Inspection Reports for Muscogee Manor & Rehab Center
7150 Manor Rd, Columbus, GA 31907, United States, GA, 31907
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Inspection Report
Re-Inspection
Census: 95
Deficiencies: 0
Jan 17, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the November 21, 2024 recertification/complaint survey.
Findings
All deficiencies cited in the prior November 21, 2024 survey were found to be corrected during this revisit survey.
Report Facts
Census: 95
Inspection Report
Re-Inspection
Census: 95
Deficiencies: 0
Jan 17, 2025
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the November 21, 2024 recertification/complaint survey.
Findings
All deficiencies cited in the prior November 21, 2024 survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 7, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Follow-Up
Deficiencies: 0
Jan 7, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Life Safety
Census: 95
Capacity: 196
Deficiencies: 4
Nov 25, 2024
Visit Reason
The visit was a Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including failure to maintain backup batteries for exit signs, failure to prevent self-closing doors from being propped open, failure to maintain the correct schedule for kitchen hood cleaning, and failure to maintain cleared access paths to electrical panels.
Severity Breakdown
E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to maintain backup batteries for exit signs near rooms 96 and 99. | E |
| Failed to prevent self-closing doors from being propped open in multiple areas including pantry/breakroom, rehabilitation room, and kitchen service door. | E |
| Failed to maintain correct schedule for kitchen hood cleaning; only one cleaning in prior 12 months instead of every 6 months. | E |
| Failed to maintain cleared access path to electrical panels; blocked by fan in electrical room and laundry cart in laundry room. | E |
Report Facts
Census: 95
Total Capacity: 196
Date of last kitchen hood cleaning: Sep 15, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during tour and interviews related to deficiencies |
Inspection Report
Annual Inspection
Census: 31
Deficiencies: 3
Nov 21, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare regulations, including dietary service, medical and nursing care, and safety protocols.
Findings
The facility was found deficient in dietary service for failing to use recipes when preparing pureed food affecting 13 residents, failed to develop or implement care plans for three residents related to meal intake monitoring and oxygen use, and failed to ensure a working alarm on an exit door on the COVID unit, which allowed a cognitively impaired resident to exit the facility unsupervised.
Deficiencies (3)
| Description |
|---|
| Failed to prepare pureed food using a recipe, affecting 13 residents on pureed diets. |
| Failed to develop and/or implement care plans for three residents regarding meal intake monitoring and oxygen use. |
| Failed to ensure a working alarm on an exit door on the COVID unit, allowing a cognitively impaired resident to exit the facility. |
Report Facts
Residents affected by pureed diet deficiency: 13
Residents with care plan deficiencies: 3
Residents housed during COVID outbreak: 31
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook BB | Observed preparing pureed food without following recipe | |
| Food and Nutrition Manager (FNM) | Discussed expectations for recipe adherence and training of dietary staff | |
| Administrator | Stated expectations for dietary staff to follow recipes for pureed diets | |
| Registered Nurse DD | Registered Nurse | Confirmed documentation requirements for meal intake percentages |
| Director of Nursing (DON) | Director of Nursing | Confirmed care plan implementation expectations and oxygen order adherence |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Confirmed care plan implementation expectations and oxygen order adherence |
| Licensed Practical Nurse EE | Licensed Practical Nurse | Confirmed oxygen settings and respiratory therapist involvement |
| MDS Coordinator CC | Responsible for creating care plan for oxygen use but had not completed it | |
| Maintenance Director (MD) | Maintenance Director | Reported alarm system failure on COVID unit exit door |
| Licensed Practical Nurse AA | Licensed Practical Nurse | Reported alarm placement on COVID unit door for resident safety |
| Administrator in training | Discussed resident placement and alarm issues related to wandering resident |
Inspection Report
Annual Inspection
Census: 96
Deficiencies: 7
Nov 21, 2024
Visit Reason
A recertification survey was conducted from November 19 through November 21, 2024, including investigation of Complaint Intake Number GA00249335, to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including failure to provide written advance directive information, failure to submit PASRR Level II for a resident, failure to develop and implement care plans for certain residents, failure to maintain a working door alarm to prevent elopement, failure to administer oxygen as ordered, failure to prepare pureed food using recipes, and failure to properly label, store, and discard food items.
Complaint Details
Complaint Intake Number GA00249335 was investigated in conjunction with the standard recertification survey.
Severity Breakdown
SS= D: 6
SS= F: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to provide residents or representatives written information regarding choices and the right to accept or refuse medical or surgical treatment for one resident. | SS= D |
| Failed to submit a Preadmission Screening and Resident Review (PASRR) Level II for a resident with a mental health diagnosis. | SS= D |
| Failed to ensure care plans were developed and implemented for three residents, including monitoring meal intake and oxygen use. | SS= D |
| Failed to ensure a working door alarm to prevent elopement of a resident on a COVID unit. | SS= D |
| Failed to ensure oxygen was administered as ordered by the physician for one resident receiving oxygen therapy. | SS= D |
| Failed to prepare pureed food using recipes to conserve nutritive value, flavor, and appearance. | SS= D |
| Failed to ensure proper labeling, storage, and discarding of food items including open and expired foods. | SS= F |
Report Facts
Residents present: 96
Residents affected by pureed diet deficiency: 13
Residents affected by food storage deficiency: 85
BIMS score: 5
BIMS score: 14
BIMS score: 10
BIMS score: 3
Oxygen order: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cook BB | Cook | Named in pureed food preparation deficiency for not following recipe |
| LPN EE | Licensed Practical Nurse | Confirmed oxygen setting for resident R6 |
| Administrator | Provided information on advance directives, elopement incident, and food storage expectations | |
| Social Service Director | SSD | Interviewed regarding advance directives and PASRR process |
| Medical Records Coordinator | Interviewed regarding PASRR Level II submission process | |
| Director of Nursing | DON | Interviewed regarding care plan and oxygen order expectations |
| Assistant Director of Nursing | ADON | Interviewed regarding care plan and oxygen order expectations |
| Maintenance Director | MD | Interviewed regarding door alarm failure leading to resident elopement |
| Food and Nutrition Manager | FNM | Interviewed regarding pureed food preparation and food storage deficiencies |
Inspection Report
Abbreviated Survey
Census: 95
Deficiencies: 0
May 1, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint numbers GA00235076, GA00240532, and GA00245205.
Findings
The complaints GA00235076 and GA00240532 were found to be unsubstantiated and no deficiencies were cited related to these complaints.
Complaint Details
The survey investigated complaints GA00235076, GA00240532, and GA00245205. Complaints GA00235076 and GA00240532 were unsubstantiated. No deficiencies were cited related to these complaints.
Report Facts
Complaint numbers investigated: 3
Inspection Report
Deficiencies: 0
Apr 14, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Muscogee Manor & Rehabilitation Center following a regulatory inspection.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 104
Deficiencies: 0
Apr 14, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the February 16, 2023 Recertification Survey conducted in conjunction with a complaint investigation.
Findings
All deficiencies cited in the prior February 16, 2023 Recertification Survey and complaint investigation were found to be corrected during the April 14, 2023 revisit survey.
Complaint Details
The revisit survey was conducted following a complaint investigation; all prior deficiencies were corrected.
Report Facts
Census: 104
Inspection Report
Annual Inspection
Deficiencies: 3
Feb 16, 2023
Visit Reason
The inspection was a State Licensure survey conducted from February 14, 2023 through February 16, 2023 to determine compliance with the State Long Term Care Requirements.
Findings
Deficiencies were cited related to insufficient surety bond coverage for resident trust funds, unsecured medication and treatment carts, improper medication storage, and failure to accommodate a resident's mobility needs due to an unrepaired wheelchair.
Severity Breakdown
Level C: 1
Level D: 1
Level E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| The facility failed to maintain a surety bond sufficient to cover the resident trust fund account balance for 107 of 108 residents and failed to ensure the surety bond obligee was the Georgia Department of Community Health. | Level C |
| The facility failed to ensure that three of eight medication carts and one of three treatment carts were locked when unattended, and medications requiring refrigeration were improperly stored. | Level E |
| The facility failed to accommodate the needs of one resident (#48) by not providing a wheelchair for mobility out of the room due to delayed repairs. | Level D |
Report Facts
Residents with trust fund accounts: 107
Surety bond amount: 90000
Resident trust fund balance range: 163521.91
Resident trust fund balance range: 208203.61
Medication carts unlocked: 3
Treatment carts unlocked: 1
Sampled residents: 30
Resident #48 wheelchair repair delay: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Acknowledged medication cart was left unattended and unlocked |
| RN BB | Registered Nurse | Reported expectation that medication carts be locked when unattended |
| LPN CC | Licensed Practical Nurse | Acknowledged medication cart was unlocked and should have been locked |
| RN DD | Registered Nurse | Reported treatment cart should be secured by locking knob |
| LPN EE | Licensed Practical Nurse | Confirmed eye drops should be refrigerated and acknowledged medication cart was unlocked |
| LPN FF | Unit Manager | Stated medication carts should be locked when unattended |
| RN GG | Registered Nurse | Stated medication carts should be locked when nurse is not administering medications |
| Director of Nurses | Director of Nursing | Stated expectation for medication carts to be locked and medications stored per manufacturer recommendations |
| Administrator | Verified surety bond amount and resident fund balances; stated plans to correct obligee and increase bond amount | |
| CNA KK | Certified Nursing Assistant | Reported resident #48 had not been seen in wheelchair since it was taken for repair |
| RN HH | Registered Nurse | Reported resident #48 had not been out of bed since wheelchair accident |
| LPN LL | Licensed Practical Nurse | Observed medication storage issues during medication pass |
| CNA JJ | Certified Nursing Assistant | Reported resident #48 had not been assisted out of bed since wheelchair taken for repair |
| Rehab Director | Requested evaluation and new wheelchair for resident #48 due to positioning and safety concerns | |
| Maintenance Director | Brought repaired wheelchair to resident #48 |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 3
Feb 16, 2023
Visit Reason
A standard survey was conducted from February 14, 2023 through February 16, 2023, including investigation of Complaint Intake Numbers GA00224466 and GA00216082 related to facility compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to provide a wheelchair for a resident after a fall, inadequate surety bond coverage for resident trust funds, and medication storage issues such as unlocked medication carts and improper refrigeration of medications.
Complaint Details
Complaint Intake Numbers GA00224466 and GA00216082 were investigated in conjunction with the standard survey.
Severity Breakdown
D: 1
C: 1
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to accommodate the needs of one resident by not providing a wheelchair for mobility after a fall. | D |
| Failed to maintain a surety bond sufficient to cover the resident trust fund account balance and failed to ensure the surety bond obligee was the Georgia Department of Community Health. | C |
| Failed to ensure medication carts and treatment carts were locked when unattended and medications were stored properly, including unrefrigerated eye drops and improperly stored inhaler. | E |
Report Facts
Resident census: 108
Residents with trust fund accounts: 107
Surety bond amount: 90000
Resident trust fund balance range: 208203.61
Resident trust fund balance range: 163521.91
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Acknowledged medication cart left unattended and unlocked; involved in medication pass observation |
| RN BB | Registered Nurse | Handed keys to LPN AA for medication cart; stated expectation that medication carts be locked when unattended |
| CNA KK | Certified Nursing Assistant | Reported resident had not been seen in wheelchair since fall |
| CNA JJ | Certified Nursing Assistant | Reported resident had not been assisted out of bed since wheelchair accident |
| RN HH | Registered Nurse | Reported resident had not been up out of bed since wheelchair accident due to needed repair |
| LPN FF | Licensed Practical Nurse | Stated medication carts should be locked when unattended |
| RN GG | Registered Nurse | Stated medication carts should be locked when nurse is not present |
| LPN EE | Licensed Practical Nurse | Acknowledged medication cart unlocked and confirmed improper storage of eye drops |
| RN DD | Registered Nurse | Reported treatment cart should be secured by knob lock |
| Administrator | Verified surety bond amount and resident fund balances; stated plans to correct obligee and increase bond amount; stated expectation medication carts be locked when unattended | |
| Maintenance Director | Reported wheelchair repair process and returned wheelchair to resident | |
| Rehab Director | Requested new wheelchair for resident due to safety concerns | |
| Director of Nurses | Stated expectation medication carts be locked and medications stored per manufacturer recommendations |
Inspection Report
Life Safety
Census: 108
Capacity: 196
Deficiencies: 0
Feb 15, 2023
Visit Reason
A Life Safety Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code standards.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety from Fire regulations under 42 CFR 483.73 and 42 CFR Subpart 483.90(a).
Report Facts
Census: 108
Certified beds: 196
Inspection Report
Original Licensing
Capacity: 26
Deficiencies: 0
Sep 23, 2021
Visit Reason
A walk-through licensure survey of 26 additional beds was conducted at Muscogee Manor and Rehabilitation Center.
Findings
The facility was found to be in compliance with state requirements.
Inspection Report
Deficiencies: 0
Jul 8, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Muscogee Manor & Rehabilitation Center following a survey completed on July 8, 2021.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the survey; however, no specific deficiencies or findings are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 110
Deficiencies: 0
Jul 8, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the previous 5/10/2021 through 5/13/2021 Re-certification Survey.
Findings
All deficiencies cited in the prior Re-certification Survey were found to be corrected during this revisit survey.
Inspection Report
Original Licensing
Capacity: 26
Deficiencies: 0
Jul 7, 2021
Visit Reason
An initial licensure walkthrough survey was conducted for 26 additional beds at Muscogee Manor and Rehabilitation.
Findings
The facility was not prepared for the initial licensure walkthrough survey and the survey will be rescheduled at a later time.
Report Facts
Additional beds: 26
Inspection Report
Deficiencies: 0
May 20, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for Muscogee Manor & Rehabilitation Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments and a summary statement of deficiencies identified during the inspection, but no specific deficiencies or findings are detailed on this page.
Inspection Report
Re-Inspection
Census: 116
Deficiencies: 0
May 20, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey conducted on 2021-03-25.
Findings
All deficiencies cited as a result of the complaint survey conducted on 2021-03-25 were found to be corrected during the revisit survey.
Complaint Details
The revisit survey was conducted following a complaint survey on 2021-03-25; all cited deficiencies were corrected.
Report Facts
Census: 116
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 1
May 13, 2021
Visit Reason
A Licensure survey was conducted from May 10 through May 13, 2021, including a Complaint Investigation survey to investigate Complaint Intake Number GA00213833 and a CMS Resource Support Survey.
Findings
The facility was found not in substantial compliance due to failure to discard expired biologicals and medications in two of four medication storage rooms. The complaint was unsubstantiated with no deficiencies cited related to it.
Complaint Details
Complaint Intake Number GA00213833 was investigated and found unsubstantiated with no deficiencies cited.
Severity Breakdown
E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility failed to discard expired biologicals prior to the expiration dates in two of four medication storage rooms, including expired aspirin, multivitamins, magnesium citrate, control solutions, antiseptic wound cleanser, preservative tubes, tracheostomy care trays, and germicidal bleach wipes. | E |
Report Facts
Facility census: 116
Expired medication counts: 19
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Verified expired medications in West Wing medication room |
| RN UM | Registered Nurse, Unit Manager | Responsible for checking medication carts for expired medications and need to order |
| LPN OO | Licensed Practical Nurse | Confirmed expired items in South Wing medication room |
| Director of Nursing | Director of Nursing | Stated expectation that all nurses check medication rooms for expired medications and supplies |
Inspection Report
Annual Inspection
Census: 116
Deficiencies: 6
May 13, 2021
Visit Reason
A standard recertification survey was conducted from May 10, 2021 through May 13, 2021, including a Complaint Investigation survey and a CMS Resource Support Survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations with deficiencies related to resident dignity, safe environment, accuracy of assessments, sufficient nursing staff, medication storage, and garbage disposal. The complaint was unsubstantiated with no deficiencies cited.
Complaint Details
Complaint was unsubstantiated with no deficiencies cited.
Severity Breakdown
SS= D: 2
SS= A: 1
SS= F: 2
SS= E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to promote, maintain, and protect residents' dignity related to indwelling urinary catheter privacy for two residents. | SS= D |
| Failure to ensure a clean, comfortable, and homelike environment due to dust buildup in vents and holes in walls in resident bathrooms and shower rooms. | SS= D |
| Failure to accurately code Minimum Data Set (MDS) to reflect PASRR Level II status for one resident. | SS= A |
| Failure to provide sufficient nursing staff on four wings to assure resident safety and highest practicable well-being. | SS= F |
| Failure to discard expired biologicals and medications in two of four medication storage rooms. | SS= E |
| Failure to ensure sanitary handling of garbage and refuse at the kitchen loading dock and dumpster area. | SS= F |
Report Facts
Resident census: 116
Residents with indwelling urinary catheter: 9
Residents on North Wing: 33
Residents on West Wing: 27
Residents on South Wing: 47
Residents on Odell Wing: 7
Staffing needed CNAs North Wing: 4
Staffing needed CNAs West Wing: 4
Staffing needed CNAs South Wing: 6
Staffing needed CNAs Odell Wing: 2
Expired medication items: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN CC | Registered Nurse Unit Manager | Interviewed regarding staffing and resident care on West Wing |
| LPN BB | Licensed Practical Nurse | Observed expired medications and interviewed about medication room checks |
| RN AA | Registered Nurse | Responsible for staffing coordination and interviewed about staffing shortages |
| Staffing Coordinator VV | Staffing Coordinator | Responsible for staffing two facilities including this one |
| HR Director | Human Resources Director | Interviewed regarding staffing and recruitment efforts |
| FSD | Food Service Director | Interviewed regarding trash and housekeeping duties |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding trash and housekeeping duties |
Inspection Report
Life Safety
Census: 116
Capacity: 242
Deficiencies: 0
May 12, 2021
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and the Life Safety Code 2012 edition standards.
Report Facts
Census: 116
Certified Beds: 242
Inspection Report
Abbreviated Survey
Deficiencies: 1
Mar 25, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey to investigate complaint GA00212676, which was found to be unsubstantiated. The visit also included an unrelated abbreviated survey where deficiencies were cited.
Findings
The facility was found compliant with COVID-19 infection control regulations but failed to provide nail care as planned for one resident (R "A") due to lost fingernail clippers, resulting in long, thick fingernails on the resident's right hand.
Complaint Details
The complaint investigation (GA00212676) was unsubstantiated.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide nail care for one resident (R "A") as care planned, resulting in long, thick fingernails extending approximately one inch beyond the fingertips. | SS= D |
Report Facts
Sample size: 7
Time since clippers lost: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse AA | Licensed Practical Nurse | Stated she usually clipped resident R "A"'s fingernails monthly and explained clippers were lost |
| Unit Manager BB | Unit Manager | Confirmed she clipped resident R "A"'s fingernails on 3/23/21 after obtaining extra clippers |
Inspection Report
Abbreviated Survey
Deficiencies: 2
Mar 25, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating complaint GA00212676, which was found to be unsubstantiated. The survey was conducted from 3/23/2021 to 3/25/2021.
Findings
The facility was found to be in compliance with COVID-19 infection control regulations. However, an unrelated deficiency was identified where the facility failed to provide nail care for one resident (R "A") as care planned, due to lost nail clippers causing delayed nail care.
Complaint Details
Complaint GA00212676 was investigated and found to be unsubstantiated.
Severity Breakdown
Level D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide nail care for one resident (R "A") as care planned, with long, thick fingernails observed extending approximately one inch beyond the fingertips. | Level D |
| Failure to provide necessary activities of daily living care, including grooming, for one resident (R "A") with self-care deficits. | Level D |
Report Facts
Sample size: 7
Date of care plan: Jun 30, 2021
Date of observation: Mar 23, 2021
Date of clipper loss: Clipper loss occurred 1-2 months prior to 3/24/21
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN AA | Licensed Practical Nurse | Stated she usually clipped resident R "A"'s fingernails monthly but lost the clippers 1-2 months prior to survey |
| Unit Manager BB | Unit Manager | Confirmed she clipped resident R "A"'s fingernails on 3/23/21 after obtaining replacement clippers |
Inspection Report
Re-Inspection
Census: 108
Deficiencies: 0
Feb 10, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the December 2, 2020 COVID-19 Infection Control Focus Survey.
Findings
All deficiencies cited in the prior COVID-19 Infection Control Focus Survey were found to be corrected during this revisit survey.
Report Facts
Census: 108
Inspection Report
Routine
Census: 109
Deficiencies: 0
Feb 3, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 120
Deficiencies: 2
Dec 2, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with infection control regulations and implementation of CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility was found not in compliance with infection control regulations due to staff failing to wear face masks properly and a staff member lacking appropriate eye protection when entering a resident's room on precautions, potentially exposing residents and staff to COVID-19.
Severity Breakdown
E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility staff failed to wear face masks covering both mouth and nose, risking spread of COVID-19 to residents and staff. | E |
| A staff member did not have appropriate eye protection when entering the room of a resident on COVID-19 precautions. | E |
Report Facts
Residents affected: 6
Residents on East and North wings: 48
Sampled residents: 13
Facility census: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nurse Aide | Observed repeatedly wearing face mask improperly and interviewed about mask use |
| LPN CC | Licensed Practical Nurse | Observed with face mask below mouth and nose, interviewed about mask use |
| CNA BB | Certified Nurse Aide | Observed delivering meals with face mask below nose and interviewed |
| CNA CC | Certified Nurse Aide | Observed with face mask below mouth and nose while talking to housekeeper |
| RT | Respiratory Therapist | Observed entering resident's room on precautions without eye protection and interviewed |
| IP | Infection Preventionist | Interviewed regarding staff PPE compliance and education |
| DON | Director of Nursing | Interviewed regarding staff PPE policies and education |
Inspection Report
Abbreviated Survey
Census: 122
Deficiencies: 0
Nov 12, 2020
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaint GA00205958 and included a COVID-19 Focused Infection Control Survey.
Findings
The complaint was unsubstantiated. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and CMS/CDC recommended COVID-19 practices.
Complaint Details
Complaint GA00205958 was investigated and found to be unsubstantiated.
Report Facts
Total census: 122
Inspection Report
Routine
Census: 94
Deficiencies: 0
Jul 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, having implemented CMS and CDC recommended practices for COVID-19.
Report Facts
Total census: 94
Inspection Report
Routine
Census: 89
Deficiencies: 0
Jun 3, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services from June 1, 2020 through June 3, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Total census: 89
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 15, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint numbers GA00197803 and GA00198182.
Findings
Both complaints GA00197803 and GA00198182 were unsubstantiated with no deficiencies found during the survey.
Complaint Details
The investigation of complaints GA00197803 and GA00198182 resulted in unsubstantiated findings with no deficiencies.
Inspection Report
Re-Inspection
Census: 111
Deficiencies: 0
Aug 15, 2019
Visit Reason
A revisit survey was conducted on 8/14/19 to 8/15/19 to verify correction of deficiencies cited during a 6/12/19 complaint survey.
Findings
All deficiencies cited as a result of the 6/12/19 complaint survey were found to be corrected during this revisit survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 6/12/19; all cited deficiencies were corrected.
Report Facts
Census: 111
Inspection Report
Complaint Investigation
Deficiencies: 2
Jun 12, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00197026, which was substantiated with deficiencies related to pressure ulcer care and skin assessments.
Findings
The facility failed to conduct routine skin assessments as care planned for one resident at risk for pressure ulcers, resulting in actual harm when three unstageable pressure ulcers were found under a wristwatch. Additionally, the facility failed to identify a pressure ulcer timely for one resident and failed to complete routine skin assessments for another resident, violating pressure ulcer prevention and treatment standards.
Complaint Details
Complaint GA00197026 was substantiated. Actual harm was identified on 5/28/19 when a wristwatch was removed from Resident #1's left arm revealing three unstageable pressure ulcers.
Severity Breakdown
G: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to conduct routine skin assessments as care planned for a resident at risk for pressure ulcers, resulting in actual harm with three unstageable pressure ulcers found. | G |
| Failure to identify a pressure ulcer timely for a resident and failure to complete routine skin assessments for another resident. | G |
Report Facts
Dates of incomplete skin assessments for Resident #1: 3
Dates of skin assessments completed for Resident #2: 5
Braden Scale score: 13
Pressure ulcer measurements: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Interviewed regarding skin assessment schedules and care for Resident #1. |
| LPN AA | Licensed Practical Nurse | On duty nurse on 5/28/19 who removed the watch from Resident #1's wrist and reported the ulcers. |
| EMT AA | Emergency Medical Technician | Assisted in transporting Resident #1 to hospital and observed necrotic wound under watch. |
| Director of Nursing | Director of Nursing | Interviewed regarding skin assessment documentation and procedures. |
| Physician | Physician | Provided wound care orders and stated expectation for routine skin assessments. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 12, 2019
Visit Reason
The inspection was conducted due to concerns about the facility's failure to conduct routine skin assessments as care planned for residents at risk for pressure ulcers, including identification and timely treatment of pressure ulcers.
Findings
The facility failed to complete weekly skin assessments as required by care plans for residents at risk of pressure ulcers, resulting in actual harm when unstageable pressure ulcers were found on a resident's wrist after a watch was removed. Documentation of skin assessments was incomplete or blank for multiple weeks. Interviews with nursing staff confirmed the failure to perform and document required skin assessments.
Complaint Details
The visit was complaint-related due to allegations of failure to conduct routine skin assessments and timely identification of pressure ulcers. Actual harm was substantiated when three unstageable pressure ulcers were found on a resident's wrist after removal of a watch on 5/28/19.
Deficiencies (1)
| Description |
|---|
| Failure to conduct routine skin assessments as care planned for residents at risk for pressure ulcers, leading to actual harm with unstageable pressure ulcers found on resident's wrist. |
Report Facts
Dates of incomplete skin assessments for Resident #1: 3
Dates of incomplete skin assessments for Resident #2: 5
Pressure ulcer measurements: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Interviewed regarding skin assessment schedules and documentation; stated uncertainty about who put the watch on Resident #1 |
| LPN AA | Licensed Practical Nurse | Nurse on duty on 5/28/19 who removed the watch from Resident #1's wrist and observed bleeding and necrotic tissue |
| Treatment Nurse | Licensed Practical Nurse | Interviewed about skin assessment protocols and notified physician of pressure ulcers |
| Director of Nursing | Director of Nursing | Reviewed skin integrity forms and confirmed documentation deficiencies |
| Physician | Physician | Stated expectation that nurses routinely assess residents' skin |
| Emergency Medical Technician AA | Emergency Medical Technician | Assisted in transporting resident to hospital and observed black necrotic area under removed jewelry |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Feb 18, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00194550.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Complaint Details
Complaint GA00194550 was investigated and found to be unsubstantiated with no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 13, 2018
Visit Reason
The inspection was conducted to investigate complaint #GA00193172 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00193172 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 6, 2018
Visit Reason
The inspection was conducted to investigate complaint #GA00192501 and determine compliance with Federal and State Long Term Care regulations under 42 CFR, Part 483, Subpart B.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00192501 was investigated and found to have no deficiencies.
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 25, 2018
Visit Reason
A revisit survey was conducted on October 25, 2018, to verify correction of deficiencies cited in the Annual survey ending August 23, 2018, and to investigate complaints GA191981 and GA192366.
Findings
All deficiencies cited in the Annual survey were found to be corrected. The complaint investigations were found to be unsubstantiated due to lack of evidence.
Complaint Details
Complaint Intake Numbers GA191981 and GA192366 were investigated and found to be unsubstantiated due to lack of evidence.
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 25, 2018
Visit Reason
A Revisit Survey was conducted from 10/22/18 through 10/25/18 to verify correction of deficiencies cited during the standard survey of 8/23/18.
Findings
All deficiencies cited in the prior standard survey of 8/23/18 were found to be corrected during the revisit survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 24, 2018
Visit Reason
A revisit survey was conducted on October 25, 2018, in conjunction with investigation of Complaint Intake Numbers GA191981 and GA192366.
Findings
All deficiencies cited as a result of the Annual survey ending on August 23, 2018, were found to be corrected. The complaint investigations were found to be unsubstantiated due to lack of evidence.
Complaint Details
Complaint Intake Numbers GA191981 and GA192366 were investigated and found to be unsubstantiated due to lack of evidence.
Inspection Report
Follow-Up
Deficiencies: 0
Oct 16, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Annual Inspection
Census: 127
Deficiencies: 7
Aug 23, 2018
Visit Reason
A standard survey was conducted from August 20, 2018 through August 23, 2018, including investigation of Complaint Intake Number GA 00190906, to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to ensure legal surrogate for a resident without family, incomplete comprehensive care plans for fluid monitoring and side rail use, failure to notify dietitian of abnormal labs, improper use and consent for bed rails, lack of documented physician response to pharmacist recommendations for gradual dose reduction of antipsychotic medication, and expired medications found in storage.
Complaint Details
Complaint Intake Number GA 00190906 was investigated in conjunction with the standard survey.
Severity Breakdown
SS= D: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failure to ensure Resident #53 had a legal surrogate to exercise resident rights when no family or responsible party was available. | SS= D |
| Failure to develop a comprehensive care plan for fluid monitoring for Resident #32 diagnosed with dehydration and for side rail use for Resident #53. | SS= D |
| Failure to ensure acceptable parameters of nutritional status and hydration for Resident #32, including lack of dietitian notification of abnormal labs and lack of coordinated care. | SS= D |
| Failure to assess risk of entrapment from bed rails, review risks and benefits with resident or representative, and obtain informed consent for Residents #23, #53, and #89. | SS= D |
| Failure to document physician response to pharmacist's recommendation for gradual dose reduction of antipsychotic medication for Resident #74. | SS= D |
| Failure to attempt gradual dose reduction of antipsychotic medication for Resident #53 despite lack of behaviors warranting continued use. | SS= D |
| Failure to ensure drugs and biologicals are labeled with expiration dates and appropriate instructions; expired influenza vaccines found in medication refrigerator. | SS= D |
Report Facts
Resident census: 127
Expired influenza vaccine vials: 21
Sodium lab value: 153
Weight loss percentage: 5.9
Fluid intake order: 2400
Fluid intake order: 1500
Gap between bed rails and mattress: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN CC | Registered Nurse, Unit Manager | Interviewed regarding Resident #53's responsible party and side rail use |
| LPN GG | Licensed Practical Nurse | Interviewed regarding Resident #53's side rails and fluid intake orders |
| Administrator | Interviewed regarding ethics committee and responsible party for Resident #53 | |
| Medical Doctor (MD) | Physician/Medical Director | Interviewed regarding Resident #53's responsible party and medication dose reductions |
| Pharmacist | Interviewed regarding recommendations for gradual dose reductions | |
| LPN JJ | Licensed Practical Nurse | Interviewed regarding medication expiration checks |
| RN EE | Registered Nurse, Unit Manager | Interviewed regarding Resident #74's medication and side rail use |
| CNA FF | Certified Nursing Assistant | Interviewed regarding Resident #74's behaviors and care |
| BSW | Bachelor of Social Work | Interviewed regarding Resident #74's behaviors |
Inspection Report
Routine
Deficiencies: 5
Aug 23, 2018
Visit Reason
The inspection was conducted to assess compliance with medical, dental, nursing care, and safety regulations, including care planning and the use of side rails for residents.
Findings
The facility failed to develop comprehensive care plans for fluid monitoring for one resident diagnosed with dehydration and for the use of side rails for another resident. Additionally, the facility failed to assess risks, obtain informed consent, and properly document the use of bed rails for three residents, placing all residents at risk for entrapment and injury.
Deficiencies (5)
| Description |
|---|
| Failure to develop a complete comprehensive care plan for fluid monitoring for resident #32 diagnosed with dehydration. |
| Failure to develop a care plan for the use of side rails for resident #53 despite their use. |
| Failure to assess risk of entrapment from bed rails, review risks and benefits with residents or representatives, and obtain informed consent for residents #23, #53, and #89. |
| Failure to measure gaps between bed rails and mattresses to ensure resident safety, contributing to risk of entrapment and falls. |
| Failure to obtain physician orders for side rail use for residents despite their use. |
Report Facts
Resident sample size: 36
Total residents affected: 127
Elevated sodium level: 153
Water intake order: 1500
Care plan dates: May 17, 2018
Care plan dates: Jun 27, 2018
Side Rail Assessment Tool date: Jun 6, 2018
Side Rail Assessment Tool date: Jul 8, 2018
Resident fall date: Jun 23, 2018
Gap measurement: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Clinical Reimbursement | Interviewed regarding care plan development and side rail use for residents #32 and #53. | |
| Unit Manager HH | Interviewed about side rail use and consent for resident #23. | |
| Certified Nursing Assistant (CNA) II | Interviewed about side rail use for resident #23. | |
| Certified Nursing Assistant (CNA) AA | Interviewed about side rail use for resident #53. | |
| Licensed Practical Nurse (LPN) BB | Interviewed about side rail use for resident #53. | |
| Registered Nurse (RN) CC | Unit Manager | Interviewed about side rail use and observations for resident #53. |
| Certified Nurse Assistant (CNA) FF | Interviewed about resident #89's fall and side rail use. | |
| Registered Nurse (RN) EE | North Unit Manager | Interviewed about side rail orders and assessments for resident #89. |
| Licensed Practical Nurse (LPN) GG | Interviewed about resident #89's fall and side rail use. | |
| Medical Director | Physician/Medical Director | Interviewed about resident #89's fall and side rail orders. |
| Director of Nursing (DON) | Interviewed about side rail safety and gap measurements. |
Inspection Report
Life Safety
Census: 131
Capacity: 170
Deficiencies: 1
Aug 22, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance due to failure to properly maintain a metal container with a self-closing lid in the smoking area, which contained combustible trash and posed a risk to residents.
Severity Breakdown
SS= D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to properly maintain a metal container with a self-closing lid in the smoking area, which contained combustible trash. | SS= D |
Report Facts
Residents at risk: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff R | Interviewed and confirmed the finding regarding the metal container in the smoking area. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 27, 2018
Visit Reason
The inspection was conducted to investigate complaint #GA00189235 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey conducted on 6/25/18 and 6/27/18.
Complaint Details
Complaint #GA00189235 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 8, 2018
Visit Reason
The inspection was conducted to investigate complaint #GA00188445 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00188445 was investigated and found to have no deficiencies.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Mar 5, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00185742.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Complaint Details
Complaint GA00185742 was investigated and found to be unsubstantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 9, 2017
Visit Reason
A revisit survey was conducted on 10/9/17 for the recertification survey originally conducted from 8/14/17 through 8/17/17.
Findings
The revisit survey revealed that all previously cited deficiencies had been corrected and the facility was in substantial compliance as of 10/1/17.
Inspection Report
Follow-Up
Deficiencies: 0
Oct 5, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited deficiencies had been corrected during the follow-up survey.
Inspection Report
Routine
Census: 129
Deficiencies: 2
Aug 17, 2017
Visit Reason
A standard survey was conducted at Muscogee Manor from August 14, 2017 through August 17, 2017 to assess compliance with Medicare/Medicaid regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, specifically failing to develop comprehensive care plans for one resident and failing to provide appropriate range of motion (ROM) services to two residents. Documentation and care plan updates were inadequate, and there was a lack of proper scheduling and delivery of ROM services by nursing assistants and restorative technicians.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to develop comprehensive care plans for one resident (Resident #22) including updates reflecting changes in care needs. | SS= D |
| Failure to provide appropriate range of motion services to two residents (Resident #22 and #30) as ordered and documented. | SS= D |
Report Facts
Resident census: 129
Residents reviewed for range of motion: 32
Deficiencies: 2
PROM sessions documented: 5
PROM frequency ordered: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| BB | Unit Manager | Interviewed regarding care planning and ROM services for residents #22 and #30 |
| DD | Certified Nursing Assistant | Assigned CNA for Resident #22, provided PROM assistance |
| HH | Minimum Data Set (MDS) Coordinator | Interviewed regarding care plan updates and ROM services |
| AA | Restorative Technician | Provided PROM services to Resident #30 |
| BB | Restorative Technician | Observed providing PROM to Resident #30 |
| EE | Director of Physical Therapy | Ordered restorative nursing services and discussed scheduling responsibilities |
| DON | Director of Nursing | Interviewed regarding care plan responsibilities and ROM service scheduling |
Inspection Report
Life Safety
Census: 129
Capacity: 170
Deficiencies: 3
Aug 17, 2017
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including failure to maintain hazardous area enclosures, corridor doors, and electrical junction boxes. Specific deficiencies included a medical records room door lacking a door closer, corridor doors with excessive gaps, and an uncovered electrical junction box in the chapel closet.
Severity Breakdown
D: 2
E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Medical records room door did not have a door closer installed. | D |
| Corridor doors were not properly maintained to resist passage of smoke; several doors had gaps greater than 0.5 inch between door face and door stop. | E |
| Electrical junction box above ceiling in chapel closet was uncovered. | D |
Report Facts
Residents at risk due to hazardous area enclosure deficiency: 10
Residents at risk due to corridor door deficiencies: 8
Patients at risk due to uncovered electrical junction box: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff R | Confirmed findings during facility tour and staff interview |
Inspection Report
Follow-Up
Deficiencies: 0
Aug 10, 2017
Visit Reason
A follow-up to the Recertification survey of July 12, 2017 was conducted to verify correction of previous deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of August 9, 2017.
Inspection Report
Abbreviated Survey
Deficiencies: 2
Jul 12, 2017
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate compliance with Federal and State Long Term Care regulations, specifically related to cancer medication administration and clinical record accuracy.
Findings
The facility failed to consult with an oncologist regarding continuation of cancer medication Letrazole after the initial 30-day administration for one resident, and failed to maintain accurate clinical records documenting this issue and related communications.
Severity Breakdown
SS= D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify/consult with oncologist regarding continuation of Letrazole 2.5 mg daily after initial 30-day administration for resident #1. | SS= D |
| Failure to maintain complete, accurate, and accessible medical records for resident #1 on cancer medications. | SS= D |
Report Facts
Medication administration days missed: 53
Refills ordered: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| AA | Unit Manager Registered Nurse | Interviewed regarding failure to consult oncologist and document communication about Letrazole medication. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 15, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00176063 and determine compliance with Federal and State Long Term Care regulations.
Findings
No deficiencies were cited during the complaint survey conducted on 6/14/17 and 6/15/17.
Complaint Details
Complaint #GA00176063 was investigated and found to have no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 10, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00170891 and determine compliance with Federal and State Long Term regulations for Long Term Care Facilities.
Findings
No deficiencies were cited during the complaint survey.
Complaint Details
Complaint #GA00170891 was investigated and found to have no deficiencies.
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