26 Reports
Inspection Report — Oct 9, 2025
Follow-Up
Date: Oct 9, 2025
Visit Reason
The inspection visit occurred as a follow-up to review the submitted plan of correction related to an incident at the facility.
Findings
The plan of correction was determined to be fully implemented, with retraining and education conducted for staff regarding securing medical care for residents. Continued compliance must be maintained.
Citations (1)
Failure to secure medical care promptly after a resident experienced an unwitnessed fall and called for help, resulting in delayed emergency medical services response.
Report Facts
Residents Served: 50
Current Hospice Residents: 4
Residents Age 60 or Older: 50
Residents with Mobility Need: 20
Total Daily Staff: 70
Waking Staff: 53
Inspection Report — Sep 16, 2025
Renewal
Date: Sep 16, 2025
Visit Reason
The inspection was conducted as a renewal review of the facility's license to ensure compliance with applicable regulations and to verify that the submitted plan of correction was fully implemented.
Findings
The inspection identified multiple deficiencies including unsecured resident records, improper placement and labeling of carbon monoxide detectors, incomplete training records, inadequate fire drill documentation, medication labeling and administration errors, and incomplete resident assessments. Plans of correction were accepted and implemented with retraining and audits scheduled.
Citations (7)
Resident records were found unlocked, unattended, and accessible on the medication cart.
Carbon monoxide detectors lacked battery installation dates and were improperly placed too close to fossil fuel burning devices; no detector on the 2nd floor.
Orientation training records for direct care staff did not include source of training or specific training topics.
Fire drill records lacked year, exit routes, and accurate resident evacuation numbers.
Medication cards contained discontinued medications and incorrect labeling of prescribed dosages.
Medication administration records did not include initials of staff administering medications.
Resident assessment did not reflect diagnosis of unspecified atrial fibrillation and ability to safely use or avoid poisonous materials.
Report Facts
Residents Served: 49
Total Daily Staff: 73
Waking Staff: 55
Current Hospice Residents: 7
Residents Age 60 or Older: 49
Residents with Mobility Need: 24
Inspection Report — Mar 17, 2025
Complaint Investigation
Date: Mar 17, 2025
Visit Reason
The inspection was conducted as a complaint investigation during an unannounced partial licensing inspection on 03/17/2025.
Complaint Details
The inspection was complaint-related, but no deficiencies or citations were found, indicating no substantiated issues.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 50
Resident Diagnosed with Mental Illness: 1
Residents with Mobility Need: 21
Residents Age 60 or Older: 50
Resident Receiving Supplemental Security Income: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Inspection Report — Feb 9, 2024
Follow-Up
Date: Feb 9, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to review the submitted plan of correction related to abuse allegations.
Complaint Details
The visit was complaint-related due to an incident involving abuse allegations against staff person A. The plan of correction was submitted and fully implemented, including suspension of the staff person and staff retraining. The violation was a repeat from 07/05/2023.
Findings
The submitted plan of correction was determined to be fully implemented. The report details a repeated abuse violation involving a staff person verbally abusing a resident and attempting to take the resident's cell phone, with subsequent staff retraining and suspension of the involved staff member.
Citations (2)
Staff person A entered resident bedroom and began yelling and swearing at resident, attempted to grab resident's cell phone, and knocked personal items off resident's side table, causing distress to the resident.
Staff person A continued to work unsupervised after the incident until the end of the shift.
Report Facts
Residents Served: 45
Current Hospice Residents: 6
Residents 60 Years or Older: 45
Residents with Mobility Need: 19
Residents with Physical Disability: 1
Total Daily Staff: 64
Waking Staff: 48
Inspection Report — Mar 1, 2023
Date: Mar 1, 2023
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing, due to an incident.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Total Daily Staff: 83
Waking Staff: 62
Resident Support Staff: 0
Current Residents in Hospice: 3
Residents Served: 56
Residents Age 60 or Older: 56
Residents with Mobility Need: 27
Residents Receiving Supplemental Security Income: 0
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Residents with Physical Disability: 0
Inspection Report — Jun 13, 2022
Renewal
Date: Jun 13, 2022
Visit Reason
The inspection was a renewal licensing inspection conducted on 06/13/2022 through 06/15/2022 to assess compliance with Department statutes and regulations.
Findings
Several deficiencies were identified including issues with resident personal equipment (wheelchair armrest damage), missing supplies in first aid kits, lack of current rabies vaccination documentation for a resident cat, and incomplete annual medical evaluations for a resident. Plans of correction were accepted and implemented with follow-up audits and staff retraining scheduled.
Citations (5)
The right armrest on the wheelchair of resident #1 was missing padding and the vinyl was only attached approximately 2 ½ inches, exposing the underlying hard plastic and hardware, also the outer edge of the left armrest was cracked, posing a skin tear hazard.
The first aid kit in the wellness center did not include gauze.
A cat named Penelope was in the home without a current certificate of rabies vaccination.
The medical evaluation for resident #2 was blank in the area of body positioning/movement.
The first aid kit in the van used for transporting residents did not contain eye coverings.
Report Facts
Residents Served: 46
Current Residents in Hospice: 3
Residents with Mobility Need: 20
Waking Staff: 50
Total Daily Staff: 66
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Named in multiple findings related to wheelchair replacement, staff retraining, and audit oversight | |
| Health and Wellness Coordinator | Named in findings related to auditing wheelchairs, restocking first aid kits, and coordinating medical evaluation updates | |
| Executive Director | Named in findings related to notifying family for cat rabies vaccination and staff retraining | |
| Resident Program Manager | Responsible for auditing pet vaccination records and ongoing compliance | |
| Activities Director | Responsible for auditing van first aid kit and reviewing audit results |
Inspection Report — Jan 26, 2022
Follow-Up
Date: Jan 26, 2022
Visit Reason
The inspection was a partial, unannounced follow-up visit triggered by an incident to verify the implementation of a previously submitted plan of correction.
Findings
The submitted plan of correction related to a deficiency in the initial resident assessment was found to be fully implemented. The deficiency involved the lack of documentation for 'Supervision need' in the assessment tool, which has since been addressed through staff retraining and audits.
Citations (1)
Resident #1's initial assessment did not include an assessment for 'Supervision need' as it was not part of the home's assessment tool.
Report Facts
Residents Served: 44
Current Hospice Residents: 1
Residents with Mobility Need: 19
Total Daily Staff: 63
Waking Staff: 47
Notice — Aug 25, 2021
Date: Aug 25, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for the Personal Care Home, Brookdale Mt. Lebanon, following receipt of the renewal application. It also advises that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It confirms the issuance of a regular license and outlines the requirement for an annual inspection to ensure compliance with applicable regulations.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter |
Inspection Report — Apr 1, 2021
Follow-Up
Date: Apr 1, 2021
Visit Reason
The inspection was a full, unannounced licensing inspection conducted on 04/01/2021 and 04/02/2021 to review compliance and verify the implementation of a previously submitted plan of correction.
Findings
The facility was found to have multiple deficiencies including undated carbon monoxide alarm batteries, missing bedside table and operable lamp for a resident, and food safety violations such as uncovered and unsealed food items stored improperly. All deficiencies had plans of correction accepted and were documented as implemented.
Citations (6)
Undated batteries in the battery-operated carbon monoxide detector in the boiler room attic.
No bedside table or shelf beside resident #1's bed.
Resident #1 did not have access to a source of light that can be turned on/off at bedside.
Uncovered tray of cooked rice stored in the walk-in cooler.
Ten 5-gallon bottles of water stored on the floor in the basement.
Unsealed bag of french fries stored in the kitchen freezer.
Report Facts
Residents Served: 36
Total Daily Staff: 51
Waking Staff: 38
Number of Deficiencies: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Suzy Quinn | Signed letter confirming plan of correction implementation | |
| Barbara Barone | On-site Department Representative for inspection dates 04/01/2021 and 04/02/2021 | |
| Maintenance Manager | Responsible for replacing carbon monoxide detector batteries and conducting audits | |
| Health & Wellness Director | Retrained staff and monitored compliance related to bedside table and lighting deficiencies | |
| Dining Director | Removed contaminated food items and retrained dining staff on food safety policies | |
| Maintenance Director | Relocated water bottles off the floor and retrained staff on storage policies | |
| Executive Director | Oversaw retraining and compliance monitoring related to food storage and carbon monoxide detector policies |
Inspection Report — Aug 3, 2020
Renewal
Date: Aug 3, 2020
Visit Reason
The document is a renewal license issued in response to the May 19, 2020 renewal application for the Personal Care Home. The Department advises that an annual onsite inspection will be conducted within the next twelve months to ensure compliance.
Findings
No inspection findings are reported in this document. It primarily serves as a license renewal notification and outlines the requirement for a future annual inspection.
Report Facts
Notice — Jul 1, 2019
Date: Jul 1, 2019
Visit Reason
The document serves as a renewal notification for the license to operate the Personal Care Home, Brookdale Mt. Lebanon, and informs that an annual onsite inspection will be conducted within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal notice confirming the facility's authorized capacity and the requirement for an annual inspection.
Report Facts
Inspection Report — Feb 19, 2019
Annual Inspection
Date: Feb 19, 2019
Visit Reason
The inspection was an annual licensing inspection conducted by the Department’s Bureau of Human Services Licensing to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
Multiple violations of 55 Pa. Code Chapter 2600 were found, including unsigned resident contracts, lack of resident education on rights, incomplete staff training on emergency procedures, improper medication labeling, incomplete mobility assessments, and inadequate documentation in resident support plans.
Citations (6)
Regulation 2600.25b: Contracts for residents #2 and #3 were not signed by the residents.
Regulation 2600.41e: Residents #2 and #3 were not educated on residents' rights and the right to lodge complaints without retaliation.
Regulation 2600.65a: Staff persons A and B did not receive training on notification of emergency services and how to reach emergency services.
Regulation 2600.184a: Medication label for resident #4 did not include the sliding scale coverage on the label.
Regulation 2600.226a: Mobility assessments for residents #3, #4, and #5 did not include assessment of mobility needs.
Regulation 2600.227d: Support plans for residents #2, #3, #4, and #5 lacked contact information for service providers and did not address how the home would meet residents' medical and behavioral health needs.
Report Facts
Residents Served: 45
Total Daily Staff: 64
Waking Staff: 48
Current Hospice Residents: 3
Residents Age 60 or Older: 45
Residents with Mobility Need: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Jones | RN, Personal Care Home Administrator | Named in multiple findings and plans of correction as the legal entity representative and signatory. |
Notice — Jun 6, 2018
Date: Jun 6, 2018
Visit Reason
The document serves as a renewal notification and license issuance for Brookdale Mt. Lebanon Personal Care Home following receipt of a renewal application.
Findings
No inspection findings are reported. The letter states that the Department will conduct an onsite inspection within the next twelve months as required by regulation.
Inspection Report — Apr 25, 2018
Routine
Date: Apr 25, 2018
Visit Reason
The Department's Bureau of Human Services representatives conducted an inspection of the facility on April 25, 2018.
Findings
No regulatory violations with 55 Pa. Code Ch. 2600 (relating to Personal Care Homes) were identified as a result of this inspection.
Inspection Report — Feb 20, 2018
Renewal
Date: Feb 20, 2018
Visit Reason
The inspection was a renewal licensing inspection conducted on February 20 and 21, 2018, for Brookdale Mt Lebanon Personal Care Home.
Findings
The inspection found violations related to medical evaluations, medication storage and administration, and resident assessments. A plan of correction was submitted addressing incomplete medical evaluations, uncalibrated glucometers, and resident self-administration of medications.
Citations (3)
55 Pa.Code §2600.141(b)(1): A resident's most recent medical evaluation did not include the resident's height.
55 Pa.Code §2600.186(a): The home failed to properly store, secure, and document blood glucose checks and medication administration for residents, including uncalibrated glucometers and missing readings.
55 Pa.Code §2600.225(a): A resident's assessment indicated self-administration of medications without assistance, but the resident was unable to identify medication names or purposes during interviews.
Report Facts
Number of Residents Served: 43
Total Daily Staff: 60
Walking Staff: 45
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 6
Residents Age 60 or Older: 43
Residents with Mobility Need: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Jones | Administrator, RN, PCHA | Named as Administrator and signed plan of correction documents related to violations. |
Inspection Report — Dec 15, 2017
Routine
Date: Dec 15, 2017
Visit Reason
The Department of Human Services licensing representatives conducted an inspection of the facility.
Findings
No regulatory violations were identified as a result of this inspection.
Inspection Report — Nov 17, 2017
Complaint Investigation
Date: Nov 17, 2017
Visit Reason
The inspection was conducted as a complaint investigation following an incident involving alleged abuse by a staff person at the facility.
Complaint Details
The complaint involved an allegation that staff person A punched resident #1 on 10/30/17 and continued to work unsupervised. The allegation was investigated and determined to be unfounded after retraining and supervision plans were implemented.
Findings
The investigation found that staff person A punched a resident and continued to work unsupervised. The allegation was determined to be unfounded after retraining and supervision plans were implemented. Additionally, the resident's assessment was updated to reflect behavioral issues.
Citations (2)
Regulation 55 Pa.Code §2600.15(b) - Staff person A was placed on a plan of supervision after an allegation of abuse involving punching a resident. The allegation was found unfounded following retraining and supervision adjustments.
Regulation 55 Pa.Code §2600.225(a) - Resident #1's initial assessment was updated to include noted behaviors such as yelling, swearing, and threatening staff. The Health and Wellness Director retrained staff on maintaining current assessments.
Report Facts
Number of Residents Served: 45
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Jones | Administrator | Named as facility administrator on page 2. |
| Lisa Flinner-Alman | Department Representative | On-site inspector for the complaint investigation on 11/17/2017. |
| Beth Park | Department Representative | On-site inspector for the complaint investigation on 11/17/2017. |
Notice — Jun 9, 2017
Date: Jun 9, 2017
Visit Reason
The document is a renewal application acknowledgment and notification that the Department will conduct an onsite inspection within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document; it serves as a license renewal confirmation and outlines the Department's inspection requirements.
Report Facts
Inspection Report — Feb 28, 2017
Renewal
Date: Feb 28, 2017
Visit Reason
The inspection was conducted as a renewal licensing inspection of the Personal Care Home facility Brookdale Mt Lebanon on February 28, 2017 and March 1, 2017.
Findings
Multiple violations of 55 Pa.Code Chapter 2600 were found related to resident confidentiality, privacy, safety, medication labeling, preadmission screening, and resident assessments. Plans of correction were submitted and partially implemented as of May 8, 2017.
Citations (6)
55 Pa.Code §2600.127 - Resident records were unlocked, unattended, and accessible in the physical therapy room and Wellness Center, compromising confidentiality.
55 Pa.Code §2600.42(b) - The home lacked signs indicating video recording entrances and exits despite having video surveillance.
55 Pa.Code §2600.64 - An accessible steam table measured 232.7°F in the dining room without protective guards or insulation to prevent resident contact.
55 Pa.Code §2600.184(a) - Prescription medication container for resident #12 was labeled incorrectly with dosage instructions differing from the pharmacy label.
55 Pa.Code §2600.224(a) - Resident #11's preadmission screening form was dated after admission, violating timely screening requirements.
55 Pa.Code §2600.225(c) - Resident #13's annual assessment lacked documentation of glaucoma, hypertension, hyperthyroidism, and thyrotoxicosis diagnoses indicated in the medical evaluation.
Report Facts
Total Daily Staff: 83
Waking Staff: 62
Number of Current Hospice Residents: 3
Number of Hospice Residents in past year: 9
Number of Residents 60 Years or Older: 56
Number of Residents with Mobility Need: 27
Number of Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Jones | RN, PCHA | Administrator and Legal Entity Representative signing plans of correction related to violations. |
Inspection Report — Dec 9, 2016
Complaint Investigation
Date: Dec 9, 2016
Visit Reason
The inspection was conducted as a complaint investigation triggered by an incident involving alleged abuse of a resident by a staff person.
Complaint Details
The complaint investigation was substantiated. The incident involved a resident being pushed by a staff person, and the home failed to report the incident timely to the Department. The home implemented a plan of correction including staff retraining and policy reinforcement.
Findings
The investigation found that a staff person pushed a resident in the chest while assisting them, and the home failed to report the incident to the Department within 24 hours as required. Additional violations included misuse of the term 'assisted living' in marketing materials.
Citations (4)
55 Pa.Code §2600.150b - The home failed to immediately develop and implement a plan of supervision or suspend the staff person involved in an alleged abuse incident.
55 Pa.Code §2600.150b - A staff person pushed a resident in the chest while assisting them, and the staff continued working unsupervised after the incident.
55 Pa.Code §2600.160c - The home failed to report the abuse incident to the Department within 24 hours as required by regulation.
55 Pa.Code §2600.18a - The home used the term 'assisted living' in marketing materials without proper licensing, violating state law.
Report Facts
Number of Residents Served: 59
Total Daily Staff: 79
Waking Staff: 59
Number of Current Hospice Residents: 2
Number of Hospice Residents in Past Year: 5
Residents Age 60 or Older: 59
Residents with Mobility Need: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Jones | Administrator, RN, PCHA | Named in plan of correction and signature on violation report |
Inspection Report — Oct 12, 2016
Complaint Investigation
Date: Oct 12, 2016
Visit Reason
The inspection was conducted as a complaint investigation at Brookdale Mt. Lebanon Personal Care Home on October 12, 2016.
Complaint Details
The inspection was complaint-driven. Specific complaints involved inadequate staff training hours and medication management issues. The report does not state substantiation status explicitly.
Findings
The inspection found multiple violations related to staff training hours, medication administration, expired medications, and controlled substances management. Plans of correction were submitted with partial implementation progress noted.
Citations (4)
Regulation 55 Pa.Code 2600.65(e): Direct care staff person A only received 7.5 hours of training during the 2015 training year instead of the required 12 hours.
Regulation 55 Pa.Code 2600.65(f): Direct care staff person A did not receive training in safe management techniques, medication self-administration, and care for residents with dementia and cognitive impairments during the 2015 training year.
Regulation 55 Pa.Code 2600.183(f): A card for resident #2's Hydrocodone/APAP medication expired on 9/20/2016 and was still in the medication cart.
Regulation 55 Pa.Code 2600.185(a): The home's medication policy requires counting controlled substances at shift end, but discrepancies were found in morphine syringes counts for resident #1.
Report Facts
Number of Residents Served: 54
Total Daily Staff: 71
Walking Staff: 53
Number of Current Hospice Residents: 4
Number of Hospice Residents in Past Year: 6
Residents with Mobility Need: 17
Residents with Physical Disability: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Jones | Administrator | Named as Administrator on page 2 and signed plan of correction pages. |
| Jason Williams | Services Licensing Supervisor | Signed the cover letter on page 1. |
Notice — Jul 5, 2016
Date: Jul 5, 2016
Visit Reason
This document serves as a renewal notice and license issuance for the Personal Care Home facility Brookdale Mt. Lebanon, confirming the renewal application and informing about the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported in this document. It is a license renewal notice and certificate of compliance.
Inspection Report — May 3, 2016
Renewal
Date: May 3, 2016
Visit Reason
The inspection was conducted as a renewal licensing inspection of the facility on May 3 and May 4, 2016.
Findings
Violations of 55 Pa.Code Ch. 2600 related to Personal Care Homes were found during the inspection. The facility submitted a Plan of Correction addressing issues such as the location of the licensing summary, medication administration, and maintenance of the community grounds.
Citations (4)
Regulation 2600.3(c): The violation binder containing the current licensing summary was initially misplaced but was relocated to a public area. Staff will be retrained and weekly audits will be conducted to ensure the summary remains accessible.
Regulation 2600.17: The Medication Administration Record (MAR) was relocated to a secure area. Medication technicians and LPNs will be retrained on confidentiality policies, and weekly audits of MARs will be performed.
Regulation 2600.100(a): Sidewalk hazards were identified and repaired. Maintenance staff will conduct daily rounds to identify and report hazards, with oversight by the Executive Director for three months.
Regulation 2600.184(a): The medication order was corrected and labeled properly. Staff will be retrained on medication administration policies, and weekly audits of medication carts will be conducted.
Report Facts
Number of Residents Served: 57
Number of Current Hospice Residents: 2
Number of Hospice Residents in past year: 5
Residents with Mobility Need: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Jones | Legal Entity Representative, PCHA | Signed Plan of Correction documents |
| Jacqueline L. Rowe | Director | Signed cover letter for inspection report |
Inspection Report — Jan 29, 2016
Date: Jan 29, 2016
Visit Reason
The inspection was an interim document review related to licensing compliance for Brookdale Mt. Lebanon personal care home.
Findings
The facility was found in violation for using the term 'Assisted Living' in its materials without being a licensed assisted living residence. A fine calculation and enforcement process was outlined pending correction.
Citations (1)
55 Pa.Code § 2600.18: The facility used the term 'Assisted Living' in its materials without being licensed as an assisted living residence.
Report Facts
Fine per resident per day: 3
Calculated Fine per day: 171
Mandated Correction Timeframe: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Matthew J. Jones | Director | Signed enforcement letter regarding violation and fine |
| Jacob Herzing | Enforcement Manager | Contact for submission of plan of correction and enforcement matters |
Inspection Report — Jan 29, 2016
Enforcement
Date: Jan 29, 2016
Visit Reason
The Department of Human Services issued a notice of intent to assess a fine for regulatory violations related to personal care homes under 55 Pa.Code Chapter 2600. The inspection was an off-site document review conducted as an interim inspection.
Findings
Brookdale Mt. Lebanon was found to be advertising as an Assisted Living residence without a license, violating 55 Pa.Code Chapter 2800. A Class III violation was cited, resulting in a fine assessment for the period from February 19, 2016 through March 4, 2016.
Citations (1)
55 Pa.Code § 2600.18: The facility advertised assisted living services without being licensed as an assisted living residence. Brookdale Mt. Lebanon is not a licensed assisted living residence.
Report Facts
Fine Amount: 2565
Fine Per Resident Per Day: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jacob Herzing | Enforcement Manager | Named as contact for appeals and enforcement |
| Matthew J. Jones | Director | Signed enforcement letter |
| Christina Jones | Legal Entity Representative | Signed plan of correction |
Notice — August 25, 2023
Date: August 25, 2023
Visit Reason
This document serves as a renewal notification and license issuance for Brookdale Mt. Lebanon Personal Care Home following receipt of the renewal application dated July 10, 2023.
Findings
The Department issued a regular license in response to the renewal application and advised that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
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