Cycle 1
Health 2024-08-22 · Fire 2024-08-22
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
24 fire-safety deficiencies
Top issue: Emergency Preparedness (15 deficiencies)
Flagstaff, AZ
Aspire Transitional Care
3-star overall rating with 2-star inspections with 12 recent health deficiencies with 24 fire-safety deficiencies in the latest cycle
1521 North Pine Cliff Drive, Flagstaff, AZ
(928) 440-2350
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
40
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Goodman Group
Operator or chain grouping
Approved since
2018-10-11
CMS approved date
Coverage
Medicare
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.58
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.38
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
3.98
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.96
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.48
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
1.28
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.24
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
1.56
CMS adjusted RN staffing hours
Adjusted total hours
3.93
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,818
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9915
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.71
Baseline 20.07% · Performance 21.10% · Measure score 0.71 · Achievement 0.71 · Improvement 0
Healthcare-associated infections
2.63
Baseline 4.93% · Performance 7.05% · Measure score 2.63 · Achievement 2.63 · Improvement 0
Total nurse turnover
9.14
Baseline 49.09% · Performance 26.32% · Measure score 9.14 · Achievement 9.14 · Improvement 8.90
Adjusted total nurse staffing
2.90
Baseline 5.04 hours · Performance 3.90 hours · Measure score 2.90 · Achievement 2.90 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 7.65% |
10.72%
3.1 pts better
|
Better than the National Rate · Eligible stays 444 · Observed rate 5.63% · Lower 95% interval 5.32% |
| Discharge to community | 65.98% |
50.57%
15.4 pts better
|
Better than the National Rate · Eligible stays 500 · Observed rate 64% · Lower 95% interval 61.52% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 93.53% |
95.27%
1.7 pts worse
|
Numerator 260 · Denominator 278 |
| Falls with major injury | 0.36% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 278 |
| Discharge self-care score | 78.74% |
53.69%
25 pts better
|
Numerator 163 · Denominator 207 |
| Discharge mobility score | 59.9% |
50.94%
9 pts better
|
Numerator 124 · Denominator 207 |
| Pressure ulcers or injuries, new or worsened | 0.36% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 278 · Adjusted rate 0.57% |
| Healthcare-associated infections requiring hospitalization | 7.05% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 243 · Observed rate 6.17% · Lower 95% interval 4.61% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 96 |
| Staff flu vaccination coverage | 9.35% |
42%
32.6 pts worse
|
Numerator 10 · Denominator 107 |
| Discharge function score | 70.53% |
56.45%
14.1 pts better
|
Numerator 146 · Denominator 207 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 97 · Denominator 97 |
| Transfer of health information to patient | 96.65% |
96.28%
0.4 pts better
|
Numerator 173 · Denominator 179 |
| Resident COVID-19 vaccinations up to date | 47.53% |
25.2%
22.3 pts better
|
Numerator 77 · Denominator 162 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
91.1%
1.2 pts better
|
81.7%
10.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.6% · Q2 93.0% · Q3 90.8% · Q4 91.9% · 4Q avg 92.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 23.5% |
10.7%
12.8 pts worse
|
12.0%
11.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 23.8% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.1%
0.2 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 1.1% · Q3 1.0% · Q4 1.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.2% |
87.3%
3.9 pts better
|
79.7%
11.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.9% |
24.6%
4.3 pts worse
|
23.9%
5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.9% · Observed 27.8% · Expected 23.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-18 · Fire 2023-08-18
6 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2022-06-23 · Fire 2022-06-23
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-08-22
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-22
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-22
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-22
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-22
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-22
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-22
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-22
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-10-16
E · Potential for more than minimal harm
2023-08-18
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-08-18
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-08-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-08-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-08-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-08-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-08-18
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-08-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-08-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-08-18
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-08-18
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-08-18
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-10-03
E · Potential for more than minimal harm
2022-06-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-01
E · Potential for more than minimal harm
2022-06-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-23
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-23
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-23
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-23
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-08-01
D · Potential for more than minimal harm
2022-06-23
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-08-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-21
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-10
E · Potential for more than minimal harm
2025-08-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-09-05
E · Potential for more than minimal harm
2024-08-22
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-16
E · Potential for more than minimal harm
2024-08-22
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-22
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-22
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-16
D · Potential for more than minimal harm
2024-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-16
E · Potential for more than minimal harm
2023-08-18
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-08-18
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-08-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-08-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-08-18
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-08-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-03
D · Potential for more than minimal harm
2023-05-26
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-03
D · Potential for more than minimal harm
2023-05-26
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-08-03
E · Potential for more than minimal harm
2022-06-23
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-08-19
E · Potential for more than minimal harm
2022-06-23
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-08-19
E · Potential for more than minimal harm
2022-06-23
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-08-19
E · Potential for more than minimal harm
2022-06-23
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-06-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-06-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-08-19
D · Potential for more than minimal harm
2022-06-23
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-08-19
Penalties and ownership
What sits behind the stars
Ownership
Edinger, Craig
5% Or Greater Indirect Ownership Interest · Individual
Goodman, Shane
5% Or Greater Indirect Ownership Interest · Individual
Reiling, Mark
5% Or Greater Indirect Ownership Interest · Individual
Salmen, Thomas
5% Or Greater Indirect Ownership Interest · Individual
Weichert, James
5% Or Greater Indirect Ownership Interest · Individual
Wilson, Mark
5% Or Greater Indirect Ownership Interest · Individual
Dorris, Keith
W-2 Managing Employee · Individual
Ebeid, Sadek
Contracted Managing Employee · Individual
Edinger, Craig
Corporate Director · Individual
Flagstaff Transitional Care, LLC
5% Or Greater Direct Ownership Interest · Organization
Goodman, Shane
Corporate Director · Individual
Knacke, Clinton
Corporate Director · Individual
Knacke, Clinton
Corporate Officer · Individual
Reiling, Mark
Corporate Director · Individual
Salmen, Thomas
Corporate Director · Individual
Salmen, Thomas
Corporate Officer · Individual
The Goodman Family Operating Foundation
5% Or Greater Direct Ownership Interest · Organization
Weichert, James
Corporate Director · Individual
Wilson, Mark
Corporate Director · Individual
Wilson, Mark
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Haven Of Flagstaff
Flagstaff, AZ
3-star overall rating with 2-star inspections with abuse icon flag with $13,098 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
The Peaks Health & Rehabilitation
Flagstaff, AZ
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Haven Of Sedona
Sedona, AZ
2-star overall rating with 1-star inspections with abuse icon flag with 24 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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