Shepherd Of The Valley Rehabilitation And Wellness
Inspection history, citations, penalties and survey trends for this long-term care facility in Casper, Wyoming.
- Location
- 60 Magnolia St, Casper, Wyoming 82604
- CMS Provider Number
- 535042
- Inspections on file
- 39
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Shepherd Of The Valley Rehabilitation And Wellness during CMS and state inspections, most recent first.
A resident who was cognitively intact but dependent for transfers and required a full body mechanical lift was being moved from bed to a recliner by two aides when a sling shoulder strap detached from the lift, causing a fall. Staff and witness statements confirmed that the lift in use lacked safety clips on the spreader bar, despite manufacturer instructions requiring safety clips to be present and properly used. The DON acknowledged that safety clips had been removed from the lifts because they were viewed as ineffective. The resident sustained a cervical fracture and subsequently went into cardiac arrest with death pronounced the same day, and the situation was determined to be immediate jeopardy.
Surveyors found that staff failed to follow infection prevention practices for urinal use and maintenance for three residents. One resident with severe cognitive impairment and multiple comorbidities had a urinal containing urine with visible discoloration and dried residue that was not dated. Two urinals for another resident were still in place more than a month after the date written on them, and a third resident’s urinal showed staining and was not labeled with a date. CNAs reported that urinals were typically changed monthly and as needed, while an LPN and the infection preventionist stated that soiled urinals should be discarded and replaced, and that urinals should be labeled and replaced at least monthly. The DON confirmed urinals should be replaced when visibly soiled and acknowledged there were no written facility policies governing urinal use.
A resident with severe cognitive impairment and a history of hip fracture, stroke, anxiety, and depression had a care plan indicating a preference for twice-weekly baths and a need for maximum assist with bathing. Bathing records showed the resident initially received showers twice weekly, but the frequency was later reduced to once weekly after the resident moved to another unit, without documented reassessment of bathing preferences. The administrator acknowledged that preferences should have been reassessed after the move, while bath aides reported that bathing schedules are generally maintained and that they would ask new residents about their preferences. The current bathing schedule and medical record confirmed the resident was only scheduled for weekly showers, with no documented reevaluation or change in the care plan to support the reduced frequency.
A resident with moderately impaired cognition, dementia, depression, cancer, identified fall risk, and risk for skin breakdown was care planned to have the call light kept within reach, but surveyors observed the resident seated in a recliner with the call light out of reach on multiple occasions. The resident did not know where the call light was, had a wet brief, and could not request assistance, which was also confirmed by the resident’s representative, who noted the resident was covered with a blanket and not wearing pants underneath. A guest ultimately activated the call light, after which a CNA responded and removed soiled linens. The DON stated staff are expected to ensure residents have access to the call light and needed items when left alone, while the NHA acknowledged there was no facility policy on call light use.
A resident with severe cognitive impairment and wandering behaviors entered another resident's room and was physically struck in the nose, resulting in a bloody nose. The resident who struck admitted to the action, and the incident was confirmed by staff and the DON. This event demonstrates a failure to protect a resident from physical abuse by another resident.
Two residents with surgical wounds experienced deficiencies in physician notification and timely implementation of treatment orders. One resident suffered actual harm and required additional surgery after the facility discontinued a wound vac without notifying the orthopedic surgeon. Another resident experienced a delay in wound care and antibiotic therapy due to failure to update physician orders, with the physician not notified of the delay. The facility did not follow its own policy for physician notification and timely care.
Three residents experienced deficiencies in care, including delayed wound assessment and treatment, failure to promptly implement physician orders for wound care and antibiotics, and inadequate neurological monitoring after a fall. One resident was hospitalized for sepsis after a wound worsened without timely intervention or family notification, another had a delay in starting prescribed wound care and antibiotics, and a third did not receive required neuro checks after a fall resulting in a nasal fracture.
A resident with a surgical wound and infection did not receive wound vac care as ordered by the surgeon. The wound vac was discontinued by facility staff without notifying the surgeon, leading to wound deterioration and the need for additional surgical intervention. Documentation showed improper wound vac application and lack of timely communication with the surgical team.
The facility failed to meet the activity needs of four residents, who expressed desires for specific activities but were not adequately informed or engaged. Residents participated minimally in independent activities, with limited group activity involvement due to staffing shortages and unappealing options.
The facility experienced staffing shortages, leading to unmet care needs and incomplete restorative programs for residents. Interviews revealed high CNA turnover and delayed responses to call lights. Discrepancies in bathing records were found, with showers documented by the DON not supported by bath schedule logs. The lack of restorative nursing was due to staff being reassigned to cover open shifts, and the East Station Bath Schedule logs were not part of official records.
The facility failed to identify and monitor target symptoms for residents receiving psychotropic medications. A resident with severe cognitive impairment and multiple diagnoses was on several psychotropic drugs without evidence of monitoring for effectiveness. This issue was also found in other residents with similar conditions, indicating a pattern of non-compliance with the facility's policy on psychotropic drug use.
The facility failed to label and date insulin pens in two medication storage areas. Observations revealed several opened insulin pens without dates. Interviews with an RN and the DON confirmed the requirement for labeling opened insulin pens. The facility's policy mandates dating multi-dose vials upon opening and discarding them within 28 days unless specified otherwise.
The facility failed to accurately document bathing records for three residents, leading to discrepancies between initial and updated records. Interviews revealed that the system was updated with information from bath schedule logs after records were requested, and the responsible staff member was no longer employed. The administrator confirmed that these logs were not part of official records, highlighting a deficiency in documentation practices.
The facility failed to provide consistent restorative nursing care to two residents, leading to a decline in their ability to perform activities of daily living. One resident, who was cognitively intact, reported a decline in mobility due to the lack of restorative care, while another resident with severe cognitive impairment experienced inconsistent delivery of restorative programs. The deficiency was attributed to staffing shortages, with restorative aides being reassigned to cover open shifts.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a gastric tube. An RN was observed providing high-contact care without wearing a gown, despite EBP signage indicating the need for gowns and gloves. Staff interviews revealed a lack of awareness about EBP requirements, and the facility's policy, which mandates gowns and gloves for high-contact care, was not adhered to.
A resident with severely impaired cognitive skills and non-Alzheimer's dementia was physically abused by another resident with moderate impairment and a history of violent comments. The altercation resulted in the victim sustaining a nasal bone fracture after being punched in the face. The incident was witnessed by a CNA student, highlighting a failure to enforce the facility's abuse prevention policy.
A resident with moderate cognitive impairment and a history of making violent comments was involved in two physical altercations with another resident, resulting in injury. The care plan was updated to include distraction techniques but failed to address the resident's physical aggression, as confirmed by the DON.
A resident with acute respiratory symptoms was not tested for COVID-19 despite exhibiting symptoms and the presence of COVID-19 in the facility. Staff interviews revealed a failure to adhere to infection prevention protocols, as the resident's representative had to bring a test from outside to confirm the infection. The facility's policy required immediate testing for respiratory symptoms, but this was not followed.
A resident with moderate cognitive impairment and enteritis experienced multiple episodes of vomiting and dehydration, but the facility failed to notify the physician or reassess the condition promptly. The resident was transported to the hospital via facility van without healthcare staff, leading to a collapse and death in the emergency room waiting area.
Failure to Use Required Safety Clips on Mechanical Lift Resulting in Resident Fall and Cervical Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe staff practices and safe working conditions when using a full body mechanical lift for a resident who was dependent for transfers. The resident had a BIMS score of 15/15, indicating intact cognition, and medical diagnoses including morbid obesity, heart failure, and renal insufficiency, and required a full body mechanical lift for transfers. On the day of the incident, the resident was being transferred from bed to a recliner by two aides using a full body mechanical lift when the left shoulder strap of the sling came loose from the lift, causing the resident to fall to the floor. Witness documentation and staff interviews indicated the resident was found face down on the floor with legs over one leg of the lift, with all but one sling strap still attached. The incident report concluded that the resident had a tendency to shift weight and reposition while in the sling and that the sling strap likely came up on one side and then came off the lift. Further investigation showed that the mechanical lift in use at the time of the fall did not have safety clips on the spreader bar, as confirmed by both aides involved in the transfer and by an RN who responded to the incident. The RN identified the specific model used and confirmed that safety clips were not present at the time of the fall. A laminated Quick Reference Guide attached to the same model of lift, and the manufacturer’s Quick Reference Guide provided by the DON, both instructed staff to ensure safety clips on the spreader bar are in position after the sling is applied and to check that safety clips are present and used properly. The DON reported that safety clips had been removed at some point because they would come off and were considered ineffective. Based on the failure to follow manufacturer instructions for use of safety clips on the mechanical lift, the resident fell from the lift and sustained a mildly displaced fracture of the left C2 transverse process with extension into the C2 vertebral body, and later went into cardiac arrest with death pronounced the same day. This failure was determined to constitute immediate jeopardy.
Failure to Implement Proper Urinal Cleaning and Replacement Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to the use and maintenance of urinals for three sampled residents. One resident with severe cognitive impairment, cancer, depression, non-Alzheimer’s dementia, lower extremity impairment, who was wheelchair bound and required substantial to maximal assistance with toileting hygiene, was observed with a urinal hanging from a trash can next to a recliner that contained approximately 100 milliliters of amber-colored urine. The urinal showed dark blue and black discoloration inside and a dried yellow substance around the opening, and it was not labeled with a date. A CNA stated that residents’ urinals were emptied every two hours and replaced monthly, and later confirmed that this urinal was not dated and appeared discolored and soiled. Additional observations showed two empty urinals dated more than a month earlier hanging from a trash can next to another resident’s bed, with a CNA confirming they had not been replaced after one month of use. Another resident’s urinal was observed hanging from a nightstand, empty but with yellow, amber, and dark blue staining inside, and it was not dated; a CNA confirmed the urinal appeared soiled and undated and reported that urinals were changed monthly and as needed. An LPN stated staff were expected to discard soiled urinals and replace them when they appeared soiled. The infection preventionist reported that staff were expected to label urinals and replace them at least monthly or when visibly soiled, and the DON confirmed urinals should have been replaced when visibly soiled and acknowledged there were no facility policies regarding urinals.
Failure to Maintain Resident’s Preferred Bathing Frequency After Unit Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s activities of daily living, specifically bathing, according to the resident’s assessed needs and stated preferences. A quarterly MDS dated 1/23/26 for resident #11 showed a BIMS score of 3/15, indicating severe cognitive impairment, and diagnoses including a history of hip fracture, stroke, anxiety, and depression. The care plan dated 10/24/25 documented that the resident preferred bathing twice a week and required maximum assistance with bathing and showering. Review of the bathing record from 12/10/25 through 1/6/25 showed the resident received showers twice weekly until 1/14/26, when the frequency was reduced to once weekly. The administrator stated on 3/12/26 that the resident had moved from another unit on 12/30/25 and that shower preferences should have been reassessed and had changed, but no evidence of such reassessment was found. Bath aide interviews indicated that bathing schedules were expected to be maintained when residents moved units and that staff would typically ask new residents about their bathing preferences. The current bathing schedule and medical record confirmed the resident was scheduled for and receiving only weekly showers, with no documented reevaluation of preferences or change in the bathing schedule.
Failure to Ensure Call Light Accessibility and Supervision for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance devices to prevent accidents for one resident with moderately impaired cognition and multiple diagnoses, including non-Alzheimer’s dementia, depression, and cancer. The admission MDS showed a BIMS score of 12/15 and the care plan, last revised on 11/19/25, identified the resident as a moderate fall risk related to confusion, gait and balance problems, and psychoactive drug use, with an intervention initiated on 11/25/24 to ensure the call light was within reach. A Braden Scale assessment on 1/2/26 scored the resident at 16/23, indicating risk for skin breakdown. Despite these identified needs and care plan interventions, observations on 1/28/26 at 9:55 AM and 10:35 AM showed the resident seated in a recliner at the foot of the bed with the call light located at the head of the bed and not within reach, while the resident’s lower body was covered with a blanket. Further observations and interviews on 1/28/26 showed the resident did not know where the call light was and stated it “should be around here somewhere.” At 11:33 AM, the resident’s brief was confirmed to be wet, and the resident reported being unable to request assistance because the call light was not accessible. The resident’s representative also observed that the resident’s brief was wet, the resident was covered with a blanket without pants underneath, and the call light had not been within reach to request help. At 11:48 AM, the call light was activated by the resident’s guest, and at 11:53 AM a CNA answered the call light, closed the door, left the room, returned with a clean blanket, and exited at 12:04 PM with two bags of soiled linens. The DON later confirmed that staff are expected, when leaving a resident alone, to set the resident up with the call light and other needs and perform hand hygiene, and the NHA reported that the facility did not have a policy on call light use.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment, wandering behaviors, and diagnoses including encephalopathy and agitation was involved in an incident where they entered another resident's room in the memory care unit. The resident whose room was entered asked the wandering resident to leave, and when this did not occur, physically struck the wandering resident in the nose, resulting in a bloody nose. The incident was documented in the facility's records, and the resident who was struck was able to stop the bleeding on their own. Interviews confirmed that the resident who struck the other admitted to the action, and the event was reported to the affected resident's representative. Staff interviews revealed that the assessment following the altercation confirmed the physical injury and emotional impact on the resident who was struck. The incident was also confirmed by the DON, who acknowledged the physical altercation and resulting injury. The deficiency centers on the facility's failure to protect a resident from physical abuse by another resident, as required by regulations.
Failure to Notify Physicians of Changes in Condition and Treatment Orders for Residents with Surgical Wounds
Penalty
Summary
The facility failed to notify physicians of changes in condition or treatment for two residents with surgical wounds, resulting in actual harm to one resident. For the first resident, who was cognitively intact and had a complex right elbow surgical wound with infection, the wound vac order was discontinued by the facility's wound nurse without notifying the orthopedic surgeon. The resident subsequently presented to the clinic without the wound vac in place, leading to exposure and deterioration of the triceps tendon, and required additional surgical intervention. Documentation showed that the facility's PA-C and nursing staff communicated with the clinic only after the wound had worsened, and the orthopedic surgeon confirmed that the lack of notification and discontinuation of the wound vac led to the need for further surgery. For the second resident, who had moderate cognitive impairment and a surgical wound on the right tibia, there was a delay in initiating physician-ordered wound care and antibiotic therapy. Orders for wound care and Keflex were written and noted in the medical record, but the treatments were not started until several days later. The DON confirmed that the nurse failed to update the physician orders in a timely manner, and the orthopedic surgeon was not notified of the delay in starting the prescribed treatments. A review of the facility's skin integrity policy indicated that licensed nurses are required to notify physicians and resident representatives of changes in wound condition or new treatment orders. The policy also requires weekly wound evaluations and prompt notification if a wound fails to improve or deteriorates. In both cases, the facility did not follow its own policy regarding physician notification and timely implementation of treatment orders, resulting in harm and delayed care for the affected residents.
Failure to Provide Timely and Appropriate Care, Wound Management, and Post-Fall Monitoring
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. One cognitively intact resident with diabetes, neuropathy, and renal insufficiency was at risk for pressure ulcers and developed a right buttock wound with increased depth, yellow/green slough, and foul odor. Despite documentation of these changes, there was a lack of timely follow-up notes regarding the wound or possible infection for several days. The resident's family was not notified of the wound's severity until the resident was hospitalized for sepsis, and the representative reported that the resident should have been sent to the hospital sooner. Another resident with moderate cognitive impairment and a surgical wound had physician orders for wound care and antibiotics that were not implemented until five days after the orders were written. The delay was discovered by the facility, and the orthopedic surgeon was not notified of the delay in starting the prescribed treatments. This lapse resulted from the nurse's failure to update the physician orders in a timely manner. A third resident with severe cognitive impairment and a high risk for falls experienced an unwitnessed fall, after which only one neurological assessment was documented, despite facility protocol requiring more frequent checks. The resident later presented with bruising and an abrasion, and a CT scan revealed a nondisplaced acute nasal bone fracture. The DON was unable to account for the missing neurological assessment records, and the facility's policy for post-fall monitoring was not followed.
Failure to Follow Wound Vac Orders and Notify Surgeon Resulting in Harm
Penalty
Summary
A resident with a history of a right elbow fracture, surgical wound, and wound infection, including methicillin-resistant Staphylococcus aureus (MRSA), was admitted with a surgical wound requiring a wound vac as ordered by the orthopedic surgeon. The care plan included dressing changes as ordered, and the medication administration record indicated wound vac changes were scheduled three times weekly. However, the wound vac order was discontinued by the facility's provider after the wound nurse reported it was not applied, without notifying the orthopedic surgeon who had placed the original order. There was no evidence that the surgeon was consulted prior to discontinuing the wound vac. Subsequently, the resident was seen in clinic without the wound vac in place, and the triceps tendon was exposed and developing eschar, prompting a recommendation for further surgical intervention. Progress notes documented that the wound vac dressing was found improperly applied, causing the wound to be dry and the tendon frayed. The facility's provider and wound care nurse decided not to reapply the wound vac, and only after further communication with the clinic was a follow-up appointment and a skin graft consult arranged. The orthopedic surgeon confirmed that the resident required additional surgeries due to the facility's failure to follow the wound vac order and to notify the surgeon of changes.
Failure to Meet Residents' Activity Needs
Penalty
Summary
The facility failed to ensure that activities met the interests and needs of four residents, as identified in the report. Resident #30, who was cognitively intact and had an amputation, expressed a desire to go outside and listen to music. However, the resident was unaware of available group activities and participated minimally in independent activities. The activity director acknowledged that activity aides should inform residents about activities upon admission. Resident #61, with moderate cognitive impairment and conditions including depression and phantom limb syndrome, expressed an interest in playing BINGO. Despite this, the resident's participation was limited to independent activities, with no recorded participation in BINGO. Similarly, Resident #41, who was cognitively intact and had multiple diagnoses, expressed a desire for more engaging activities. The resident participated in some independent activities but did not engage in group activities due to a lack of interest and the facility's limited ability to organize outings. Resident #22, also cognitively intact, had a range of interests including reading, music, and outdoor activities. However, the resident found the facility's activities unappealing and participated only in independent activities. The activity director noted that the facility had been understaffed, affecting their ability to offer diverse activities and outings. The director also mentioned efforts to hire additional staff and assess residents' activity preferences.
Staffing Shortages and Documentation Issues in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of residents, affecting two of the five resident care units. Interviews with residents during a council meeting revealed issues such as high turnover of CNAs, delayed response to call lights, unmade beds, and untidy rooms. Several residents expressed concerns about the lack of staff, with one resident specifically mentioning a decline in their ability to transfer due to insufficient restorative nursing care. This resident's restorative nursing plan was not being followed because restorative staff were reassigned to cover open shifts. The documentation review revealed discrepancies in the bathing records for multiple residents. For instance, one resident's bathing record initially showed no showers for a period, but was later updated by the DON to reflect showers that were not documented in the East Station Bath Schedule logs. Similar inconsistencies were found in the records of other residents, where showers were documented by the DON but not supported by the bath schedule logs. These discrepancies indicate a lack of proper documentation and verification of care provided. Interviews with the DON, MDS coordinator, administrator, and regional clinical director confirmed that the lack of restorative nursing was due to staff being pulled to cover other duties. Additionally, the East Station Bath Schedule logs were not considered part of the official resident records, leading to further inconsistencies in documentation. The facility's failure to maintain accurate records and provide adequate staffing resulted in unmet care needs and incomplete restorative programs for residents.
Failure to Identify and Monitor Target Symptoms for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that target symptoms were identified and monitored for five residents who were receiving psychotropic medications. Resident #45, with severe cognitive impairment and multiple diagnoses including non-Alzheimer's dementia and anxiety disorder, was receiving several psychotropic medications such as Ativan, bupropion, buspirone, sertraline, and trazadone. However, there was no evidence in the physician orders or care plan that the facility had identified or was monitoring specific target symptoms to evaluate the effectiveness of these medications. Similarly, Resident #96, who was cognitively intact but had diagnoses including non-Alzheimer's dementia and depression, was receiving quetiapine and sertraline. The facility again failed to identify or monitor specific target symptoms for these medications. This pattern was repeated with Resident #120, who had severe cognitive impairment and was receiving escitalopram, olanzapine, and divalproex, as well as Resident #72 and Resident #114, both of whom had severe cognitive impairments and were on various psychotropic medications without identified target symptoms. The facility's policy on psychotropic drugs, last updated in October 2022, states that the Interdisciplinary Team (IDT) should validate appropriate diagnoses of behavioral symptoms and evaluate the resident's medication regime to avoid duplicate drug therapy. However, the facility did not adhere to this policy, as evidenced by the lack of documentation of target symptoms and monitoring for the effectiveness of psychotropic medications in the residents' care plans and physician orders.
Failure to Label and Date Insulin Pens
Penalty
Summary
The facility failed to properly label and date medications in two of six medication storage areas, specifically on the South Hall medication carts #1 and #2. During an observation, it was found that several insulin pens, including Lantus Solostar, Novolog Insulin Aspart, and Humalog, were opened but not dated. Interviews with a registered nurse (RN) and the Director of Nursing (DON) confirmed that insulin pens should be labeled with the date they were opened, and that nursing staff were responsible for labeling multidose medications with the resident's name and the date of opening. A review of the facility's policy on Medication Storage and Handling indicated that multi-dose vials should be dated when opened and discarded within 28 days unless otherwise specified by the manufacturer.
Inaccurate Documentation of Bathing Records
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for three residents regarding their bathing schedules. Resident interviews and medical record reviews revealed discrepancies in the documentation of showers received. One resident reported not receiving showers consistently due to staffing issues, and the initial 30-day bathing record showed no showers documented before a certain date. However, an updated record later showed showers documented by the DON, which were not initially recorded. Similar discrepancies were found for two other residents, where the updated records showed showers that were not documented in the original records. Interviews with the DON and MDS coordinator revealed that the system was updated with information from bath schedule logs after the records were requested, and the staff member responsible for completing these logs was no longer employed at the facility. The administrator and regional clinical director confirmed that the bath schedule logs were not part of the official resident records, and bathing was expected to be documented in the resident records when it occurred. This lack of accurate documentation led to the deficiency identified by the surveyors.
Inadequate Restorative Nursing Care Due to Staffing Issues
Penalty
Summary
The facility failed to provide restorative nursing care to maintain the ability of residents to perform activities of daily living. Resident #22, who was cognitively intact and had functional limitations in range of motion, reported a decline in mobility and the need for a full body mechanical lift due to the lack of restorative care. Despite having an active restorative nursing plan, the resident's programs were inconsistently provided, with only a few sessions documented over several months. The resident expressed a desire to participate in restorative care but was informed that staffing shortages were preventing the implementation of the plan. Resident #100, who had severe cognitive impairment and no range of motion impairment, also experienced inconsistent delivery of restorative programs. The resident's scheduled activities were sporadically provided, with significant gaps between sessions. Interviews with the Director of Nursing and MDS coordinator confirmed that the lack of restorative nursing was due to restorative aides being reassigned to cover open shifts on the floor. The facility's policy indicated that residents at risk of functional decline should receive restorative care, but this was not adhered to in practice.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection control procedures for a resident under Enhanced Barrier Precautions (EBP). During an observation, a stop sign indicating EBP was posted on the resident's room door, but the registered nurse (RN) did not adhere to the required precautions. The RN was observed wearing gloves but no gown while providing high-contact care, including removing a gastric tube dressing and assisting in repositioning the resident. The RN admitted that gowns were supposed to be worn for such care but were not available in the room at the time. Interviews with staff revealed a lack of awareness and understanding of the EBP requirements. A certified nursing assistant (CNA) stated she was unaware of the need to wear gowns until the day before the interview. The infection preventionists confirmed that EBP required gowns and gloves for high-contact care involving residents with medical devices like feeding tubes. The facility's policy on EBP, last revised in March, outlined the necessity of using gowns and gloves to prevent the transfer of multi-drug resistant organisms, but this was not followed in practice.
Resident-to-Resident Physical Abuse Incident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual harm. Resident #1, who had severely impaired cognitive skills and a diagnosis of non-Alzheimer's dementia, was involved in an altercation with Resident #2. Resident #2, with a BIMS score indicating moderate impairment and a history of making violent comments, punched Resident #1 in the face after a confrontation in the hallway. This incident led to Resident #1 sustaining a nasal bone fracture and being taken to the hospital. The altercation occurred after Resident #1 approached Resident #2 and engaged in behavior that led to a physical confrontation. Despite Resident #2's history of making comments about past violence, the facility did not prevent the escalation that resulted in physical harm. The incident was witnessed by a CNA student, and the facility's policy on abuse, which defines physical abuse as including punching, was not effectively enforced to prevent the incident.
Failure to Address Physical Aggression in Resident Care Plan
Penalty
Summary
The facility failed to develop an individualized, comprehensive care plan for a resident with a history of traumatic brain injury and non-Alzheimer's dementia, who exhibited moderate cognitive impairment. The resident had a documented behavior problem of making comments about past violence towards women, although they would laugh and claim they would never act on these comments. Despite this, the care plan did not address potential or actual physical aggression, which became evident in two separate incidents involving physical altercations with another resident. In the first incident, the resident was involved in a shoving match with another resident after a verbal exchange, although no injuries were reported. In a subsequent incident, the resident punched the other resident in the face, resulting in a nasal bone fracture for the victim. The care plan was updated to include an intervention to engage the resident in conversation as a distraction when anxious, but it still failed to address the resident's physical aggression. The Director of Nursing confirmed that the care plan did not include measures for potential or actual physical aggression, highlighting a deficiency in the care planning process.
Failure to Implement Infection Prevention Protocols
Penalty
Summary
The facility failed to implement appropriate infection prevention interventions for a resident with acute respiratory symptoms. The resident, who was cognitively intact and had a history of atrial fibrillation, morbid obesity, diaphragmatic hernia, and obstructive sleep apnea, reported feeling unwell with symptoms such as weakness and a runny nose for several days before testing positive for COVID-19. Despite the resident's complaints and the presence of COVID-19 in the facility, staff did not test the resident for COVID-19, and the resident's representative had to bring a test from outside, which confirmed the infection. Interviews with staff revealed a lack of adherence to the facility's infection prevention protocols. RN #1 stated that nurses should follow up with the doctor and infection prevention staff regarding testing if residents exhibit COVID-19 symptoms. However, RN #2 admitted to not contacting the physician or performing COVID-19 testing, as the resident seemed to feel better. The facility's policy required immediate testing for residents showing respiratory symptoms, but this was not followed in the case of the resident. The infection preventionist confirmed that staff were expected to notify the infection prevention team and the physician for a COVID-19 order if a resident exhibited respiratory symptoms. The administrator and DON also indicated that nurses should monitor symptoms and notify the infection preventionist and doctor if symptoms worsen. Despite these protocols, the facility did not test the resident as required, leading to a deficiency in infection prevention and control.
Failure to Provide Timely Assessment and Treatment Leads to Resident Harm
Penalty
Summary
The facility failed to ensure timely assessment and treatment for a resident with a change of condition, resulting in actual harm. The resident, who had moderate cognitive impairment and required assistance with daily activities, was on antiplatelet therapy and had been prescribed anti-emetic medications for enteritis. Despite showing signs of dehydration and experiencing nausea and vomiting, the facility did not notify the physician promptly or reassess the resident's condition adequately. The resident experienced multiple episodes of vomiting and refused meals, yet there was no evidence of physician notification or reassessment of the resident's condition. The facility's staff did not consider the resident's condition critical, and the resident was transported to the hospital via the facility van without a healthcare staff member accompanying them. The resident's family had expressed concerns about the resident's condition, but the facility delayed contacting the physician and arranging for hospital transport. The resident was eventually taken to the emergency room after significant delays, during which time their condition worsened. The resident was left in the emergency department waiting area without facility staff, and subsequently collapsed and passed away. Interviews with facility staff revealed a lack of urgency in responding to the resident's condition and a failure to follow standard procedures for transporting unstable residents.
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A resident with severe cognitive impairment and dementia had facility-managed trust funds used to purchase three Meta virtual reality headsets via Amazon. The corresponding debit was recorded in the trust account, but the devices were later found stored, largely unopened, in the activities room, with the activities director unaware of their ownership or use and unable to operate them. The resident’s representative was not informed of the purchase and believed the resident could not use such devices, while the NHA stated the items were bought as part of a Medicaid spend-down for the resident and possibly friends.
A resident with mild cognitive impairment, dementia, and depression developed UTI symptoms and was started on Keflex after a positive urine culture, with multiple notes documenting the infection and antibiotic treatment. The resident later told their representative they were taking medication for an infection, leading the representative to contact the facility for information. Facility records showed the representative was only notified days later when a follow-up urine sample was collected to confirm clearance of the infection, with no documentation of notification at the onset of the UTI or initiation of treatment. The DON confirmed the absence of documentation, despite a facility policy requiring immediate notification of the resident, physician, and resident representative when a new treatment is started.
A resident who was cognitively intact but dependent for transfers and required a full body mechanical lift was being moved from bed to a recliner by two aides when a sling shoulder strap detached from the lift, causing a fall. Staff and witness statements confirmed that the lift in use lacked safety clips on the spreader bar, despite manufacturer instructions requiring safety clips to be present and properly used. The DON acknowledged that safety clips had been removed from the lifts because they were viewed as ineffective. The resident sustained a cervical fracture and subsequently went into cardiac arrest with death pronounced the same day, and the situation was determined to be immediate jeopardy.
Surveyors found that staff failed to follow infection prevention practices for urinal use and maintenance for three residents. One resident with severe cognitive impairment and multiple comorbidities had a urinal containing urine with visible discoloration and dried residue that was not dated. Two urinals for another resident were still in place more than a month after the date written on them, and a third resident’s urinal showed staining and was not labeled with a date. CNAs reported that urinals were typically changed monthly and as needed, while an LPN and the infection preventionist stated that soiled urinals should be discarded and replaced, and that urinals should be labeled and replaced at least monthly. The DON confirmed urinals should be replaced when visibly soiled and acknowledged there were no written facility policies governing urinal use.
A resident with severe cognitive impairment and a history of hip fracture, stroke, anxiety, and depression had a care plan indicating a preference for twice-weekly baths and a need for maximum assist with bathing. Bathing records showed the resident initially received showers twice weekly, but the frequency was later reduced to once weekly after the resident moved to another unit, without documented reassessment of bathing preferences. The administrator acknowledged that preferences should have been reassessed after the move, while bath aides reported that bathing schedules are generally maintained and that they would ask new residents about their preferences. The current bathing schedule and medical record confirmed the resident was only scheduled for weekly showers, with no documented reevaluation or change in the care plan to support the reduced frequency.
The facility failed to prevent accident hazards and provide adequate supervision related to hot beverage service. A resident with moderate cognitive impairment, stroke, hemiplegia, contractures, and dysphagia, who was care-planned to receive hot liquids only in a Kennedy cup and at non-scalding temperatures, was instead given hot coffee in a Styrofoam cup without a lid and left unsupervised, resulting in burns to the thighs requiring ED treatment. Surveyors also observed multiple residents independently dispensing very hot coffee or water directly from a machine into open cups, then ambulating with walkers while carrying these beverages, sometimes spilling them. Staff interviews confirmed that machine water was not supposed to be served directly to residents, that dining room staffing was often below the intended level, and that there were no clear interventions to prevent residents from independently accessing the hot beverage machine, leading to an immediate jeopardy finding.
Two cognitively impaired roommates, one with severely impaired memory and verbal behavioral symptoms and the other with moderate cognitive impairment, dementia, and anxiety, became involved in a physical altercation after a CNA briefly left their shared room. Staff heard loud noises and found one resident with a raised fist and the other holding a Bible raised toward the first, with both admitting they had been fighting and one stating the other was in the way. The injured resident was found to have blood, scratches, and two small abrasions on the left cheek, while the other had no injuries, demonstrating a failure to protect a resident from physical abuse by another resident.
A resident was documented by nursing staff as calmly walking in the dining room, then suddenly punching another seated resident in the face, after which the aggressor was removed and placed on 1:1 supervision and the victim was assessed, showing only a pre-existing red cheek mark without swelling or pain. However, the facility’s internal incident report later characterized the event as a face "push" with no injury or distress, and the allegation was not reported to the state survey agency until more than 24 hours later. The administrator acknowledged that the original allegation of a punch was not accurately reported and that the facility reported the investigation’s conclusion instead of the actual allegation, contrary to the facility’s abuse reporting policy requiring prompt reporting of all abuse allegations.
A cognitively intact resident with stable mood and no recent behavioral issues intervened when another resident, who had bipolar disorder and a recent history of increased aggression, inappropriate sexual behaviors, refusal of care, and delusions following hospitalization for aspiration pneumonia, was teasing another resident in the dining room. In response, the behaviorally escalated resident directed profane and threatening language at the intervening resident, causing visible distress and a verbal exchange before staff arrived and the aggressive resident left the area. Surveyors found that the facility failed to protect the resident’s right to be free from verbal abuse by another resident.
Surveyors found unsanitary kitchen conditions and inadequate food safety monitoring, including a grimy Traulsen refrigerator with a sticky handle, a soap dispenser with dark buildup, and an ice scoop stored on top of the ice machine near hair nets. An undated, unlabeled package of ham and a partially uncovered, undated bowl of crushed vanilla wafers were observed in food storage areas, and the walk-in refrigerator thermostat showed no temperature. No temperature logs were available for the walk-in refrigerator, freezer, or the Ecolab XL dish machine, despite manufacturer requirements for specific wash and sanitizing temperatures and facility policies mandating daily logging of cooler, freezer, and dishwasher temperatures, as well as labeling and dating of refrigerated foods and maintaining clean, sanitary food service areas.
Misappropriation of Resident Trust Funds for Unused Virtual Reality Devices
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when items were purchased with the resident’s trust account funds and not used for the resident’s benefit. The resident had severe cognitive impairment, with a BIMS score of 3/15 and diagnoses including dementia, non‑traumatic brain dysfunction, and Meniere’s disease, and the facility managed the resident’s funds through a trust account. Documentation showed that an Amazon order was placed for this resident that included three Meta virtual reality headsets at $399.99 each, and the resident’s trust account transaction history reflected a corresponding debit of $1,878.78 for Amazon purchases. Attempts to interview the resident were unsuccessful due to cognitive debilities. Surveyor observation found three Meta virtual reality headsets in their original boxes, one opened, stored in the activities storage room near the main dining room. The activities director stated she did not know who the devices belonged to, that they had been stored in the closet since February of the prior year, that the devices required internet access, and that she did not know how to use them. The resident’s responsible party reported having no knowledge of the Meta purchase and did not believe the resident would have been capable of operating the devices. The NHA stated that the resident was obligated to spend down the trust account as a Medicaid requirement and that three Meta virtual reality headsets were ordered for the resident and possibly some friends to use.
Failure to Notify Resident Representative of UTI and New Antibiotic Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a change in condition when the resident developed a urinary tract infection (UTI) and was started on antibiotic therapy. The resident had a diagnosis of non-Alzheimer’s dementia and depression, with an annual MDS showing a BIMS score of 11/15 (mild cognitive impairment), no delirium, behaviors, or hallucinations, and independence with personal, oral, and toileting hygiene, and continence of bowel and bladder. On 2/2/26 at 8:02 AM, a health status note documented the resident’s complaints of dysuria, urinary urgency, and frequency, and that a urinalysis was collected. Later that day at 10:38 PM, another health status note documented that the resident was being monitored on Keflex (cephalexin) day 1 of 7 for a UTI with no adverse reaction. On 2/3/26 at 11:45 AM, a health status note documented the resident was on Keflex day 2 of 7 for a UTI, was up out of bed, alert to staff, and had no complaints of nausea, vomiting, diarrhea, skin reactions, or discomfort. An infection note on 2/3/26 at 1:30 PM documented a confirmed UTI diagnosis based on dysuria, increased urgency/frequency, and a positive urine culture, with a 7-day course of cephalexin ordered and instructions for good hygiene and fluids. The resident’s representative reported in a telephone interview that she learned of the infection only after the resident told her they were taking medication for an infection, prompting her to contact the facility for information. Review of communication notes showed the representative was notified on 2/12/26 that a urine sample was being collected to ensure the infection had cleared, but there was no documentation that the representative had been notified at the onset of the UTI or when treatment was initiated. The DON confirmed there was no documentation of notification, despite the facility’s policy requiring immediate notification of the resident, physician, and resident representative when there is a need to commence a new form of treatment.
Failure to Use Required Safety Clips on Mechanical Lift Resulting in Resident Fall and Cervical Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe staff practices and safe working conditions when using a full body mechanical lift for a resident who was dependent for transfers. The resident had a BIMS score of 15/15, indicating intact cognition, and medical diagnoses including morbid obesity, heart failure, and renal insufficiency, and required a full body mechanical lift for transfers. On the day of the incident, the resident was being transferred from bed to a recliner by two aides using a full body mechanical lift when the left shoulder strap of the sling came loose from the lift, causing the resident to fall to the floor. Witness documentation and staff interviews indicated the resident was found face down on the floor with legs over one leg of the lift, with all but one sling strap still attached. The incident report concluded that the resident had a tendency to shift weight and reposition while in the sling and that the sling strap likely came up on one side and then came off the lift. Further investigation showed that the mechanical lift in use at the time of the fall did not have safety clips on the spreader bar, as confirmed by both aides involved in the transfer and by an RN who responded to the incident. The RN identified the specific model used and confirmed that safety clips were not present at the time of the fall. A laminated Quick Reference Guide attached to the same model of lift, and the manufacturer’s Quick Reference Guide provided by the DON, both instructed staff to ensure safety clips on the spreader bar are in position after the sling is applied and to check that safety clips are present and used properly. The DON reported that safety clips had been removed at some point because they would come off and were considered ineffective. Based on the failure to follow manufacturer instructions for use of safety clips on the mechanical lift, the resident fell from the lift and sustained a mildly displaced fracture of the left C2 transverse process with extension into the C2 vertebral body, and later went into cardiac arrest with death pronounced the same day. This failure was determined to constitute immediate jeopardy.
Failure to Implement Proper Urinal Cleaning and Replacement Practices
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control practices related to the use and maintenance of urinals for three sampled residents. One resident with severe cognitive impairment, cancer, depression, non-Alzheimer’s dementia, lower extremity impairment, who was wheelchair bound and required substantial to maximal assistance with toileting hygiene, was observed with a urinal hanging from a trash can next to a recliner that contained approximately 100 milliliters of amber-colored urine. The urinal showed dark blue and black discoloration inside and a dried yellow substance around the opening, and it was not labeled with a date. A CNA stated that residents’ urinals were emptied every two hours and replaced monthly, and later confirmed that this urinal was not dated and appeared discolored and soiled. Additional observations showed two empty urinals dated more than a month earlier hanging from a trash can next to another resident’s bed, with a CNA confirming they had not been replaced after one month of use. Another resident’s urinal was observed hanging from a nightstand, empty but with yellow, amber, and dark blue staining inside, and it was not dated; a CNA confirmed the urinal appeared soiled and undated and reported that urinals were changed monthly and as needed. An LPN stated staff were expected to discard soiled urinals and replace them when they appeared soiled. The infection preventionist reported that staff were expected to label urinals and replace them at least monthly or when visibly soiled, and the DON confirmed urinals should have been replaced when visibly soiled and acknowledged there were no facility policies regarding urinals.
Failure to Maintain Resident’s Preferred Bathing Frequency After Unit Transfer
Penalty
Summary
The deficiency involves the facility’s failure to maintain a resident’s activities of daily living, specifically bathing, according to the resident’s assessed needs and stated preferences. A quarterly MDS dated 1/23/26 for resident #11 showed a BIMS score of 3/15, indicating severe cognitive impairment, and diagnoses including a history of hip fracture, stroke, anxiety, and depression. The care plan dated 10/24/25 documented that the resident preferred bathing twice a week and required maximum assistance with bathing and showering. Review of the bathing record from 12/10/25 through 1/6/25 showed the resident received showers twice weekly until 1/14/26, when the frequency was reduced to once weekly. The administrator stated on 3/12/26 that the resident had moved from another unit on 12/30/25 and that shower preferences should have been reassessed and had changed, but no evidence of such reassessment was found. Bath aide interviews indicated that bathing schedules were expected to be maintained when residents moved units and that staff would typically ask new residents about their bathing preferences. The current bathing schedule and medical record confirmed the resident was scheduled for and receiving only weekly showers, with no documented reevaluation of preferences or change in the bathing schedule.
Inadequate Supervision and Unsafe Hot Beverage Practices Leading to Burns and Accident Hazards
Penalty
Summary
The deficiency involves the facility’s failure to ensure the environment was free from accident hazards and that residents received adequate supervision and appropriate devices to prevent accidents, particularly related to hot beverages. One resident with moderate cognitive impairment, a history of stroke, hemiplegia, hemiparesis with hand contractures, and dysphagia had a care plan requiring use of a Kennedy cup for all hot beverages and that food and fluids be served at non-scalding temperatures. Despite these interventions, the resident was given hot coffee in a Styrofoam cup without a lid during a period when the facility was using disposable dinnerware due to an influenza outbreak. The CNA who provided the coffee left the room to care for another resident, and the resident subsequently spilled the coffee into their lap, resulting in burns to the thighs that required ED evaluation and treatment. Surveyors identified additional concerns in the dining room where multiple residents independently accessed hot beverages from a coffee machine and water spout without lids or assistance. One resident independently obtained coffee in an open cup, placed it on a walker seat, and ambulated, causing the coffee to spill. Other residents independently obtained hot water from the coffee machine water spout into open cups and walked back to their tables while simultaneously pushing walkers, sometimes spilling coffee on themselves and tables, though without documented injury in those instances. Observations showed that residents were routinely allowed to obtain hot beverages on their own, often in open cups without lids, while using walkers. Further observations and staff interviews revealed that the water from the coffee machine measured 176.7°F and later 168.7°F, and dietary staff stated that water from the coffee machine was never supposed to be given directly to residents and that coffee and water temperatures were checked in the kitchen and not to be served directly from the machine. A CNA reported that residents were allowed to independently obtain beverages, that there was supposed to be two aides in the dining room prior to meals but usually only one was present, and that she was unaware of any interventions to prevent residents from filling cups from the coffee machine. She also stated that specialty adaptive items were identified on meal trays, but beverages were usually provided before trays came out, contributing to residents independently accessing hot beverages. These combined actions and inactions led to the determination of immediate jeopardy related to accident hazards and inadequate supervision.
Failure to Prevent Resident-on-Resident Physical Abuse Between Cognitively Impaired Roommates
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident when two cognitively impaired roommates engaged in a physical altercation. One resident had severely impaired memory, verbal behavioral symptoms directed toward others, and a diagnosis of non-Alzheimer’s dementia. The roommate had moderate cognitive impairment with a BIMS score of 10/15 and diagnoses including dementia and anxiety. On the day of the incident, a CNA had taken the first resident into the shared room to watch television while the roommate was on their side of the room looking through personal belongings. After the CNA briefly left for the nurses’ station, loud noises were heard coming from the room. When the CNA returned, both residents were next to each other, with the first resident holding a fist up and the roommate holding a Bible raised toward the first resident. Both residents stated they had been fighting, and the roommate said the other was “in the way.” The CNA and RN observed blood and scratches on the first resident’s face, and assessment revealed two small abrasions to the left cheek. The roommate had no injuries. Staff interviews confirmed that the altercation occurred between the two roommates and that the injured resident required cleaning of the facial abrasion. This sequence of events constituted a failure to ensure the resident’s right to be free from physical abuse by another resident.
Failure to Accurately and Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to accurately and timely report an allegation of resident-to-resident abuse involving one sampled resident. A nurse’s progress note documented that a resident was walking calmly in the dining room, approached another seated resident, and, without any cue, drew back a clenched fist and punched the seated resident in the face. The aggressor was immediately redirected, removed from the situation, and placed on one-to-one supervision, and was noted to have no recollection of the event. A separate allegation form for the involved resident who was struck stated that this resident had been sitting in the dining room when another resident punched them in the face, that they had done nothing to incur the event, and that they did not recall the situation moments later. The resident who was struck was assessed and found to have a red mark on the cheek that appeared pre-existing, with no swelling or pain noted. A facility-reported incident created later the same day described the event differently, stating that one resident walked near another and “pushed” the other resident’s face, with both residents separated and redirected and no injury or distress noted. This incident was not reported to the state survey agency until the following day at 5:45 PM, approximately 24 hours and 45 minutes after the alleged incident. The administrator confirmed that the allegation that one resident punched another was not accurately reported, explaining that the facility’s investigation concluded the action was a push, and that the facility reported the results of the investigation as the allegation rather than reporting the original allegation itself. The facility’s abuse reporting policy required the Executive Director or designee to report all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, and misappropriation of resident property immediately but not later than 2 hours when the events involve abuse or result in serious bodily injury.
Failure to Protect Resident From Verbal Abuse During Dining Room Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by another resident during a dining room incident. One resident, who was cognitively intact with a BIMS score of 15, a low mood score, and no documented behaviors or refusal of care during the look-back period, intervened when another resident was teasing an unidentified resident. The second resident, who also had a BIMS score of 15, a mood score of 4, and a diagnosis of bipolar disorder, had recently experienced aspiration pneumonia requiring hospitalization and readmission, and subsequently exhibited increased aggressive and inappropriate sexual behaviors toward staff, refusal of care, and delusional behavior over several days. On the date of the incident, when the cognitively intact resident asked the behaviorally escalated resident to stop teasing another resident, the latter responded by calling the resident a “fat bitch,” telling the resident to “shut the fuck up,” and threatening to “knock [their] fucking teeth out.” The verbally abused resident became visibly upset and responded by challenging the other resident to hit them. The altercation occurred in the dining area before additional staff arrived, at which point the aggressive resident left and returned to their room. The survey determined that, in this event, the facility failed to protect the resident’s right to be free from verbal abuse by another resident.
Unsanitary Kitchen Conditions and Lack of Temperature Monitoring for Food and Dishwashing Equipment
Penalty
Summary
Surveyors identified a deficiency related to unsanitary conditions and inadequate food safety practices in the facility’s kitchen. Observation of the kitchen preparation area showed the Traulsen refrigerator had visible grime and dried food particles on its surface and a sticky handle. The handwashing sink’s soap dispenser had a dark, reddish buildup on the pump, and the ice machine scoop was stored on top of the machine next to packaged hair nets. In the food storage areas, surveyors observed an undated, unlabeled package of ham in the Traulsen refrigerator, and a partially uncovered, undated bowl of crushed vanilla wafers on a bottom shelf of the walk-in pantry. The walk-in refrigerator did not display a temperature on its thermostat, and there were no visible temperature logs for the walk-in refrigerator or freezer. Further review and interviews showed additional failures in monitoring and documentation of required temperatures. There were no temperature logs available for the Ecolab XL dishwashing machine, despite manufacturer’s instructions specifying minimum operating temperatures of 150°F for the wash cycle and 180°F for the sanitizing rinse. The assistant dietary manager confirmed there were no dish machine temperature logs, acknowledged the ham was undated and should have been labeled with the food name and open date, and stated the ice scoop was washed after each use and placed on top of the dish machine. He was unsure about the buildup on the soap dispenser and incorrectly reported that the walk-in refrigerator temperature should have been 20–30 degrees. He believed the dietary manager kept the walk-in logs, but the director of maintenance confirmed there were no temperature logs for the walk-in refrigerator or freezer and that the outside refrigerator temperature reading was incorrect. These practices were inconsistent with facility policies requiring daily logging of cooler/freezer and dishwasher temperatures, maintaining specific temperature ranges for refrigerated and frozen storage, and ensuring refrigerated food is labeled, dated, and monitored, as well as policies requiring all food areas to be kept clean and sanitary.
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