Deficiencies (last 4 years)
Deficiencies (over 4 years)
15 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
305% worse than Arizona average
Arizona average: 3.7 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
20% occupied
Based on a January 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 2
Date: Jun 27, 2025
Visit Reason
The inspection was conducted to assess compliance with medication administration, storage, resident safety, and accident prevention in the nursing home.
Findings
The facility failed to ensure proper self-administration of medications for one resident, resulting in medications being left at bedside without assessment. Additionally, a resident was mistakenly given Dakin's solution orally instead of water, posing a risk of adverse effects. The facility also failed to ensure adequate supervision to prevent accidents.
Deficiencies (2)
Allow residents to self-administer drugs if determined clinically appropriate; medications were left at bedside without proper assessment.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Report Facts
Residents affected: 1
Residents affected: 1
Sample size: 13
Medication dosage: 7.6
Medication dosage: 0.5
Medication dosage: 50
Dakin's solution ingested: 30
Elevated systolic pressure: 147
Elevated blood sugar: 386
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #100 | Licensed Practical Nurse (LPN) | Identified medications left at bedside and stated policy on medication administration |
| Staff #60 | Licensed Practical Nurse (LPN) | Interviewed about medication administration procedures |
| Staff #92 | Director of Nursing (DON) | Provided information on medication self-administration policy and incident awareness |
| Staff #61 | Licensed Practical Nurse (LPN) | Administered incorrect substance (Dakin's solution) to resident |
| Staff #91 | Assistant Director of Nursing (ADON) | Interviewed regarding wound care and medication administration |
| Staff #210 | Nurse Practitioner | Interviewed regarding wound care and medication administration |
| Staff #87 | Licensed Practical Nurse (LPN) | Interviewed about medication error reporting procedures |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 27, 2025
Visit Reason
The inspection was conducted to investigate complaints related to medication administration and storage practices, and to ensure resident safety from preventable accidents in the nursing home.
Complaint Details
The investigation was complaint-driven, focusing on medication administration errors and resident safety. The complaint was substantiated with findings of medication left at bedside without assessment and a resident ingesting a hazardous solution mistakenly given instead of water.
Findings
The facility failed to ensure proper medication administration and storage, including lack of assessment for self-administration of medications for one resident, and an incident where a resident ingested Dakin's solution instead of water. Both deficiencies posed minimal harm with potential for actual harm to residents.
Deficiencies (2)
Failure to ensure medications were administered, stored properly, and residents assessed for self-administration of medication for one resident.
Failure to ensure the nursing home area was free from accident hazards and provide adequate supervision to prevent accidents, resulting in a resident ingesting Dakin's solution.
Report Facts
Resident sample size: 13
Dakin's solution ingested: 30
BIMS score: 15
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)/Staff #100 | Mentioned in medication administration and storage deficiency | |
| Licensed Practical Nurse (LPN)/Staff #60 | Interviewed regarding medication administration practices | |
| Director of Nursing (DON)/Staff #92 | Interviewed regarding medication self-administration policy and incident awareness | |
| Licensed Practical Nurse (LPN)/Staff #61 | Involved in incident where resident ingested Dakin's solution | |
| Assistant Director of Nursing (ADON)/Staff #91 | Interviewed regarding medication administration and wound care | |
| Nurse Practitioner/Staff #210 | Interviewed regarding medication administration and incident | |
| Licensed Practical Nurse (LPN)/Staff #87 | Interviewed regarding medication error reporting and prevention |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 12, 2025
Visit Reason
The inspection was conducted due to concerns about a Licensed Practical Nurse (Staff #29) who was found to have a revoked nursing license, potentially impacting resident care safety and quality.
Complaint Details
The investigation was complaint-related, focusing on the revocation of Staff #29's nursing license and the facility's failure to prevent her from working while unlicensed. The complaint was substantiated as the license revocation was confirmed and the staff worked 24 shifts during the period.
Findings
The facility failed to ensure that one Licensed Practical Nurse had a valid license to practice in Arizona. Staff #29's license was revoked, but she worked 24 shifts before being suspended. The facility's process for ongoing license verification was unclear, and the Human Resources department conducted random audits but was not fully aware of risks associated with invalid licenses.
Deficiencies (1)
Failure to ensure one Licensed Practical Nurse had a valid license to practice in the State of Arizona.
Report Facts
Shifts worked by unlicensed nurse: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #29 | Licensed Practical Nurse | Nurse with revoked license who worked 24 shifts. |
| Staff #22 | Director of Nursing | Interviewed regarding license verification processes and risks. |
| Staff #49 | Director of Human Resources | Interviewed about license verification and audits. |
Inspection Report
Deficiencies: 1
Date: Feb 12, 2025
Visit Reason
The inspection was conducted to assess compliance with nursing staff licensing requirements after discovering that a Licensed Practical Nurse (Staff #29) had a revoked license and was working at the facility.
Findings
The facility failed to ensure that one Licensed Practical Nurse had a valid license to practice in Arizona. Staff #29's license was revoked, but she worked 24 shifts before being suspended. The facility's Human Resources department performs random audits of licenses but was not immediately notified of the revocation due to the license originating from Texas.
Deficiencies (1)
Failure to ensure nurses and nurse aides have appropriate competencies and valid licenses to care for residents safely.
Report Facts
Shifts worked by unlicensed nurse: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #29 | Licensed Practical Nurse | Nurse with revoked license who worked 24 shifts. |
| Staff #22 | Director of Nursing | Interviewed regarding license verification and risks to residents. |
| Staff #49 | Director of Human Resources | Interviewed regarding license verification process and audits. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 24, 2024
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to develop a complete baseline care plan for a resident and failure to ensure appropriate monitoring of a resident post fall.
Complaint Details
The complaint investigation found that resident #3 was left unattended after a fall, and the baseline care plan lacked necessary interventions for bladder incontinence. The complaint was substantiated based on staff interviews, family statements, and policy review.
Findings
The facility failed to develop a complete baseline care plan including necessary interventions for bladder incontinence for resident #3, and failed to ensure the resident was appropriately monitored after a fall, resulting in potential harm. Multiple staff interviews and documentation reviews confirmed these deficiencies.
Deficiencies (2)
Failure to develop a complete baseline care plan including interventions for bladder incontinence for resident #3.
Failure to ensure appropriate monitoring of resident #3 post fall, leaving the resident unattended on the floor for a short time.
Report Facts
BIMS score: 11
Date baseline care plan initiated: Jun 17, 2024
Date of fall incident: Jun 19, 2024
Time resident left alone post fall: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #40 | Social Services Director | Interviewed regarding baseline care plan expectations and deficiencies |
| Staff #35 | Licensed Practical Nurse | Interviewed regarding baseline care plan and fall incident response |
| Staff #2 | Assistant Director of Nursing | Interviewed regarding care plan review and post fall monitoring expectations |
| Staff #12 | Registered Nurse | Entered interdisciplinary team note about fall incident |
| Staff #15 | Licensed Practical Nurse | Interviewed regarding fall protocol |
| Staff #28 | Licensed Practical Nurse | Interviewed regarding post fall monitoring and observations |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 24, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to develop a complete baseline care plan for a resident and failure to ensure appropriate monitoring post fall.
Complaint Details
The complaint involved resident #3 who was found on the floor after a fall and was left alone without supervision. The resident's daughter reported the incident and lack of staff presence post fall. The investigation included interviews with staff and review of policies.
Findings
The facility failed to develop a complete baseline care plan including necessary interventions for bladder incontinence for resident #3, and failed to ensure adequate supervision and monitoring of the resident after a fall, which could result in harm to the resident.
Deficiencies (2)
Failure to develop a complete baseline care plan including interventions for bladder incontinence for resident #3.
Failure to ensure appropriate monitoring and supervision of resident #3 post fall, resulting in the resident being left alone on the floor for a short time without supervision.
Report Facts
BIMS score: 11
Date baseline care plan initiated: Jun 17, 2024
Date of fall incident: Jun 19, 2024
Time of fall incident: 1815
Duration resident left alone: 5
Toileting frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #40 | Social Services Director | Interviewed regarding baseline care plan expectations and deficiencies |
| Staff #35 | Licensed Practical Nurse | Interviewed about baseline care plan and post fall response |
| Staff #2 | Assistant Director of Nursing | Interviewed regarding care plan deficiencies and post fall supervision expectations |
| Staff #12 | Registered Nurse | Entered interdisciplinary team note documenting fall incident and post fall care |
| Staff #15 | Licensed Practical Nurse | Interviewed about fall protocol and post fall procedures |
| Staff #28 | Licensed Practical Nurse | Telephonic interview about fall incident and supervision |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: May 1, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify residents and their representatives in writing about hospital transfers, failure to provide bed-hold policy information, failure to provide baseline care plan summaries, infection control protocol breaches during medication administration, and failure to maintain kitchen equipment properly.
Complaint Details
The complaint investigation found substantiated deficiencies related to failure to notify residents and representatives in writing about hospital transfers, failure to provide bed-hold policy information, failure to provide baseline care plan summaries, breaches in infection control during medication administration, and failure to maintain kitchen equipment.
Findings
The facility failed to notify residents and their representatives in writing about hospital transfers, failed to provide bed-hold policy information to a resident, did not provide a summary of the baseline care plan to a resident and their representative, failed to ensure proper hand hygiene during medication administration for two residents, and failed to maintain kitchen equipment in proper working order, specifically a cracked meat slicer food contact plate.
Deficiencies (5)
Failed to ensure two residents and their representatives were notified in writing of the reason for hospital transfer.
Failed to notify one resident in writing of the bed-hold policy before hospital transfer.
Failed to provide one resident and their representative with a summary of the baseline care plan within 48 hours of admission.
Failed to ensure infection control protocols were followed during medication administration for two residents, including failure to perform hand hygiene before and after medication administration.
Failed to keep essential kitchen equipment (meat slicer) working safely; plastic food contact plate was cracked and not repaired timely.
Report Facts
BIMS score: 10
BIMS score: 8
BIMS score: 7
Medication dosage: 81
Medication dosage: 500
Medication dosage: 30
Medication dosage: 200
Medication dosage: 5
Medication dosage: 40
Medication dosage: 500
Medication dosage: 20
Medication dosage: 0.4
Date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #45 | Director of Social Services | Interviewed regarding notification of hospital transfers and bed-hold policy |
| Staff #28 | Licensed Practical Nurse | Interviewed regarding notification and bed-hold policy provision |
| Staff #33 | Administrator | Interviewed regarding notification procedures and equipment maintenance |
| Staff #8 | RAI Coordinator | Interviewed regarding baseline care plan provision |
| Staff #12 | Director of Nursing | Interviewed regarding hand hygiene expectations |
| Staff #35 | Licensed Practical Nurse | Observed and interviewed regarding failure to perform hand hygiene during medication administration |
| Staff #46 | Head Chef | Interviewed regarding meat slicer maintenance and food preparation adjustments |
| Staff #13 | Maintenance Director | Interviewed regarding equipment repair process and work order for meat slicer |
Inspection Report
Routine
Deficiencies: 5
Date: May 1, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident notification of hospital transfers, bed-hold policies, baseline care plan provision, infection prevention and control, and equipment safety in the facility.
Findings
The facility was found deficient in timely written notification to residents and their representatives regarding hospital transfers, failure to provide bed-hold policy information upon transfer, failure to provide baseline care plan summaries to residents and representatives, lapses in infection control practices during medication administration, and failure to maintain kitchen equipment in proper working order.
Deficiencies (5)
Failure to provide timely written notification to residents and their representatives about hospital transfers.
Failure to notify resident and representative in writing about bed-hold policy before hospital transfer.
Failure to provide resident and representative with a summary of the baseline care plan within 48 hours of admission.
Failure to ensure infection control protocols were followed during medication administration, including lack of hand hygiene before and after medication administration.
Failure to ensure kitchen equipment (meat slicer) was in proper working order; cracked food contact plate not repaired timely.
Report Facts
BIMS score: 10
BIMS score: 8
BIMS score: 7
Medication dosage: 81
Medication dosage: 500
Medication dosage: 30
Medication dosage: 200
Medication dosage: 5
Medication dosage: 40
Medication dosage: 500
Medication dosage: 20
Medication dosage: 0.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #45 | Director of Social Services | Interviewed regarding resident transfer notifications and bed-hold policy |
| Staff #28 | Licensed Practical Nurse | Interviewed regarding transfer notifications and bed-hold policy |
| Staff #33 | Administrator | Interviewed regarding transfer notifications, bed-hold policy, and equipment maintenance |
| Staff #8 | RAI Coordinator | Interviewed regarding baseline care plan provision |
| Staff #12 | Director of Nursing | Interviewed regarding infection control expectations |
| Staff #35 | Licensed Practical Nurse | Observed and interviewed regarding hand hygiene during medication administration |
| Staff #46 | Head Chef | Interviewed regarding kitchen equipment maintenance |
| Staff #13 | Maintenance Director | Interviewed regarding equipment repair process and meat slicer work order |
Inspection Report
Routine
Census: 31
Deficiencies: 14
Date: Jan 5, 2023
Visit Reason
Routine inspection of Brookdale Santa Catalina nursing home to assess compliance with regulatory requirements including resident care, infection control, medication management, staff training, and vaccination policies.
Findings
The facility was found deficient in multiple areas including failure to complete advance directives timely, update care plans after falls, convey discharge information and medication reconciliation, ensure staff competencies and training, implement infection prevention and control programs, monitor antibiotic use, ensure infection preventionist training, provide vaccination education and documentation, maintain COVID-19 vaccination exemption documentation for staff, and provide abuse prevention training for staff.
Deficiencies (14)
Failed to ensure one resident's advance directives were completed upon admission.
Failed to update one resident's care plan to meet changing needs after multiple falls.
Failed to convey discharge summary information and medication reconciliation to one resident and/or authorized person.
Failed to ensure two CNAs demonstrated necessary competencies and skills.
Failed to complete yearly performance reviews and provide regular in-service education for one CNA.
Failed to ensure pharmacist recommendations were reviewed and acted upon for one resident's medication regimen.
Failed to ensure consistent monitoring for behaviors and side effects for one resident receiving psychotropic medications and failed to limit PRN orders duration.
Failed to implement a surveillance plan for infection control and failed to ensure ongoing analysis and documentation of follow-up.
Failed to conduct ongoing review for antibiotic stewardship and failed to review clinical signs, symptoms, and lab reports to determine antibiotic indication.
Infection preventionist lacked completed specialized infection control training prior to assuming role.
Failed to provide information and offer influenza and pneumococcal vaccinations to one resident according to policy.
Failed to maintain documentation related to COVID-19 vaccine exemption requirement for one staff member.
Failed to provide evidence that one staff member received training on abuse, neglect, exploitation, and misappropriation of resident property.
Failed to ensure one CNA received the required minimum 12 hours per year of in-service training.
Report Facts
Census: 31
Sample size: 15
Sample size: 5
Sample size: 10
Required in-service hours: 12
Completed in-service courses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #6 | Licensed Practical Nurse / Infection Preventionist | Named as infection preventionist lacking specialized training and responsible for infection control surveillance and antibiotic stewardship |
| Staff #81 | Regional Director of Clinical Operations | Interviewed regarding care plan updates, medication monitoring, and infection control issues |
| Staff #62 | Social Services Director | Interviewed regarding discharge process and infection control monitoring |
| Staff #84 | Director of Human Resources | Interviewed regarding staff training and competency monitoring |
| Staff #35 | Certified Nursing Assistant | Named for failure to demonstrate competencies and incomplete in-service training |
| Staff #33 | Certified Nursing Assistant | Named for COVID-19 vaccine exemption documentation issues |
| Staff #36 | Dietary Assistant | Named for lack of abuse, neglect, exploitation training |
| Staff #82 | Licensed Practical Nurse | Interviewed regarding advance directives and discharge process |
| Staff #83 | Registered Nurse | Interviewed regarding medication monitoring |
Inspection Report
Routine
Census: 31
Deficiencies: 14
Date: Jan 5, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident care, infection control, medication management, staff competencies, and facility policies.
Findings
The facility was found deficient in multiple areas including failure to complete advance directives timely, update care plans after falls, communicate discharge information properly, ensure staff competencies and training, monitor medication regimens especially psychotropic medications, maintain infection prevention and antibiotic stewardship programs, ensure infection preventionist training, provide vaccination education and documentation, maintain COVID-19 vaccination exemption documentation for staff, and provide abuse prevention training for staff.
Deficiencies (14)
Failed to ensure one resident's advance directives were completed upon admission.
Failed to update care plan to meet changing needs after resident falls.
Failed to convey discharge summary information and medication reconciliation to resident and/or representative.
Failed to ensure two CNAs demonstrated necessary competencies and skills.
Failed to complete yearly performance reviews and provide regular in-service education for one CNA.
Failed to ensure pharmacist recommendations were reviewed and acted upon for one resident's medication regimen.
Failed to monitor psychotropic medication use including duration and side effects for one resident.
Failed to implement an infection prevention and control program with adequate surveillance and follow-up.
Failed to implement an antibiotic stewardship program with ongoing review and monitoring.
Infection preventionist lacked completed infection control training prior to assuming role.
Failed to provide information and offer influenza and pneumococcal vaccinations according to policy for one resident.
Failed to maintain documentation related to COVID-19 vaccine exemption requirements for one staff member.
Failed to provide training for abuse, neglect, exploitation and misappropriation of resident property for one staff member.
Failed to ensure one CNA received the required minimum 12 hours per year of in-service training.
Report Facts
Census: 31
Deficiencies cited: 14
Medication review sample size: 5
Staff training sample size: 10
CNA training sample size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #82 | Licensed Practical Nurse | Named in advance directive deficiency and discharge summary documentation |
| Staff #81 | Regional Director of Clinical Operations | Interviewed regarding care plan updates, medication monitoring, infection control, and staff training |
| Staff #83 | Registered Nurse | Interviewed regarding care plan updates and medication monitoring |
| Staff #84 | Director of Human Resources | Interviewed regarding staff training and COVID-19 vaccination documentation |
| Staff #6 | Licensed Practical Nurse / Infection Preventionist | Named as infection preventionist lacking formal training and responsible for infection control and antibiotic stewardship |
| Staff #62 | Social Services Director | Interviewed regarding discharge process and infection control awareness |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 6
Date: Jan 14, 2022
Visit Reason
The inspection was conducted due to a complaint regarding a Certified Nursing Assistant drawing on a resident's arm and upper lip with a permanent marker, which raised concerns about respecting resident dignity.
Complaint Details
The complaint involved a CNA drawing on a resident (#133) with a permanent marker on her arm and upper lip. The incident was substantiated by the facility investigation, and the CNA was terminated.
Findings
The facility substantiated the complaint that a CNA drew on a resident with a permanent marker and terminated the staff member. The facility provided in-service training on resident rights and dignity. Additional deficiencies were found related to pressure ulcer care, urinary catheter care, weight monitoring, medication administration, and food safety practices.
Deficiencies (6)
Failed to ensure one resident was treated with dignity when a CNA drew on her arm and upper lip with a permanent marker.
Failed to provide appropriate pressure ulcer care and assessment for one resident, lacking thorough wound assessment and documentation.
Failed to provide appropriate urinary catheter care in accordance with physician's orders for one resident.
Failed to address significant weight loss for one resident, including lack of weekly weights and unsigned dietary recommendations.
Failed to administer opioid pain medication according to physician's ordered parameters, administering oxycodone for pain levels less than ordered.
Failed to ensure kitchen staff wore hairnets properly and failed to maintain clean equipment, dishware, and cookware, risking foodborne illness.
Report Facts
Facility census: 33
Weight loss percentage: 17.51
Number of occasions oxycodone administered inappropriately: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) staff #87 | Named in dignity violation for drawing on resident with permanent marker; terminated | |
| Licensed Practical Nurse (LPN) staff #86 | Observed catheter care and provided statements regarding documentation | |
| Director of Nursing (DON) staff #45 | Provided statements on dignity, wound care expectations, and medication administration | |
| Administrator staff #78 | Provided statements on resident dignity and observed hairnet violations | |
| Director of Dietary Services staff #44 | Provided statements on hairnet policy and dishwashing deficiencies | |
| Diet Technician staff #51 | Provided statements on nutritional supplement recommendations and weight monitoring |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 6
Date: Jan 14, 2022
Visit Reason
The inspection was conducted following a complaint regarding a Certified Nursing Assistant drawing on a resident with a permanent marker, which raised concerns about respecting resident dignity.
Complaint Details
The complaint involved a CNA drawing on a resident with a permanent marker. The incident was substantiated by the facility investigation, and the staff member was terminated.
Findings
The facility substantiated the complaint that a CNA drew on a resident with a permanent marker, resulting in termination of the staff member and in-service training. Additional deficiencies were found related to pressure ulcer care, catheter care, weight monitoring, medication administration, and food safety practices.
Deficiencies (6)
Failure to ensure one resident was treated with dignity, including an incident where a CNA drew on the resident with a permanent marker.
Failure to provide appropriate pressure ulcer care and assessment for one resident, including lack of thorough wound assessment and documentation.
Failure to provide urinary catheter care in accordance with physician's orders for one resident, increasing risk of infection.
Failure to address significant weight loss in one resident, including lack of weekly weights and follow-up.
Failure to administer opioid pain medication according to ordered parameters, including administering oxycodone for pain levels less than ordered.
Failure to ensure kitchen staff wore hairnets properly and failure to maintain clean equipment, dishware, and cookware, risking foodborne illness.
Report Facts
Residents present: 33
Weight loss percentage: 17.51
Medication administration instances: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #87 | Certified Nursing Assistant | Named in dignity violation for drawing on resident with permanent marker |
| Staff #45 | Director of Nursing | Interviewed regarding dignity, wound care, catheter care, and medication administration findings |
| Staff #86 | Licensed Practical Nurse | Observed providing catheter care and interviewed regarding documentation |
| Staff #50 | Assistant Director of Nursing / Wound Care Nurse | Interviewed regarding wound care assessments |
| Staff #44 | Director of Dietary Services | Interviewed regarding hairnet and kitchen cleanliness deficiencies |
| Staff #51 | Diet Technician | Interviewed regarding nutritional care and weight monitoring |
| Staff #17 | Licensed Practical Nurse | Interviewed regarding catheter care and medication administration |
| Staff #22 | Certified Nursing Assistant | Interviewed regarding resident dignity |
| Staff #78 | Administrator | Interviewed regarding resident dignity and kitchen observations |
| Staff #92 | Cook | Observed with hairnet deficiencies in kitchen |
| Staff #89 | Dishwasher | Observed washing dishes with unclean equipment and dishware |
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