Inspection Reports for Legend Personal Care and Memory Care of Lititz
80 WEST MILLPORT ROAD,, LITITZ, PA, 17543
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
36.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
683% worse than Pennsylvania average
Pennsylvania average: 4.7 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
75% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 75
Capacity: 100
Deficiencies: 3
Date: Jun 10, 2025
Visit Reason
The inspection was conducted as a complaint investigation with an interim exit conference on 06/10/2025 to review compliance and plan of correction submissions.
Complaint Details
The inspection was complaint-driven, with the reason stated as 'Complaint, Interim'.
Findings
The inspection found discrepancies in medication labeling, failure to follow prescriber's orders, and improper documentation of medication administration. The submitted plan of correction was accepted and later fully implemented.
Deficiencies (3)
Resident #1's prescription medication label dosage instructions did not match the Medication Administration Record (MAR).
An 8 fluid ounce container of Ensure Chocolate therapeutic nutrition drink belonging to resident #2 was not labeled with the resident's name.
Resident #1’s blood sugar was not checked before breakfast as prescribed; medications and treatments were missed or refused for residents #2 and #3.
Report Facts
License Capacity: 100
Census: 75
Secured Dementia Care Unit Capacity: 40
Residents Served in Dementia Unit: 28
Hospice Residents: 8
Residents with Mobility Need: 33
Residents 60 Years or Older: 75
Inspection Report
Renewal
Census: 74
Capacity: 100
Deficiencies: 9
Date: Apr 7, 2025
Visit Reason
The inspection was conducted as a renewal and provisional licensing inspection of Legend Personal Care and Memory Care of Lititz to assess compliance with 55 Pa. Code Chapter 2600 relating to Personal Care Homes.
Findings
The facility was found to be in compliance overall, with a submitted plan of correction fully implemented. Several deficiencies were noted related to medication administration, record confidentiality, training, assessment accuracy, and follow-up on refusals and prescriber orders, all with corrective actions planned and implemented by June 17, 2025.
Deficiencies (9)
Resident #1's narcotic count was unlocked, unattended, and accessible in a medication cart in the Secure Dementia Care Unit.
Staff Person A and Staff Person B did not receive required training on meeting resident needs and personal care service needs during 2024.
Resident #2's medication label for Lantus Solostar did not match the prescribed dosage and instructions.
Blood glucose readings for Residents #2 and #3 were inaccurately documented or missing in medication administration records.
Resident #5 and #6's medication administration records lacked staff initials for administered medications.
Resident #2 and #3 refused medications or topical treatments but refusals were not reported timely to prescribers.
Resident #4 and #7 had medications not administered due to unavailability in the home.
Resident #4's initial assessment did not include use of a rollator for mobility.
Resident #3's assessment was not updated to reflect current mobility status using a transfer board; Resident #8's assessment was completed late.
Report Facts
License Capacity: 100
Residents Served: 74
Secure Dementia Care Unit Capacity: 40
Secure Dementia Care Unit Residents Served: 31
Current Hospice Residents: 8
Total Daily Staff: 115
Waking Staff: 86
Residents with Mobility Need: 41
Residents with Physical Disability: 1
Inspection Report
Follow-Up
Census: 80
Capacity: 100
Deficiencies: 3
Date: Mar 4, 2025
Visit Reason
The inspection was a follow-up visit to verify the implementation of the submitted plan of correction related to complaints and incidents at the facility.
Complaint Details
The visit was complaint-related with substantiation of abuse and incident allegations involving physical altercations between residents.
Findings
The submitted plan of correction was found to be fully implemented with continued compliance required. Deficiencies related to abuse incidents, provision of towels/washcloths/soap, and refusal of medication documentation were addressed with corrective actions and monitoring plans.
Deficiencies (3)
Physical altercations between residents resulting in injuries including a fractured nose, abrasions, and redness.
The home did not provide each resident with a towel or washcloth; residents were responsible for supplying these items.
Failure to document and report resident medication refusals to the prescriber within required timeframes.
Report Facts
License Capacity: 100
Residents Served: 80
Secured Dementia Care Unit Capacity: 40
Secured Dementia Care Unit Residents Served: 31
Hospice Current Residents: 9
Residents with Mobility Need: 42
Residents Age 60 or Older: 80
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Physical Disability: 1
Inspection Report
Complaint Investigation
Census: 70
Capacity: 100
Deficiencies: 31
Date: Jul 2, 2024
Visit Reason
The inspection was conducted as a complaint investigation and interim incident review following allegations of neglect and other regulatory concerns at Legend Personal Care and Memory Care of Lititz.
Complaint Details
The inspection was complaint-related, triggered by allegations of neglect and other regulatory concerns. Specific substantiation status is not stated.
Findings
Multiple violations were found including failure to provide immediate DHS access, resident neglect, improper medication administration and storage, fire safety deficiencies, sanitary issues, and incomplete resident records. The facility was issued a second provisional license due to these violations and submitted plans of correction.
Deficiencies (31)
Failure to provide immediate access to DHS agents and incomplete staff and resident lists.
Resident neglect: Resident left unattended in bathroom contrary to support plan; failure to report neglect to Area Agency on Aging.
Failure to report incidents to the Department within required timeframes.
Resident abuse and neglect including failure to provide required assistance and improper staff conduct.
Failure to complete Pennsylvania criminal background checks for staff.
Lack of fire safety orientation for new staff.
Unsecured poisonous materials accessible to residents in secured dementia care unit.
Unsanitary conditions including blood stains in resident bedroom and bathroom.
Trash outside the home not properly contained; dumpster lid open and trash on ground.
Hot water temperature exceeded 120°F in multiple locations accessible to residents.
Freezer in theater room lacked thermometer.
Food stored uncovered or in unsealed containers.
Emergency procedures not submitted annually to local emergency management agency.
Fire drill records incomplete; missing exit routes, problems encountered, and time of day.
Failure to evacuate all residents during fire drills.
Fire drill during sleeping hours not conducted within required 6 month period.
Menus not posted one week in advance as required.
Menu changes not posted in advance to residents.
First aid kits in vehicles missing required items including thermometer, eye coverings, and breathing shield.
Vehicle used for resident transport had expired inspection certificate.
Medication administration failures including failure to observe resident taking medications and incomplete documentation.
Medications and syringes not kept locked in resident rooms; unlocked medications accessible to residents.
Prescription and OTC medications not stored properly according to sanitation and manufacturer instructions.
Resident assessments incomplete or inaccurate regarding mobility and enabler bar needs.
Key-locking devices for secured dementia care unit did not allow immediate egress and lacked posted directions.
Resident records lacked required information on religion and language.
Resident records confidentiality breached by unattended medication carts and accessible medication return logs.
Medication carts and medication room contained loose pills.
Medication records lacked prescribed dosage and instructions; sliding scale insulin orders not properly documented.
Medication administration records lacked date/time of medication administration and accurate documentation of doses given.
Failure to follow prescriber's orders for medication administration; doses missed or medication unavailable.
Report Facts
License Capacity: 100
Residents Served: 70
Residents Served in Secured Dementia Care Unit: 24
Current Hospice Residents: 9
Total Daily Staff: 74
Waking Staff: 56
Number of Deficiencies Cited: 29
Residents Served: 78
Residents Served in Secured Dementia Care Unit: 24
Current Hospice Residents: 8
Total Daily Staff: 107
Waking Staff: 80
Inspection Report
Complaint Investigation
Census: 70
Capacity: 100
Deficiencies: 30
Date: Jul 2, 2024
Visit Reason
The inspection was conducted as a provisional licensing inspection following complaints and incidents at Legend Personal Care and Memory Care of Lititz.
Complaint Details
The inspection was complaint-related, triggered by incidents including neglect and abuse allegations, failure to provide DHS access, and other regulatory concerns. The report includes substantiation of neglect and abuse findings.
Findings
Multiple violations were found including failure to provide immediate DHS access to records, resident neglect and abuse, inadequate criminal background checks, fire safety deficiencies, medication administration errors, and improper storage and documentation of medications. The facility was issued a second provisional license based on an acceptable plan of correction.
Deficiencies (30)
Failure to provide immediate access to home, residents, and records to DHS agents.
Resident neglect: Resident left alone in bathroom without assistance as required by support plan; failure to report neglect to Area Agency on Aging.
Failure to report resident abuse and neglect incidents timely to the Department.
Criminal background check missing for a staff member.
Fire safety orientation not provided to a staffing agency employee on first day.
Poisonous materials unlocked and accessible in secured dementia care unit.
Unsanitary conditions: blood stains in resident bedroom and bathroom.
Trash outside home not properly contained; dumpster lid open and trash on ground.
Hot water temperature exceeded 120°F in multiple locations accessible to residents.
Freezer in theater room lacked thermometer.
Food stored uncovered or in unsealed containers in kitchen and bistro.
Emergency procedures not submitted annually to local emergency management agency.
Fire drill records incomplete; missing exit routes, problems encountered, and drill times.
Residents not fully evacuated during fire drills.
Fire drill during sleeping hours not conducted within required 6 month period.
Menus not posted for one week in advance.
Menu changes not posted in advance to residents.
First aid kits in vehicles missing thermometer, eye coverings, and breathing shield.
Vehicle used for resident transport had expired inspection certificate.
Medication administration failure: staff did not observe resident consuming medications.
Medications and syringes not locked in resident rooms; medications accessible and unattended.
Prescription medications, OTC medications, and CAM not stored properly; loose pills found.
Medication records missing diagnosis or reason for medication and dose of insulin administered.
Resident assessments incomplete or inaccurate regarding mobility and enabler bar needs.
Resident records missing religion or language information.
Confidential resident information left unsecured on medication carts and in binders.
Medication record did not document amount of insulin administered per sliding scale order.
Medication administration records did not record date/time of medication administration accurately.
Medication administration did not follow prescriber's orders; doses missed or medication unavailable.
Key-locking devices for secured dementia care unit did not allow immediate egress; signage inadequate.
Report Facts
License Capacity: 100
Residents Served: 70
Residents in Secured Dementia Care Unit: 24
Current Hospice Residents: 9
Total Daily Staff: 74
Waking Staff: 56
Number of Deficiencies Cited: 29
Fire Drill Evacuation Counts: 12
Fire Drill Evacuation Counts: 11
Fire Drill Evacuation Counts: 8
Fire Drill Evacuation Counts: 11
Fire Drill Evacuation Counts: 23
Fire Drill Evacuation Counts: 16
Fire Drill Evacuation Counts: 10
Inspection Report
Follow-Up
Census: 66
Capacity: 100
Deficiencies: 1
Date: Apr 2, 2024
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 04/02/2024 to review the submitted plan of correction related to previous medication administration deficiencies and compliance issues.
Findings
The submitted plan of correction was determined to be fully implemented, with new policies established to ensure timely medication provision and a minimum 7-day supply of medications on-site. Weekly audits were initiated to monitor compliance with prescriber orders and medication availability.
Deficiencies (1)
Failure to administer prescribed medication from 3/13/24 through 3/21/24 as ordered, including delayed administration due to medication unavailability.
Report Facts
License Capacity: 100
Residents Served: 66
Secured Dementia Care Unit Capacity: 40
Secured Dementia Care Unit Residents Served: 23
Hospice Current Residents: 6
Resident Mobility Need: 28
Resident Age 60 or Older: 66
Resident Supplemental Security Income: 0
Resident Diagnosed with Mental Illness: 0
Resident Diagnosed with Intellectual Disability: 0
Total Daily Staff: 94
Waking Staff: 71
Inspection Report
Renewal
Census: 66
Capacity: 100
Deficiencies: 23
Date: Dec 12, 2023
Visit Reason
The inspection was conducted as part of a renewal, complaint, and incident investigation at Legend Personal Care and Memory Care of Lititz.
Complaint Details
The inspection included complaint investigations related to abuse (misappropriation of resident funds) and incident reporting failures.
Findings
Multiple violations were found including failure to report incidents timely, abuse involving misappropriation of resident funds, inadequate first aid/CPR trained staff during night shifts, unsecured poisonous materials, unsanitary conditions, uncovered trash receptacles, soiled surfaces, unlabeled soap in shared bathrooms, improper food storage, lint accumulation in dryers, missing or delayed medical evaluations, smoking policy violations, missing first aid kit in transportation vehicle, medication storage and administration issues, and incomplete preadmission cognitive screenings.
Deficiencies (23)
Failure to submit incident reports timely for resident falls and monetary loss.
Abuse: Staff misappropriated $12,000 from a resident's personal bank account.
Inadequate first aid/CPR trained staff present during night shifts.
Poisonous materials (toothpaste and deodorant) were unlocked and accessible to residents not assessed as safe to use them.
Pungent odor of urine detected in resident room.
Uncovered and unattended trash can in kitchen of secured dementia care unit.
Food warmers and refrigerator in kitchenette soiled with dried food and beverage stains.
Unlabeled bar of soap in shared resident bathroom.
Opened and unsealed slice of pie in refrigerator.
Accumulation of lint in lint traps of resident dryers.
Resident medical evaluation not completed within required timeframe.
No smoking policy violated with cigarette butts found around dumpsters.
Transportation vehicle lacked a first aid kit.
Loose pills found in medication cart.
Expired medications found in medication cart.
Medications prescribed as needed were not available in the home.
Failure to follow prescriber's orders for medication administration.
Resident support plan did not document the need for a bedside mobility device.
Unsealed and undated pitcher of brown substance found in refrigerator.
Cigarette butts found at front entrance and bench area violating no smoking policy.
Expired PRN Voltaren gel found and not removed timely.
Missing PRN Tylenol and other medications not available in the home.
Resident admitted to secured dementia care unit without completed cognitive preadmission screening.
Report Facts
License Capacity: 100
Residents Served: 66
Residents Served in Secure Dementia Care Unit: 28
Current Residents in Hospice: 4
Staffing Hours - Total Daily Staff: 97
Staffing Hours - Waking Staff: 73
Fine Amount: 350
License Capacity: 100
Residents Served: 70
Residents Served in Secure Dementia Care Unit: 31
Current Residents in Hospice: 8
Staffing Hours - Total Daily Staff: 103
Staffing Hours - Waking Staff: 77
Inspection Report
Renewal
Census: 66
Capacity: 100
Deficiencies: 18
Date: Dec 12, 2023
Visit Reason
The inspection was conducted as a renewal inspection combined with complaint and incident investigations at Legend Personal Care and Memory Care of Lititz.
Findings
Multiple violations were found including failure to report incidents timely, abuse involving misappropriation of resident funds, inadequate first aid/CPR trained staff coverage, unlocked poisonous materials accessible to residents, unsanitary conditions, uncovered trash receptacles, unclean surfaces, unlabeled soap in shared bathrooms, improper food storage, lint accumulation in dryers, missing or untimely medical evaluations, smoking policy violations, missing first aid kit in transportation vehicle, medication storage and administration issues, and incomplete cognitive preadmission screenings.
Deficiencies (18)
Failure to submit incident reports to the Department within required timeframes.
Misappropriation of $12,000 from a resident's personal bank account by staff members.
Insufficient number of staff trained in first aid and CPR during night shifts.
Poisonous materials (toothpaste and deodorant) were unlocked and accessible to residents not assessed as safe to use them.
Pungent urine odor detected in resident room indicating unsanitary conditions.
Uncovered trash can in kitchen of secured dementia care unit.
Food warmers and refrigerator in kitchenette were soiled with dried food and beverage stains.
Unlabeled bar soap observed in shared resident bathroom.
Opened and unsealed slice of pie found in refrigerator.
Accumulation of lint in lint traps of resident dryers.
Resident medical evaluation not completed within required timeframe.
No first aid kit in the home's transportation vehicle.
Loose pills found in medication cart.
Expired medications found in medication cart.
Medications prescribed as needed were not available in the home.
Failure to follow prescriber's orders for medication administration on multiple occasions.
Support plan did not document the need for a bedside mobility device.
Cognitive preadmission screening not completed within 72 hours prior to admission to secured dementia care unit.
Report Facts
Fine amount: 350
License capacity: 100
Residents served: 66
Residents served in secured dementia care unit: 28
Residents served: 70
Residents served in secured dementia care unit: 31
Staff total daily: 97
Staff waking: 73
Staff total daily: 103
Staff waking: 77
Inspection Report
Follow-Up
Census: 74
Capacity: 100
Deficiencies: 7
Date: Oct 4, 2023
Visit Reason
The inspection was a partial, unannounced follow-up visit conducted on 10/04/2023 and 10/05/2023 to review complaint and incident concerns at the facility.
Complaint Details
The visit was complaint and incident related, as noted in the inspection information section.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies related to egress obstruction, medical evaluations, medication storage and administration, key-locking devices, and admission support plans were identified and addressed with corrective actions including staff reeducation and audits.
Deficiencies (7)
A large piece of furniture blocked egress from the exit hallway in the Secure Dementia Care Unit.
Residents' initial medical evaluations were not completed within required timeframes.
A small white round pill was found improperly stored in medication cart 1.
Medication went missing after being left unattended on top of the medication cart.
Resident requested PRN medication for 3 days but did not receive it; no documentation was found in the MAR.
The Secure Dementia Care Unit exit near resident room 311 did not have the correct code posted to unlock the exit.
A new support plan was not completed within required timeframes for a resident admitted to the Secure Dementia Care Unit.
Report Facts
License Capacity: 100
Residents Served: 74
Secured Dementia Care Unit Capacity: 40
Secured Dementia Care Unit Residents Served: 32
Hospice Current Residents: 8
Residents Age 60 or Older: 74
Residents with Mobility Need: 1
Total Daily Staff: 75
Waking Staff: 56
Inspection Report
Follow-Up
Census: 78
Capacity: 100
Deficiencies: 1
Date: Mar 15, 2023
Visit Reason
The inspection visit on 03/15/2023 was a follow-up to verify the implementation of a previously submitted plan of correction related to a complaint.
Complaint Details
The inspection was complaint-related, with the deficiency concerning the missing cognitive preadmission screening. The plan of correction was accepted and fully implemented.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. The deficiency involved a missing written cognitive preadmission screening for a resident admitted to the Secure Dementia Care Unit, which was completed on the day of inspection.
Deficiencies (1)
Resident 1 was admitted to the Secure Dementia Care Unit without a completed written cognitive preadmission screening within 72 hours prior to admission.
Report Facts
License Capacity: 100
Residents Served: 78
Secured Dementia Care Unit Capacity: 40
Residents Served in Secured Dementia Care Unit: 32
Hospice Residents: 3
Residents 60 Years or Older: 77
Residents with Mobility Need: 37
Residents with Physical Disability: 1
Inspection Report
Census: 76
Capacity: 100
Deficiencies: 0
Date: Feb 9, 2023
Visit Reason
The inspection was an unannounced partial inspection conducted due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified as a result of this inspection.
Report Facts
Residents Served: 76
License Capacity: 100
Residents Served in Secured Dementia Care Unit: 30
Capacity of Secured Dementia Care Unit: 40
Current Hospice Residents: 6
Resident Support Staff Hours: 0
Total Daily Staff Hours: 111
Waking Staff Hours: 83
Residents Age 60 or Older: 76
Residents with Mobility Need: 35
Residents with Physical Disability: 1
Residents Diagnosed with Mental Illness: 0
Residents Diagnosed with Intellectual Disability: 0
Residents Receiving Supplemental Security Income: 0
Inspection Report
Renewal
Census: 76
Capacity: 100
Deficiencies: 14
Date: Oct 20, 2021
Visit Reason
The inspection was conducted as a renewal and complaint investigation visit to assess compliance with licensing regulations and to review the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including failure to post current licenses conspicuously, unsigned resident contract, incomplete direct care staff training, missing grab bars in bathrooms, improper refrigerator temperatures, unsealed food storage, incomplete medical evaluations, inadequate staff training for transportation, medication storage and documentation issues, outdated support plans, delayed preadmission screening, missing keypad lock operation instructions, and outdated resident photographs. Plans of correction were accepted and implemented for all deficiencies.
Deficiencies (14)
Licensing inspection summaries from previous inspections were not posted in a conspicuous and public place in the home.
Resident #1's home contract was not signed by the resident.
Direct Care Staff Person A did not complete the Department-approved direct care training course and pass the competency test until after hire.
No grab bar, hand rail or assist bar at the toilet in the women's bathroom stall nearest the door.
Refrigerators had temperatures above 40°F and lacked internal thermometers.
Food items in dry storage and refrigerators were open and not sealed.
Resident #2's medical evaluation did not include blood pressure, height, weight, pulse rate, temperature, and allergies.
Staff Persons B, C, and D transporting residents had not completed initial direct care staff training.
Resident #3's prescription medication was not dated when opened.
Blood glucose testing results for Residents #3 and #4 were not accurately recorded in medication administration records.
Resident #1's support plan was not revised for diet change; Resident #4's support plan was not updated for bed enabler bar use.
Resident #3's written cognitive preadmission screening was completed after admission to the Secure Dementia Care Unit.
Directions for operating keypad locking mechanisms were not conspicuously posted near Secure Dementia Care Unit exit doors.
Resident #4's photograph in the record was dated more than two years old.
Report Facts
License Capacity: 100
Residents Served: 76
Secured Dementia Care Unit Capacity: 40
Secured Dementia Care Unit Residents Served: 25
Hospice Residents: 5
Total Daily Staff: 108
Waking Staff: 81
Residents with Mobility Need: 32
Residents 60 Years or Older: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jarrett Zellers | LPN | Completed new medical evaluation for Resident #2. |
| Charles Mershon | PCP | Completed new medical evaluation for Resident #2. |
Notice
Capacity: 100
Deficiencies: 0
Date: Sep 7, 2021
Visit Reason
The document serves as a renewal notification and license issuance for Legend Personal & Memory Care of Lititz, confirming receipt of the renewal application and advising of the requirement for an annual onsite inspection within the next twelve months.
Findings
No inspection findings are reported; the document confirms issuance of a regular license following the renewal application and outlines the Department's plan to conduct an annual inspection within the next year.
Report Facts
Maximum capacity: 100
Secure Dementia Care Unit capacity: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed letter regarding license renewal and inspection requirements |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 100
Deficiencies: 7
Date: May 6, 2021
Visit Reason
The inspection was a complaint investigation conducted as an unannounced partial inspection on 05/06/2021.
Complaint Details
The inspection was conducted due to a complaint regarding mask wearing and dietary concerns.
Findings
The inspection identified multiple deficiencies including improper mask wearing by staff, unsanitary kitchen conditions, improper food storage, and failure to follow dietary orders for residents. Plans of correction were submitted and determined to be fully implemented by follow-up reviews.
Deficiencies (7)
Staff observed wearing masks improperly, exposing nose or pulled down under chin in the memory care unit.
Kitchen walls had black debris splatters, dirt and sticky food debris on baseboards, prep sink splattered with juice and wrapper, and grimy sink faucet handles.
Walk-in freezer contained an open box of puff pastry and unsealed hamburger patties; walk-in refrigerator had an open plastic bag of lunch meat; large stainless steel bowl with plastic wrap had a hole; gallon bottle of molasses was not capped; spice rack had a partially melted jar with no lid; refrigerator bottle of raspberry topping was not sealed and leaking.
Outdated or unlabeled food items found in dry storage area including undated bag of crispy onions and opened bottle of chocolate syrup missing lid.
Residents served mechanical soft diet had turkey cut into pieces larger than ordered and were observed trying to bite off large pieces.
Support plans for residents were not updated to include physician or doctor orders for mechanical soft diet.
Resident admitted to secured dementia care unit did not have cognitive preadmission screening completed.
Report Facts
License Capacity: 100
Residents Served: 63
Secured Dementia Care Unit Capacity: 33
Secured Dementia Care Unit Residents Served: 24
Resident Diagnosed with Mental Illness: 1
Resident Diagnosed with Intellectual Disability: 0
Resident Have Mobility Need: 32
Resident Have Physical Disability: 1
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