Cycle 1
Health 2025-12-01 · Fire 2025-12-01
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Thornton, CO
Skylake Post Acute
2-star overall rating with 2-star inspections with $25,572 in total fines with 11 recent health deficiencies
12080 Bellaire Wy, Thornton, CO
(303) 450-2700
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
242
Certified beds
Average residents
178
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1988-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 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
0.53
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.62
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
2.99
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.69
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.46
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,917
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9838
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.30
Baseline 30.77% · Performance 46.09% · Measure score 4.30 · Achievement 4.30 · Improvement 0
Adjusted total nurse staffing
0.76
Baseline 3.41 hours · Performance 3.29 hours · Measure score 0.76 · Achievement 0.76 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.92% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 13.89% · Lower 95% interval 7.36% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 26 · Denominator 26 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 26 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 3.85% |
2.29%
1.6 pts worse
|
Numerator 1 · Denominator 26 · Adjusted rate 3.17% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 27.14% |
8.2%
18.9 pts better
|
Numerator 54 · Denominator 199 |
| Staff flu vaccination coverage | 90.57% |
42%
48.6 pts better
|
Numerator 221 · Denominator 244 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.6 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.7
1.1 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.7 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
93.5%
5.4 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 99.4% · Q3 99.4% · Q4 98.2% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.4%
1.4 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.8% · Q3 4.8% · Q4 5.4% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.2% |
7.4%
1.2 pts better
|
11.4%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.2% · Q3 6.5% · Q4 6.4% · 4Q avg 6.2% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
5.0%
2.2 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.4% · Q3 2.7% · Q4 4.0% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.9% |
11.2%
2.7 pts worse
|
19.6%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 14.9% · Q3 13.9% · Q4 13.1% · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.7% |
20.6%
3.1 pts worse
|
16.7%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.4% · Q2 22.6% · Q3 21.2% · Q4 23.0% · 4Q avg 23.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.0% |
15.2%
2.8 pts worse
|
16.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.9% · Q2 13.2% · Q3 7.3% · Q4 11.4% · 4Q avg 18.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.5% |
14.6%
1.1 pts better
|
14.9%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 33.6% · Q2 9.6% · Q3 8.2% · Q4 4.1% · 4Q avg 13.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.8%
0.6 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.5% |
1.5%
1 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.6% · Q4 0.6% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.3% |
22.4%
2.1 pts better
|
19.8%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 22.9% · Q3 19.7% · Q4 13.9% · 4Q avg 20.3% |
| Percentage of long-stay residents with pressure ulcers | 5.4% |
3.7%
1.7 pts worse
|
5.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 5.8% · Q3 7.0% · Q4 3.7% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.0% |
76.4%
5.6 pts better
|
81.7%
0.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.9% · Q2 81.9% · Q3 88.5% · Q4 71.7% · 4Q avg 82.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.7% |
12.8%
2.1 pts better
|
12.0%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 12.9% · Expected 13.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.5% |
75.6%
11.9 pts better
|
79.7%
7.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.1% |
20.3%
11.8 pts worse
|
23.9%
8.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.1% · Observed 32.3% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-09 · Fire 2024-01-09
22 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (5 deficiencies)
12 fire-safety deficiencies
Top issue: Emergency Preparedness (12 deficiencies)
Cycle 3
Health 2022-09-16 · Fire 2022-09-16
4 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-01-09
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2024-02-03
F · Potential for more than minimal harm
2024-01-09
E13 · Emergency Preparedness Deficiencies
Fire Safety
Develop Emergency Preparedness policies and procedures.
Corrected 2024-02-03
F · Potential for more than minimal harm
2024-01-09
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2024-02-03
F · Potential for more than minimal harm
2024-01-09
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-02-03
F · Potential for more than minimal harm
2024-01-09
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2024-02-03
F · Potential for more than minimal harm
2024-01-09
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2024-02-03
F · Potential for more than minimal harm
2024-01-09
E33 · Emergency Preparedness Deficiencies
Fire Safety
Establish methods for sharing information.
Corrected 2024-02-03
F · Potential for more than minimal harm
2024-01-09
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2024-02-03
F · Potential for more than minimal harm
2024-01-09
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2024-02-03
F · Potential for more than minimal harm
2024-01-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-02-03
F · Potential for more than minimal harm
2024-01-09
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-02-03
F · Potential for more than minimal harm
2024-01-09
E9 · Emergency Preparedness Deficiencies
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-02-03
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-01
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 2025-12-11
F · Potential for more than minimal harm
2025-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-11
E · Potential for more than minimal harm
2025-12-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-11
E · Potential for more than minimal harm
2025-12-01
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 2025-12-11
D · Potential for more than minimal harm
2025-12-01
F569 · Resident Rights Deficiencies
Health
Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.
Corrected 2025-12-11
D · Potential for more than minimal harm
2025-12-01
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 2025-12-11
D · Potential for more than minimal harm
2025-12-01
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-12-15
D · Potential for more than minimal harm
2025-12-01
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-12-11
D · Potential for more than minimal harm
2025-12-01
F813 · Nutrition and Dietary Deficiencies
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2025-12-11
D · Potential for more than minimal harm
2025-12-01
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-12-11
D · Potential for more than minimal harm
2025-05-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-02
J · Immediate jeopardy
2024-06-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-06-14
F843 · Administration Deficiencies
Health
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-14
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-14
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 2024-07-19
D · Potential for more than minimal harm
2024-06-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-01-09
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 2024-02-03
F · Potential for more than minimal harm
2024-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-03
F · Potential for more than minimal harm
2024-01-09
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-02-03
E · Potential for more than minimal harm
2024-01-09
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-02-03
E · Potential for more than minimal harm
2024-01-09
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-02-03
E · Potential for more than minimal harm
2024-01-09
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-02-03
E · Potential for more than minimal harm
2024-01-09
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-02-03
E · Potential for more than minimal harm
2024-01-09
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-02-03
E · Potential for more than minimal harm
2024-01-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-20
E · Potential for more than minimal harm
2024-01-09
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-02-03
E · Potential for more than minimal harm
2024-01-09
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-02-03
E · Potential for more than minimal harm
2024-01-09
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-02-27
E · Potential for more than minimal harm
2024-01-09
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2024-02-03
D · Potential for more than minimal harm
2024-01-09
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 2024-02-03
D · Potential for more than minimal harm
2024-01-09
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 2024-02-03
D · Potential for more than minimal harm
2024-01-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-03
D · Potential for more than minimal harm
2024-01-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-02-07
J · Immediate jeopardy
2022-09-16
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 2022-09-16
F · Potential for more than minimal harm
2022-09-16
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 2022-09-19
D · Potential for more than minimal harm
2022-09-16
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-09-19
D · Potential for more than minimal harm
2022-09-16
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-09-19
Penalties and ownership
What sits behind the stars
$25,572
2024-06-14
Fine
Fine · fine $25,572
Fine
$0
2024-06-14
Payment Denial
Payment Denial · denial start 2024-07-17 · 2 days
2 day denial
Ownership
Panther Master Tenant, LLC
5% Or Greater Direct Ownership Interest · Organization
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Apt, Frederick
Corporate Officer · Individual
Fraser, Malcolm
Contracted Managing Employee · Individual
Goldhammer, Grady
W-2 Managing Employee · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Providence Group Nh, LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Malley Transitional Care Center
Northglenn, CO
3-star overall rating with 2-star inspections with $32,003 in total fines with 6 recent health deficiencies
#2
Villas At Sunny Acres, The
Thornton, CO
4-star overall rating with 3-star inspections with $19,988 in total fines with 9 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Center At Northridge, LLC, The
Westminster, CO
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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