeping up with the news, and conversing with others, with a preference for morning or afternoon activities. Her care plan documented that she preferred to stay in her room for activities and would engage in one-to-one activities with staff. She reported being bedbound, disliking group activities such as bingo, and stated that no one had ever come to her room to offer one-to-one activities. Observations over multiple days showed both residents had activity calendars posted across the room, out of their view, and activity staff were seen inviting other residents to group activities but did not invite these two residents or provide in-room activities. The Activities Director stated that residents requiring one-to-one activities should receive visits at least twice weekly with documentation of the type and length of activity, but was unable to provide any activity documentation for these two residents, despite the facility policy stating the activity program is to be geared to each resident’s needs and interests.
Improper Crushing and Administration of Aspirin Contrary to Physician Order
Penalty
Summary
The facility failed to administer medication as ordered by the physician for one resident. The resident, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dysphagia following unspecified cerebrovascular disease, and gastro-esophageal reflux disease without esophagitis, had a physician order dated 02/12/22 for aspirin tablet chewable 81 mg to be given by mouth once daily. The physician also wrote on the order sheet that medications may be crushed unless contraindicated. During a medication administration observation, an LPN crushed an 81 mg delayed-release (enteric-coated) aspirin tablet, mixed it in applesauce, and administered it to the resident instead of the ordered chewable aspirin tablet. When interviewed, the DON stated that a delayed-release aspirin tablet should not be crushed and acknowledged that some medications can be crushed but not that one. The LPN reported administering the delayed-release aspirin in crushed form because she thought regular aspirin was better to crush than the chewable and that it was easier for the resident to swallow. Review of the facility’s policy on crushing medications indicated staff should follow manufacturer recommendations for medications labeled “do not crush.” Manufacturer information for enteric-coated aspirin 81 mg tablets stated they should not be crushed because the coating is designed to protect the stomach by allowing the tablet to pass through and dissolve later, and that crushing destroys this protection and may cause stomach issues.
Improper Management of Urinary Drainage Bag and Positioning
Penalty
Summary
The facility failed to ensure proper management of a urinary drainage system for a resident with neuromuscular dysfunction of the bladder who used an external catheter connected to a urinary drainage bag. The resident’s Significant Change MDS indicated use of an external catheter to a urinary drainage bag. On multiple observations during the same day, the resident’s urinary drainage bag was seen dragging on the floor, beginning at 12:16 PM after a CNA had finished providing care. Subsequent observations at 12:45 PM and 2:40 PM showed the drainage bag continued to drag on the floor, with approximately 300 milliliters of amber-colored urine in the bag. During an interview and concurrent observation at 2:50 PM, an LPN was asked to inspect the resident’s positioning. The urinary drainage bag was still on the floor. The LPN picked up the drainage bag and held it above the level of the resident’s bladder, causing urine in the tubing to back up toward the bladder, then placed the full drainage bag on the bed with the resident while pulling the resident up in bed. As the resident was repositioned, the drainage bag fell back onto the floor, and the LPN stepped on the bag while continuing to position the resident. Only afterward did the LPN instruct the CNA to place the drainage bag in a basin so it would not touch the floor. The LPN later stated he could not explain the concern about the drainage bag touching the floor or being held above the bladder area. The facility’s policy for external catheter care directed that the collection bag should remain dependent to the bladder to prevent urine from flowing back to the resident, which was not followed in this instance.
Expired Medications and Undated Tuberculin Vial Found in Medication Room Refrigerator
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage practices when observing the first-floor medication storage room refrigerator with an LPN. The refrigerator contained five bags of Fetroja, an IV antibiotic (2 gm/100 mg), that were expired but remained in active storage. One bag had a use-by date of 04/16/26 and four bags had use-by dates of 04/19/26. These medications had not been removed from the refrigerator or returned to the pharmacy despite being past their labeled use-by dates. During the same observation, surveyors found an opened box containing a vial of Tuberculin with the vial’s top removed, but neither the vial nor the box was dated to indicate when it had been opened. The LPN stated he was responsible for removing the Fetroja bags when new medication arrived on the 16th and 19th but acknowledged he did not remove or send them back to the pharmacy as required by policy. He also stated he did not open the Tuberculin vial and did not know its expiration once opened. The DON confirmed that the expired medication should not have been in the medication room and that staff are required to date vials when first opened. Review of the facility’s 2013 policies showed instructions to label the date opened on medications that expire (e.g., insulin, irrigation solutions) but did not address procedures for replacing or returning expired medications to the pharmacy.
Failure to Follow PPE Requirements for Contact Isolation and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failures in implementing appropriate infection prevention and control practices, specifically related to Enhanced Barrier Precautions (EBP) and contact isolation. One resident with diagnoses including a left hip open wound, resistance to multiple antimicrobial drugs, ESBL resistance, carbapenem resistance, and MRSA was ordered for contact isolation and had signage on the door indicating both contact isolation and EBP, along with instructions to don and doff PPE including a face mask. An isolation cart with masks, gowns, gloves, and hand sanitizer was available outside the room. Despite this, an LPN entered the resident’s room, remained inside for approximately five minutes with the door closed, and did not wear a gown or gloves. The LPN acknowledged awareness that the resident was on contact isolation for MRSA but stated he did not believe PPE was necessary because he did not go “all the way in” the room. The DON later confirmed that staff should wear gowns and gloves when entering this resident’s room according to the posted contact isolation signage and that the EBP signage on the door was incorrect for this resident. A second resident, cognitively intact per a recent MDS and with diagnoses including cerebrovascular infarction with right-sided hemiplegia and hemiparesis, diabetes mellitus, neuromuscular bladder dysfunction, and major depression, had physician orders for EBP related to use of a condom catheter. EBP signage on this resident’s door directed staff to wear gowns and gloves while providing direct care. During observations, a CNA assisted this resident with dressing while wearing only gloves and no gown, and on another occasion was observed having just completed peri-care for the resident while again wearing only gloves and no gown. The CNA stated he forgot to don the gown. The Infection Preventionist later stated that EBP should not have been used for the first resident with MRSA and other antimicrobial organisms and IV antibiotic therapy, and that staff were expected to wear gowns and gloves for residents on EBP when providing direct care. The facility’s EBP policy directs staff to use targeted gown and glove use during high-contact resident care activities such as dressing, bathing, transferring, providing hygiene, changing linens or briefs, device care, and wound care.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Alexandria
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| George Washington Health & Rehabilitation | 1.1 mi | ★★★★★ | 0 | 0 |
| Ft Washington Rehabilitation And Wellness Center | 4.9 mi | ★★★★★ | 35 | 0 |
| Woodbine Rehabilitation & Healthcare Center | 5.4 mi | ★★★★★ | 0 | 0 |
| Alexandria Rehabilitation And Healthcare Center | 6.2 mi | ★★★★★ | 0 | 0 |
| Belvoir Woods Health Care Center At The Fairfax | 6.4 mi | ★★★★★ | 14 | 0 |
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