Nursing Investigation Results -

Pennsylvania Department of Health
MAYBROOK HILLS REHABILITATION AND HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
MAYBROOK HILLS REHABILITATION AND HEALTHCARE CENTER
Inspection Results For:

There are  141 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
MAYBROOK HILLS REHABILITATION AND HEALTHCARE CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and a Complaint Survey completed on January 24, 2020, it was determined that Maybrook Hills Rehabilitation and Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.




 Plan of Correction:


483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
483.25(d) Accidents.
The facility must ensure that -
483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:


Based on review of policies, clinical records, and facility investigation reports, as well as staff interviews, it was determined that the facility failed to provide an environment that was free of potential accident hazards for two of 57 residents reviewed (Residents 51, 197), which resulted in a fall with a facial fracture for Resident 51.

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated November 5, 2019, revealed that the resident was severely cognitively impaired, continuously had inattention and disorganized thinking, required extensive assistance from two staff members during transfers, walked on one to two occasions with the assistance of two staff members, had unsteady balance during walking and transitions that only stabilized with the assistance of staff, was always incontinent of bowel and bladder, and had diagnoses that included dementia (causes deterioration of brain function), schizophrenia (mental disorder characterized by abnormal social behavior and failure to understand reality), and psychotic disorder (strange behavior often accompanied by voices, images, sensations, and other hallucinations). The resident's care plan, dated April 8, 2018, revealed that she was to have leg rests on her wheelchair during transportation for safety.

A nursing note for Resident 51, dated September 3, 2019, at 3:21 a.m. and a facility investigation, dated September 4, 2019, revealed that the resident had a history of falls and being impulsive, was noncompliant with safety interventions, and was unable to be educated regarding safety. The resident was last seen sitting in her wheelchair in the hallway at 2:30 a.m., was then found sitting on the floor with her knees flexed up to her chest, and she received a skin tear to her left arm.

A witness statement from Nurse Aide 5, dated September 3, 2019, revealed that she brought the resident to the nurses' desk at the beginning of the shift and the resident wandered back. She was outside her room and took her slipper socks off and tried to stand up. The statement indicated that the leg rests on the wheelchair were obstacles; however, there was no documented evidence that new and/or revised interventions to prevent the leg rests from being an obstacle/accident hazard were developed and implemented following this fall.

A nursing note for Resident 51, dated September 5, 2019, at 6:30 p.m. revealed that the resident was lying face down on the floor in front of her wheelchair, her feet were bare, and her gripper socks were lying in the chair beside her. The wheelchair leg rests had the foot pedals down and staff noted that the resident stood up and appeared to trip over the foot pedals. The resident fell forward striking her head on the floor, and upon assessment there was a large amount of blood noted on the floor under the left temple area of her head. The physician was notified and orders were received to send the resident to the hospital for evaluation and treatment. A nursing note, dated September 5, 2019, at 11:52 p.m. revealed that the resident returned from the hospital with diagnoses that included a maxillary fracture (bone of the face) and a hematoma (collection of blood caused by injuries) to the left temple.

A statement from Licensed Practical Nurse 6, dated September 5, 2019, indicated that an obstacle was the foot rests on Resident 51's wheelchair.

Interview with the Director of Nursing on January 24, 2020, at 2:02 p.m. confirmed that Resident 51 was to have leg rests during transportation for safety, and the resident's care plan was not revised to include that the leg rests were required for transportation only (were to be removed after the resident was transported) until September 16, 2019.


The facility's policy regarding air mattress safety and assessment, dated September 9, 2019, revealed that it was the policy of the facility to promote residents' well being and safety by administering an air mattress safety assessment prior to use. The assessment was to be used to determine the risks and benefits of use, as well as to ensure proper placement, function, and any concerns that may be determined. Air mattress safety assessments were to be completed prior to the application of the air mattress and as needed thereafter. Completed assessments were to be added to the resident's medical record.

A quarterly MDS assessment for Resident 197, dated January 4, 2020, revealed that the resident was understood and could understand others; required extensive assistance from staff for daily care tasks, including bed mobility and transfers; and received hospice services while as a resident.

Physician's orders for Resident 197, dated September 27, 2019, included an order for the resident to have a pressure-reduction mattress. A delivery ticket from a durable medical equipment provider, dated September 30, 2019, documented, "please take air mattress to Maybrook." Physician's orders, dated November 28, 2019, included an order to discontinue the pressure-reduction mattress.

Observations of Resident 197 on January 21, 2020, at 10:45 a.m. revealed that the resident's bed was equipped with an air mattress.

There was no documented evidence that there was a physician's order for the air mattress and that the use of the air mattress was assessed prior to being installed on the resident's bed to ensure that it did not create safety hazards for Resident 197.

Interview with Licensed Practical Nurse 1 on January 22, 2020, at 2:10 p.m. confirmed that Resident 197 had an air mattress on her bed and they normally obtain orders for air mattresses, but there was not a documented physician's order for Resident 197's air mattress, and no documented evidence that the use of an air mattress was assessed to ensure that it did not create safety hazards prior to being placed on the resident's bed.

Interview with the Director of Nursing on January 23, 2020, at 8:45 a.m. confirmed that an air mattress safety assessment for Resident 197 was not completed until January 22, 2020.

42 CFR 483.25(d)(1)(2) Free of Accident Hazards/Supervision/Devices.
Previously cited 3/2/18.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 7/16/19, 7/10/19, 2/28/19, 10/4/18, 3/2/18.

28 Pa. Code 201.18(b)(1) Management.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 7/16/19, 2/28/19, 10/4/18, 3/2/18.

28 Pa. Code 211.10(d) Resident care plan.
Previously cited 9/20/19, 2/28/19.

28 Pa. Code 211.12(d)(1) Nursing services.
Previously cited 9/20/19, 7/10/19, 2/28/19, 11/5/18, 3/2/18.

28 Pa. Code 211.12(d)(5) Nursing services.
Previously cited 9/20/19, 7/10/19, 2/28/19, 11/5/18, 10/4/18, 3/2/18.





 Plan of Correction - To be completed: 02/29/2020

1. Resident 51 environment was immediately reviewed by nursing staff. No accident hazards noted Resident care plan related to legrests is being followed appropriately.

Resident 197 air mattress assessment was completed on 01/22/2020

2. All residents who utilize leg rests on their wheelchairs have the potential to be affected by this alleged deficient practice.
Observation of all residents on all
nursing units who utilize wheelchair
leg rests completed on 1/22/2020
with no other issues identified.

All residents who utilize air mattresses have the potential to be affected by this alleged deficient practice.
Whole House audit completed on air mattresses assessments
No other issues identified

3. Facility staff and agency staff will be re-educated on leg rest use policy and procedure including safe transport practices to avoid accidents and injuries including the use and / or removal of wheelchair footrests.

Department heads and registered nurses will be re-educated on facility policy related to accident investigations including possible cause and effect.

Facility staff will be re-educated on facility policy realted to incident, accident, injury, and fall prevention that include care plan interventions and orders.

licensed clinical nursing staff will be re-educated on facility policy related to supervisory role in ensuring incident, accident, injury and / or fall prevention intervention are care planned and physician orders received.

Approved Directed Inservice will be completed.


Licensed clinical nursing staff will be re-educated on facility air mattress assessment policy and procedure

4. Director Of Nursing or designee will conduct random observation audits of residents on the nursing units who utilize legrests weekly x 4 weeks then monthly x 3.
Findings will be reviewed by the
Quality Assurance Performance
Improvement Committee during
monthly meetings x 3 months or until substantial compliance

Director Of Nursing or designee will conduct random audits of mattress assessments weekly x 4 weeks then monthly x 3.
Findings will be reviewed by the
Quality Assurance Performance
Improvement Committee during
monthly meetings x 3 months or until substantial compliance




483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

483.20(b) Comprehensive Assessments
483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

483.20(b)(2) When required. Subject to the timeframes prescribed in 413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in 413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.
Observations:








Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive Minimum Data Set assessments were completed in the required time frame for five of 57 residents reviewed (Residents 58, 69, 71, 72, 352). Findings include:The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that for admission MDS assessments, the assessment completion date and the Care Area Assessment (CAA - the process of completing an in-depth assessment of triggered, potentially problematic care areas) completion date (Item V0200B2) were to be no later than the resident's admission date plus 13 calendar days, and for annual and significant change assessments they were to be no later than 14 days after the Assessment Reference Date (the last day of an assessment's review period).A comprehensive admission MDS assessment for Resident 352 revealed that the resident was admitted on December 20, 2019. The MDS assessment was dated as completed on January 10, 2020, which was 21 days after her admission.A comprehensive annual MDS assessment for Resident 72, with an ARD of November 7, 2019, was dated as completed on November 22, 2019, which was 15 days after the ARD.A comprehensive annual MDS assessment for Resident 71, with an ARD of November 7, 2019, was dated as completed on November 22, 2019, which was 15 days after the ARD.A comprehensive annual MDS assessment for Resident 58, with an ARD of October 30, 2019, revealed that the CAA was dated as completed on November 14, 2019, which was 15 days after the ARD.A comprehensive annual MDS assessment for Resident 69, with an ARD of November 7, 2019, revealed that the assessment and CAA were dated as completed on November 22, 2019, which was 15 days after the ARD.Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on January 24, 2020, at 5:11 p.m. confirmed that the above assessments were not completed in the required time frames.28 Pa. Code 211.5(f) Clinical records.Previously cited 7/10/19, 2/28/19.
 Plan of Correction - To be completed: 03/17/2020

1.Comprehensive Assessments for
Resident 58,resident 69,resident 71,resident 72,and resident 352 are all up to date and within compliance
2.All residents have the potential to be affected by this alleged deficient practice.
Comprehensive assessments completed 1/24/2020 - 2/5/2020 were audited for timely completion with no issues identified
3.Careplanning department employees have been re educated on the requirement to ensure timely completion and submission of comprehensive assessments
Administrator or designee will review completion report monthly.
4. Registered Nurse Assessment Coordinator/designee will audit the comprehensive assessments and complete audit tool weekly to ensure timely completion and submission weekly x 4 weeks then monthly x 3.Findings will be reviewed by the Quality Assurance Performance Improvement Committee during
monthly meetings x 3 months or until substantial compliance.


483.20(c) REQUIREMENT Qrtly Assessment at Least Every 3 Months:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.20(c) Quarterly Review Assessment
A facility must assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months.
Observations:


Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for five of 57 residents reviewed (Residents 68, 70, 73, 90, 182).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days.

A quarterly MDS assessment for Resident 182, with an ARD of November 7, 2019, was not signed as completed until November 22, 2019, which was 15 days after the ARD.

A quarterly MDS assessment for Resident 90, with an ARD of November 12, 2019, was not signed as completed until November 27, 2019, which was 15 days after the ARD.

A quarterly MDS assessment for Resident 70, with an ARD of November 7, 2019, was not signed as completed until November 22, 2019, which was 15 days after the ARD.

A quarterly MDS assessment for Resident 68, with an ARD of November 7, 2019, was not signed as completed until November 22, 2019, which was 15 days after the ARD.

A quarterly MDS assessment for Resident 73, with an ARD of November 7, 2019, was not signed as completed until November 22, 2019, which was 15 days after the ARD.

Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on January 24, 2020, at 5:11 p.m. confirmed that the above assessments were not completed in the required time frame.

28 Pa. Code 211.5(f) Clinical records.
Previously cited 7/10/19, 2/28/19.




 Plan of Correction - To be completed: 03/17/2020

1. Quarterly Assessments for
Resident 68,resident 70,resident 73,resident 90,and resident 182 are all up to date and within compliance
2. All residents have the potential to be affected by this alleged deficient practice.
Quarterly assessments completed 1/24/2020 - 2/5/2020 were audited for timely completion with no issues identified
3. Careplan department employees have been re educated on requirement to ensure timely submission of quarterly assessments
Administrator or designee will review completion report monthly.
4. Registered Nurse Assessment Coordinator/designee will audit submission of quarterly assessments and complete audit tool weekly to ensure timely submission weekly x 4 then monthly x 3.
Findings will be reviewed by the
Quality Assurance Performance
Improvement Committee during
monthly meetings x 3 months or until substantial compliance




483.10(c)(6)(8)(g)(12)(i)-(v) REQUIREMENT Request/Refuse/Dscntnue Trmnt;Formlte Adv Dir:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.

483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that living will decisions were documented correctly for two of 57 residents reviewed (Residents 105, 198).

Findings include:

The facility's policy regarding advanced directives, dated September 9, 2019, revealed that upon admission residents and/or their responsible party were to be asked to complete a Physicians Orders for Life-Sustaining Treatment form (POLST - a legal form that gives residents control of their end-of-life care in an emergency medical situation). Nursing staff were to review the POLST with the physician, the physician was to sign the POLST, the resident or responsible party was then to sign the form, and an order was to be obtained (that reflected the decisions made by the resident and/or responsible party).

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 105, dated November 2, 2019, revealed that the resident was cognitively impaired, required extensive assistance for care, and had diagnoses that included dementia.

A POLST form for Resident 105, dated November 13, 2019, indicated that the resident was a full code (cardiopulmonary resuscitation/full treatment, including intubation). The form was signed by Resident 105's responsible party.

A face sheet (patient information in an easy-to-use format that is used by physicians, caregivers and care managers) for Resident 105, indicated that the resident's advance directives included antibiotics, comfort only, CPR, full treatment, trial tube feeding/hydration.

Interview with Licensed Practical Nurse 2 on January 23, 2020, at 1:15 p.m. confirmed that Resident 105's face sheet did not accurately reflect the resident's advance directives for full treatment because it included "comfort only."


A POLST form for Resident 198, dated January 3, 2020, indicated that she was a DNR (do not attempt resuscitation) and her medical intervention was "limited additional intervention" (includes comfort measures and also medical treatment, intravenous fluids, cardiac monitor and transfer to the hospital as indicated). Physician's orders, dated January 6, 2020, indicated that hospice services (end-of-life care) was to be consulted due to the resident's end-stage renal (kidney) disease, and a second POLST form, dated January 7, 2020, indicated that the resident was comfort measures only with no limited additional interventions.

However, as of January 23, 2020, Resident 198's face sheet included "limited interventions."

Interview with Registered Nurse 3 on January 23, 2020, at 2:27 p.m. revealed that the resident's face sheet should reflect the current POLST, and she confirmed that Resident 198's face sheet did not. The nurse indicated that when a POLST is changed, the attending physician was to be notified to obtain an order, then the face sheet was to be changed to reflect the physician's order; however, when Resident 198's POLST was changed, a new physician's order was not obtained.

28 Pa. Code 201.29(a) Resident rights.

28 Pa. Code 201.29(d) Resident rights.



 Plan of Correction - To be completed: 03/17/2020

1.
Resident 105 facesheet was updated to match the Physician Order for Life Sustaining Treatment (POLST)
Resident 198 facesheet and physician order were updated to match the POLST

2.All residents have the potential to be affected by this alleged deficient practice.
POLST audit to be completed on the whole house to ensure facesheets, orders, and POLST match

3.Licensed nursing staff to be re- educated on facility policy and procedure related to POLST forms. Agency staff will be educated on facility policy and procedure realted to POLST forms.

4. Director or Nursing (DON) or designee will conduct random audits of Advanced Directives to ensure POLST, order, and facesheet match weekly x 4 weeks then monthly x 3.
Findings will be reviewed by the Quality Assurance Performance Improvement Committee during monthly meetings x 3 or until substantial compliance.
POLST will be reviewed quarterly by interdisciplinary care plan review.

483.75(g)(2)(ii) REQUIREMENT QAPI/QAA Improvement Activities:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.75(g) Quality assessment and assurance.

483.75(g)(2) The quality assessment and assurance committee must:
(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
Observations:


Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct and/or maintain compliance with quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) for the surveys ending February 28, July 10 and September 20, 2019, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 24, 2020, identified repeated deficiencies related to a failure to develop and implement a comprehensive individualized care plan for each resident, failures to review and revise care plans for each resident, failure to store/label medications properly, and a failure to maintain complete and accurate medical records.

The facility's plan of correction for a deficiency regarding developing and implementing a comprehensive, individualized care plan for each resident, cited during the survey ending February 28, 2019, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulation regarding developing and implementing a comprehensive, individualized care plan for each resident.

The facility's plan of correction for a deficiency regarding reviewing and revising care plans for each resident, cited during the survey ending September 20, 2019, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulation regarding reviewing and revising care plans for each resident.

The facility's plan of correction for a deficiency regarding storing/labeling medications properly, cited during the survey ending February 28, 2019, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulation regarding storing/labeling medications properly.

The facility's plan of correction for a deficiency regarding failure to maintain complete and accurate medical records, cited during the survey ending July 10, 2019, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F842, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulation regarding maintaining complete and accurate medical records.

Refer to F656, F657, F761, F842.

42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities.
Previously cited 2/28/19, 3/2/18.

28 Pa. Code 201.14(a) Responsibility of licensee.
Previously cited 7/16/19, 7/10/19, 2/28/19, 10/4/18, 3/2/18.

28 Pa. Code 201.18(e)(1) Management.
Previously cited 7/16/19, 2/28/19, 10/4/18, 3/2/18.




 Plan of Correction - To be completed: 03/17/2020

1. All current outstanding deficiencies are being reviewed at quarterly Quality Assurance Performance Improvement Meetings.
2.Quality Assurance meetings are being held monthly to ensure quality care is being delivered to the residents that reside at the facility.
3.Audit tools have been created to specifically target the deficient practice that took place as well as an added section for comments on performance improvement on the audit form to be later reviewed by the Quality Assurance Performance Improvement Committee.
Quality Assurance Performance Improvement Committee utilizes a root cause approach.
4. Nursing Home Administrator/designee will audit outstanding deficiency audits to ensure that improvements are being made to move facility forward. Findings of the audits will be reported to the Quality Assurance Performance Improvement Committee for recommendations or resolution at its regularly scheduled meeting times three or until substantial compliance for results, areas of improvement and/or continuation of audits.

483.20(f)(5), 483.70(i)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

483.70(i) Medical records.
483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

483.70(i)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

483.70(i)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

483.70(i)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under 483.50.
Observations:








Based on clinical record reviews and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 57 residents reviewed (Resident 174).Findings include:Physician's orders for Resident 174, dated January 3, 2020, included an order to measure the resident's coccyx (tailbone area) wound three times a week and then document the measurements in the electronic medical record every evening shift on Monday, Wednesday, and Friday. Resident 174's Treatment Administration Record (TAR) for January 2020 revealed that staff signed off that they completed the measurement on January 3, 20 and 22, 2020; however, there was no documented evidence that the wound measurements were placed into the resident's electronic medical record. Interviews with Licensed Practical Nurse Unit Coordinator 7 and the Director of Nursing on January 24, 2020, at 11:24 a.m. and 3:25 p.m. confirmed that Resident 174's TAR indicated that wound measurements were completed, but the measurements were not documented in the resident's electronic medical record on the above dates. 42 CFR 483.20(f)(5), 483.70(i)(1)-(5) Resident Records - Identifiable InformationPreviously cited 7/10/19. 28 Pa. Code 211.5(f) Clinical records.Previously cited 7/10/19, 2/28/19. 28 Pa. Code 211.12(d)(3) Nursing services.Previously cited 9/20/19, 7/10/19, 2/28/19.
 Plan of Correction - To be completed: 03/17/2020

1.Resident 174 physician notified and order received for wound measurements one time er week.
2.All residents with wounds have the potential to be affected by this alleged deficient practice.
audit of residents with wounds completed no further issues noted
3.Licensed clinical nursing staff and agency staff will be re-educated on the facility pressure sore policy including the need to document wound measurements in accordance with facility policy
Wound Measurements will be reviewed on a weekly basis.
4. Director Of Nursing or designee will conduct random audits of residents with wounds to ensure documentation is complete. Audits will be completed weekly x 4 and monthly x3.
Findings will be reviewed by the
Quality Assurance Performance
Improvement Committee during
monthly meetings x 3 months or until substantial compliance



483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

483.45(h) Storage of Drugs and Biologicals

483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:







Based on review of facility policies and physician's orders, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications were properly labeled for one of 57 residents reviewed (Resident 135).Findings include:The facility's policy regarding labeling medications, dated September 19, 2019, indicated that if the physician's directions for use changed, or the label was inaccurate, the nurse was to notify the pharmacy so that the pharmacist could generate a new label, make sure the contents were checked, and place a new label on the container. The pharmacist was to come to the facility to put the correct label on the container, and/or the nurse may be asked to send the medication back to the pharmacy to be checked. The nurse was to fax the new order to ensure that the pharmacy was current with their orders for the resident. Physician's orders for Resident 135, dated July 20, 2019, included an order for the resident to receive timolol hemihydrate solution 0.25 percent (eye drops used to treat glaucoma), instill one drop in the right eye one time a day for glaucoma (an eye condition that can cause blindness). Observations during medication administration on January 23, 2020, at 8:36 a.m. revealed that Resident 135's bottle of timolol eye drops was labled to instill one drop in the right eye two times a day, instead of one time a day as ordered by the physician. Interview with Licensed Practical Nurse 4 on January 23, 2020, at 10:50 a.m. confirmed that the label on Resident 135's eye drops was incorrect, and she would call the pharmacist so they can generate a label change. Interview with Registered Nurse Supervisor 3 on January 23, 2020, at 11:18 p.m. confirmed that the label on Resident 135's eye drops was incorrect. 42 CFR 483.45(g)(h)(1)(2) Label/Store Drugs and Biologicals.Previously cited 2/28/19, 3/2/18.28 Pa. Code 211.9(h) Pharmacy services. Previously cited 2/28/19.28 Pa. Code 211.12(d)(1)Nursing services.Previously cited 9/20/19, 7/10/19, 2/28/19, 11/5/18, 3/2/18.
 Plan of Correction - To be completed: 03/17/2020

1.Resident 135 physician was contacted. New eye drop order obtained and accurate label was obtained from the pharmacy on 1/23/2020.
2.All residents receiving timolol hemihydrate solution 0.25 percent have the potential to be affected by this alleged deficient practice.
audit will be completed for residents on timolol hemihydrate solution 0.25 percent
3.Licensed clinical nursing staff and agency staff will be re-educated on medication labeling policy and procedure including the needs to obtain corrected labels from the pharmacy to ensure accuracy with physicians orders.
Duplicate copy of medication change orders will be printed and given to Licensed Nurse / Medication Nurse to review. Copy will be signed off on by staff. Pharmacy will be notified for medication. Pharmacy direction change label will be applied to current medication until new medication is obtained.
4. Director Of Nursing or designee will conduct random audits of residents with medication changes to ensure orders and labels are accurate. Audits will be completed weekly x 4 and monthly x3.
Findings will be reviewed by the
Quality Assurance Performance
Improvement Committee during
monthly meetings x 3 months or until substantial compliance



483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:







Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to review and revise care plans for one of 57 residents reviewed (Resident 197).Findings include:The facility's policy regarding care planning, dated September 9, 2019, revealed that the facility's care planning/interdisciplinary team was responsible for the development of an individualized comprehensive care plan for each resident.The facility's policy regarding care plan review, dated September 9, 2019, revealed that whenever possible, the resident's care plan was to be updated by each discipline before the interdisciplinary conference, and between interdisciplinary conferences, all disciplines may update the resident's care plans using proper procedures for entering and discontinuing items based on an assessment of the resident's needs. Assessments of residents were to be ongoing, and care plans were to be revised as information about the resident and the resident's condition changed. Care plans were to be reviewed and updated when there was a significant change in the resident's condition, upon readmission from a hospital stay, and quarterly. A quarterly MDS assessment for Resident 197, dated January 4, 2020, revealed that the resident was understood and could understand others, required extensive assistance from staff for daily care tasks, including bed mobility and transfers, and received hospice services while a resident. The resident's care plan, dated October 1, 2019, revealed that she has the potential for skin integrity impairment related to immobility and cognitive impairment, and staff were to ensure that a pressure-reduction mattress was in place. Physician's orders for Resident 197, dated September 27, 2019, included an order for the resident to have a pressure-reduction mattress. A delivery ticket from a durable medical equipment provider, dated September 30, 2019, documented, "please take air mattress to Maybrook." Physician's orders, dated November 28, 2019, included an order to discontinue the pressure-reduction mattress. Observations of Resident 197 on January 21, 2020, at 10:45 a.m. revealed that the resident's bed was equipped with an air mattress.There was no documented evidence that Resident 197's care plan was revised to reflect the use of an air mattress. Interview with Licensed Practical Nurse 1 on January 22, 2020, at 2:10 p.m. confirmed that Resident 197's bed had an air mattress in place and that the resident's care plan was not revised to reflect the use of the air mattress. Interview with the Director of Nursing on January 23, 2020, at 8:45 a.m. confirmed that Resident 197's care plan was not revised to reflect the use of the air mattress. 42 CFR 483.21(b)(2)(i)-(iii) Care Plan Timing and Revision.Previously cited 9/20/19, 2/28/19.28 Pa. Code 211.10(d) Resident care plan.Previously cited 9/20/19, 2/28/19.28 Pa. Code 211.12(d)(1) Nursing services.Previously cited 9/20/19, 7/10/19, 2/28/19, 11/5/18, 3/2/18.28 Pa. Code 211.12(d)(3) Nursing services.Previously cited 9/20/19, 7/10/19, 2/28/19.28 Pa. Code 211.12(d)(5) Nursing services.Previously cited 9/20/19, 7/10/19, 2/28/19, 11/5/18, 10/4/18, 3/2/18.
 Plan of Correction - To be completed: 03/17/2020

1.Resident 197 care plan was immediately updated to include air mattress
2.All residents who utilize an air mattress have the potential to be affected by this alleged deficient practice.
Whole House audit completed on residents using air mattresses for care plans
No other issues identified
3.Licensed nursing staff and agency staff will be re-educated on the air mattress assessment policy and procedure including the requirement to have a care plan in place
Careplan team will review careplans quarterly.
4. Director Of Nursing or designee will conduct random audits of air mattress, care plans weekly x 4 weeks then monthly x 3.
Findings will be reviewed by the
Quality Assurance Performance
Improvement Committee during
monthly meetings x 3 months or until substantial compliance




483.21(b)(1) REQUIREMENT Develop/Implement Comprehensive Care Plan:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
483.21(b) Comprehensive Care Plans
483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.24, 483.25 or 483.40; and
(ii) Any services that would otherwise be required under 483.24, 483.25 or 483.40 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
Observations:







Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop an individualized care plan for constipation for one of 57 residents reviewed (Resident 32). Findings include:A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 32, dated November 10, 2019, revealed that the resident was cognitively impaired and totally dependent on staff for care. A nursing note, dated October 25, 2019, revealed that the resident was having seizure activity and was sent to the hospital where she was admitted for seizure activity.As of January 24, 2020, there was no documented evidence that a care plan regarding seizures was developed for Resident 32. Interview with the Director of Nursing on January 24, 2020, at 9:32 a.m. confirmed that a care plan to address Resident 32's new seizure diagnosis was not developed and it should have been. 42 CFR 483.21(b)(1) Develop/Implement Comprehensive Care Plan.Previously cited 2/28/19, 3/2/18.28 Pa. Code 211.11(d) Resident care plan.Previously cited 2/28/19, 3/2/18.28 Pa. Code 211.12(d)(5) Nursing services.Previously cited 9/20/19, 7/10/19, 2/28/19, 11/5/18, 10/4/18, 3/2/18.
 Plan of Correction - To be completed: 03/17/2020

1.Resident 32 care plan for seizures and constipation were added to residents plan of care
2.All residents who have a diagnosis of seizures or exhibit symptoms of constipation have the potential to be affected by this alleged deficient practice.
Whole house care plan audit related to seizures and constipation completed
care plans updated as appropriate
3.Licensed clinical nursing staff and agency staff will be re-educated on facility care plan policy and procedure with emphasis on ensuring residents with diagnoses of seizures and constipation have a care plan in place
Careplan team will review care plans for accuracy quarterly.
4. Director Of Nursing or designee will conduct random audits of seizure and constipation care plans weekly x 4 weeks then monthly x 3.
Findings will be reviewed by the
Quality Assurance Performance
Improvement Committee during monthly meetings x 3 months or until substantial compliance




483.10(g)(17)(18)(i)-(v) REQUIREMENT Medicaid/Medicare Coverage/Liability Notice:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.10(g)(17) The facility must--
(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of-
(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged;
(B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and
(ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in 483.10(g)(17)(i)(A) and (B) of this section.

483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate.
(i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible.
(ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change.
(iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements.
(iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility.
(v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.
Observations:








Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage for two of two residents reviewed (Residents 49, 57) who remained in the facility for long-term care. Findings include:An undated Skilled Nursing Facility (SNF) Advanced Beneficiary Notice form completed by the facility revealed that Medicare coverage for Resident 49 started on July 4, 2019, and that the resident's last covered day was August 5, 2019. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. An Advanced Beneficiary Notice of Non-coverage (ABN - a notice given to Medicare beneficiaries to convey that Medicare is not likely to provide coverage for a skilled service) for Resident 49, dated July 31, 2019, was incomplete as it did not include the details of what skilled service the resident was receiving and how much that skilled service would cost.An undated SNF Advanced Beneficiary Notice form completed by the facility revealed that Medicare coverage for Resident 57 started on June 27, 2019, and that her last covered day for Medicare coverage was August 6, 2019. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. The Advanced Beneficiary Notice of Non-coverage for Resident 57, dated August 1, 2019, was incomplete as it did not include the details of what skilled service the resident was receiving and how much that skilled service would cost.Interview with Licensed Practical Nurse/Transition Care Nurse 12 on January 24, 2020, at 10:50 a.m. confirmed that the ABN notices for Residents 49 and 57 were incomplete and did not include the details of what skilled service the residents were receiving and how much those services would cost.28 Pa. Code 201.18(e)(1) Management.Previously cited 7/16/19, 2/28/19, 10/4/18, 3/2/18.
 Plan of Correction - To be completed: 03/17/2020

1. Advanced Beneficiary Notice for Resident 49 was updated and copy sent to his daughter (emergency contact).
Advanced Beneficiary Notice for Resident 57 was updated and copy provider to the resident.

2. All residents being discharged from Medicare A services and remain in the facility have the potential to be affected by this alleged deficient practice. Audit completed for Medicare A residents with Advanced Beneficiary Notices issued from 1/24/2020 - 2/7/2020 no issues identified

3. Careplan department and social service director have been re educated on the Advanced Beneficiary Notice process to ensure thorough and accurate completion of the form.

Administrator will review the Advanced Beneficiary notices on a monthly basis.

4. Licensed Practical Nurse Assessment Coordinator will audit the Advanced Beneficiary Notices and complete audit tool weekly x 4 weeks then monthly x 3.
Findings will be reviewed by the Quality Assurance Performance Improvement Committee during monthly meetings x 3 months or until substantial compliance



205.25(b) LICENSURE Kitchen.:State only Deficiency.
(b) A service pantry shall be provided for each nursing unit. The pantry shall contain a refrigerator, device for heating food, sink, counter and cabinets. For existing facilities, a service pantry shall be provided for a nursing unit unless the kitchen is sufficiently close for practical needs and has been approved by the Department.
Observations:


Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that three of five service pantries were equipped with a device for heating resident food.

Findings include:

The facility's policy regarding microwaves, dated January 16, 2019, revealed that microwaves on the units were for staff use only and for residents who requested food to be heated, nursing staff were to request a new item from the kitchen.

Observations of the S2 Nourishment Center on January 22, 2020, at 3:05 p.m. revealed that there was a microwave with food debris on the inside top surface. Interview with Registered Nurse 8 on January 22, 2020, at 3:58 p.m. confirmed that there was food debris on the inside of the microwave. She indicated that the microwave was used for residents and that the staff had a microwave for their use in another area of the building.

Observations of the S1 Nourishment Center on January 22, 2020, at 3:11 p.m. revealed that there was a microwave with food debris on the inside top surface and the side walls. Interview with Nurse Aide 9 on January 22, 2020, at 4:04 p.m. confirmed that there was food debris on the inside of the microwave. She indicated that the microwave was used for residents.

Observations of the D1 Nourishment Center on January 22, 2020, at 3:23 p.m. revealed that there was a microwave with food debris on the inside top surface. Interview with Registered Nurse 10 on January 22, 2020, at 4:08 p.m. confirmed that there was food debris on the inside of the microwave. Interview with Nurse Aide 11 on January 22, 2020, at 4:15 p.m. revealed that they used the microwave for residents.

Interview with the Nursing Home Administrator on January 23, 2020, at 8:20 a.m. revealed that the microwaves on the units we to be for staff use only, they went to the units and marked them for staff use only, and on the units that had two microwaves, they removed one.

The Nursing Home Administrator could provide no information regarding what devices were available in the service pantries for heating residents' food/drinks.



 Plan of Correction - To be completed: 03/17/2020

1.Nursing units each have a microwave available for heating / reheating resident food / beverages.
2.All residents who reside on those nursing units have the potential to be affected by this alleged deficient practice.
3. Facility Microwave Policy updated. Each nursing kitchenette has a microwave available. Re-education to be provided to facility staff on policy, procedure, and precautions.
4. Administrator will complete random audits to ensure microwaves are available for heating / reheating resident food / beverages weekly x 4 and monthly x 3. Findings will be reviewed by the Quality Assurance Performance Improvement Committee during monthly meetings x 3 months or until substantial compliance.






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