Cycle 1
Health 2024-11-07 · Fire 2024-11-07
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Flagstaff, AZ
The Peaks Health & Rehabilitation
2-star overall rating with 2-star inspections with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
3150 North Winding Brook Road, Flagstaff, AZ
(928) 774-7106
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
58
Certified beds
Average residents
42
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
The Goodman Group
Operator or chain grouping
Approved since
2000-05-03
CMS approved date
Coverage
Medicare + Medicaid
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
0.96
Registered nurse staffing · state 0.72 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 1.04 · national 0.87
Aide hours / resident day
2.83
Nurse aide staffing · state 2.36 · national 2.35
Total nurse hours
4.44
All reported nurse hours · state 4.12 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.76 · national 1.54
Weekend hours
3.95
Weekend nurse staffing · state 3.62 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.51 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.94
CMS adjusted RN staffing hours
Adjusted total hours
4.36
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
68%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,412
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9874
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.64% · Performance 21.25% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.89
Baseline 7.03% · Performance 5.78% · Measure score 6.89 · Achievement 6.89 · Improvement 5.66
Total nurse turnover
1.88
Baseline 62.96% · Performance 56.00% · Measure score 1.88 · Achievement 1.88 · Improvement 1.33
Adjusted total nurse staffing
4.41
Baseline 4.90 hours · Performance 4.33 hours · Measure score 4.41 · Achievement 4.41 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 188 · Observed rate 11.17% · Lower 95% interval 8.68% |
| Discharge to community | 61.44% |
50.57%
10.9 pts better
|
Better than the National Rate · Eligible stays 194 · Observed rate 59.28% · Lower 95% interval 53.87% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 87.9% |
95.27%
7.4 pts worse
|
Numerator 109 · Denominator 124 |
| Falls with major injury | 1.61% |
0.77%
0.8 pts worse
|
Numerator 2 · Denominator 124 |
| Discharge self-care score | 72.53% |
53.69%
18.8 pts better
|
Numerator 66 · Denominator 91 |
| Discharge mobility score | 72.53% |
50.94%
21.6 pts better
|
Numerator 66 · Denominator 91 |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 4 · Denominator 124 · Adjusted rate 3.44% |
| Healthcare-associated infections requiring hospitalization | 5.78% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 110 · Observed rate 2.73% · Lower 95% interval 3.17% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 175 |
| Staff flu vaccination coverage | 14.96% |
42%
27 pts worse
|
Numerator 19 · Denominator 127 |
| Discharge function score | 83.52% |
56.45%
27.1 pts better
|
Numerator 76 · Denominator 91 |
| Transfer of health information to provider | 91.11% |
95.95%
4.8 pts worse
|
Numerator 82 · Denominator 90 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 35.94% |
25.2%
10.7 pts better
|
Numerator 23 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
97.1%
1.3 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.6%
5.4 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 | 1.6% |
2.1%
0.5 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.7% |
4.2%
5.5 pts worse
|
11.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 13.3% · Q3 13.3% · Q4 6.2% · 4Q avg 9.7% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
5.3%
0.3 pts worse
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 4.2% · Q3 4.2% · Q4 4.8% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
20.5%
3.5 pts better
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 11.5% · Q3 20.0% · Q4 17.4% · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.2% |
11.8%
1.4 pts worse
|
16.7%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 13.6% · 4Q avg 13.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 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 need for help with daily activities has increased | 7.1% |
10.8%
3.7 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 8.7% · Q3 0.0% · Q4 9.5% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
1.2%
1.3 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 0.0% · Q3 0.0% · Q4 3.1% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.1% |
20.5%
9.6 pts worse
|
19.8%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 53.2% · Q3 28.8% · Q4 21.1% · 4Q avg 30.1% |
| Percentage of long-stay residents with pressure ulcers | 13.0% |
4.8%
8.2 pts worse
|
5.1%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 18.2% · Q3 12.0% · Q4 8.5% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.7% |
91.1%
1.6 pts better
|
81.7%
11 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 92.9% · Q3 95.5% · Q4 93.8% · 4Q avg 92.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 18.8% |
10.7%
8.1 pts worse
|
12.0%
6.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 18.8% · Observed 17.9% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
1.1%
1.9 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.1% · Q3 3.3% · Q4 3.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.1% |
87.3%
5.8 pts better
|
79.7%
13.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.9% |
24.6%
4.7 pts better
|
23.9%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 18.9% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-22 · Fire 2023-09-22
2 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
18 fire-safety deficiencies
Top issue: Emergency Preparedness (7 deficiencies)
Cycle 3
Health 2022-08-11 · Fire 2022-08-11
14 health deficiencies
Top issue: Resident Rights (4 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-07
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-11-18
E · Potential for more than minimal harm
2023-09-22
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-09-22
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-09-22
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-09-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-09-22
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-09-22
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-09-22
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-09-22
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-09-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-09-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-09-22
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-22
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-22
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-09-22
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-10-16
E · Potential for more than minimal harm
2022-08-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-10-03
E · Potential for more than minimal harm
2022-08-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-03
E · Potential for more than minimal harm
2022-08-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-08-11
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-08-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-08-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-08-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-08-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-08-11
K926 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
Corrected 2022-10-03
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-07-10
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
2025-01-29
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 2025-03-28
E · Potential for more than minimal harm
2024-11-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-11-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-11-07
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 2024-12-13
D · Potential for more than minimal harm
2024-11-07
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-07
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 2024-12-13
D · Potential for more than minimal harm
2024-11-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-07
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 2024-12-13
D · Potential for more than minimal harm
2024-11-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-07
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 2024-12-13
D · Potential for more than minimal harm
2024-11-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-12-13
E · Potential for more than minimal harm
2023-09-22
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 2023-11-15
G · Actual harm
2022-08-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2021-01-18
E · Potential for more than minimal harm
2022-08-11
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-08-11
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-08-11
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-08-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-08-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-08-11
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-08-11
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-08-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-08-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-08-11
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 2022-10-15
D · Potential for more than minimal harm
2022-08-11
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-08-11
F885 · Infection Control Deficiencies
Health
Report COVID19 data to residents and families.
Corrected 2022-10-15
B · Minimal harm
2022-08-11
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-10-15
Penalties and ownership
What sits behind the stars
Ownership
Bavasi, Christopher
Corporate Director · Individual
Bavasi, Christopher
Corporate Officer · Individual
Davison, Lisa
Corporate Director · Individual
Ebeid, Sadek
Contracted Managing Employee · Individual
Farr, Cameron
W-2 Managing Employee · Individual
Knacke, Clinton
Corporate Officer · Individual
Lansburg, Jacob
Corporate Director · Individual
Northern Arizona Healthcare Corporation
5% Or Greater Direct Ownership Interest · Organization
Northern Arizona Healthcare Corporation
Operational/Managerial Control · Organization
Northern Arizona Senior Living Community, LLC
5% Or Greater Direct Ownership Interest · Organization
Northern Arizona Senior Living Community, LLC
Operational/Managerial Control · Organization
Salmen, Thomas
Corporate Director · Individual
The Goodman Family Operating Foundation
5% Or Greater Direct Ownership Interest · Organization
Wilson, Mark
Corporate Director · Individual
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Haven Of Flagstaff
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#3
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