Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Care Village At Mattapan during CMS and state inspections, most recent first.
Nursing staff did not document a urinary catheter change for a resident with neuromuscular bladder dysfunction, despite physician orders and the procedure being performed due to catheter blockage. The nurse involved confirmed the omission, and the DON acknowledged that catheter care was not properly recorded in the medical record.
The facility failed to adhere to physician orders and recommendations for several residents, including not following up on a clinic referral, not obtaining orders for air mattress settings, and not holding tube feeding during a resident's absence. Additionally, heel booties were not used as ordered, and documentation inaccurately reflected care provided.
The facility failed to follow food safety standards by storing dented cans on the can rack and not labeling or dating opened food in the refrigerator. Dented cans, which pose a botulism risk, were not set aside for return, and opened meats were found undated and unlabeled, contrary to facility policy. Interviews with staff confirmed these lapses in protocol.
The facility failed to maintain accurate medical records for several residents, including incorrect MRSA diagnosis, improper blood pressure documentation, and errors in enteral feeding records. A resident's record contained information from another resident, and staff interviews confirmed these documentation issues.
A resident with severe cognitive impairment was observed lying topless in bed with the privacy curtain and door open, exposing them to the hallway. Despite a care plan intervention to assist with the privacy curtain, staff failed to maintain the resident's dignity and privacy. Interviews with staff revealed awareness of the issue, but the resident was repeatedly exposed, indicating non-compliance with facility policy.
A resident with a history of embolism and hemiplegia experienced increased leg swelling and pain, which was not reported to the physician by the nursing staff. Despite the resident's complaints and observations of worsening edema, the nurse did not notify the physician, citing it as normal for the resident. The physician and nurse practitioner were unaware of the condition, indicating a failure to follow the facility's policy on notifying changes in condition.
A resident with severe cognitive impairment was found in a room with dead cockroaches and a soiled brief on the floor. Despite expectations for daily cleaning, the facility failed to maintain a clean and homelike environment, as confirmed by interviews with the DON and Corporate Nurse.
A resident with intact cognition reported observing their roommate using drugs and alcohol, but the facility failed to investigate the allegations. The resident was discouraged from submitting a grievance, and the grievance book did not document any investigation into the report, contrary to the facility's policy.
The facility failed to complete Significant Change in Status MDS assessments for two residents. One resident experienced significant weight loss, urinary catheter removal, and developed a stage 4 pressure ulcer, while another was admitted to hospice care. Both changes required assessments within 14 days, which were not completed, indicating a lapse in adherence to assessment protocols.
A facility failed to document a resident's indwelling urinary catheter in the MDS assessment, despite the resident having a neuromuscular dysfunction of the bladder and being observed with a catheter. Physician orders and treatment records confirmed the catheter's use, and staff interviews acknowledged the oversight.
A facility failed to create a baseline care plan within 48 hours of admission for a resident with acute embolism and deep vein thrombosis. The medical record review showed the absence of a timely care plan, and a Unit Manager confirmed the necessity of completing it within two days to guide caregivers.
A facility failed to create a comprehensive care plan for a resident with end-stage renal disease and osteomyelitis, lacking plans for dialysis and skin impairment. Despite physician orders for dialysis and wound care, the care plans did not address these needs. A Unit Manager confirmed the necessity for a person-centered care plan triggered by the MDS.
A resident with severe cognitive impairment and dysphagia was left without supervision during meals, despite their care plan indicating the need for assistance. Facility staff were unaware of the care plan requirements, leading to a deficiency in providing necessary ADL support.
A resident with a history of embolism and hemiplegia experienced increased leg swelling and pain, which was reported to nursing staff but not communicated to medical personnel. Despite visible swelling, the condition was not addressed until eight days later when an ultrasound was ordered to rule out a DVT.
A resident with impaired vision and a recommendation for cataract surgery did not receive the necessary follow-up care in a timely manner. Despite being cognitively intact and expressing a desire to proceed with surgery, the facility failed to schedule a follow-up appointment with an ophthalmologist. Interviews with staff revealed a lack of awareness and action regarding the resident's need for cataract surgery, highlighting a deficiency in the coordination of care.
A facility failed to follow a physician's order for air mattress settings for a resident with pressure ulcers. The resident, with multiple sclerosis and stage 3 and 4 pressure ulcers, was observed with the air mattress set at 100 pounds instead of the ordered 150 pounds. The care plan required the mattress to be set as ordered, and staff interviews confirmed the need for regular checks.
A facility failed to administer continuous enteral feeding as ordered for a resident with multiple sclerosis and dysphagia. The resident, who was cognitively intact, went on a leave of absence for seven hours without receiving the prescribed feeding. The medical record lacked documentation of physician notification regarding the feeding interruption, and staff interviews confirmed the oversight.
The facility failed to ensure proper respiratory care for two residents, resulting in unlabeled and improperly stored oxygen and nebulizer tubing. One resident's oxygen concentrator filter was dusty, and another resident's nebulizer equipment was not stored in a bag. Staff interviews confirmed that labeling and proper storage were required but not adhered to.
A resident with severe cognitive impairments and schizophrenia did not receive a required psychiatric consult or enrollment in psychiatric services, despite being on antipsychotic medications and exhibiting aggressive behavior. The facility failed to follow through on a physician's order for psychological evaluation and treatment, and the Director of Nursing was unaware of the oversight.
A facility failed to conduct an AIMS assessment for a resident receiving antipsychotic medications, as required by policy. The resident, with severe cognitive impairment and diagnoses including schizophrenia, was prescribed Haldol and Olanzapine. Despite recommendations from the consultant pharmacist, the medical record lacked evidence of the assessment, and staff interviews confirmed the oversight.
The facility failed to follow proper infection control practices, as observed when a CNA exited a resident's room with soiled linen while wearing the same gloves used to bag the linen. The CNA walked through the hallway and disposed of the linen in the chute before removing the gloves, contrary to infection control standards. The Infection Preventionist confirmed that gloves should not be worn in hallways and must be removed with hand hygiene performed before entering the hallway.
Failure to Document Urinary Catheter Change
Penalty
Summary
Nursing staff failed to maintain a complete and accurate medical record for a resident with Cauda Equina Syndrome and neuromuscular bladder dysfunction. The resident had physician orders allowing nursing staff to change an indwelling urinary catheter as needed for blockage or dislodgement. Despite these orders, there was no documentation in the resident's medical record or Treatment Administration Record (TAR) indicating that a catheter change occurred during the relevant period. An internal investigation revealed that a nurse changed the resident's Foley catheter at the resident's request due to discomfort and blockage, but did not document the procedure anywhere in the medical record. The nurse confirmed during an interview that the catheter change was performed but not recorded. The Director of Nursing also acknowledged that the catheter change should have been documented and that daily care related to indwelling catheters was not being properly recorded.
Failure to Adhere to Physician Orders and Recommendations
Penalty
Summary
The facility failed to meet professional standards of practice for several residents, as evidenced by the lack of adherence to physician recommendations and orders. For one resident, the facility did not follow a physician's recommendation to send the resident to an HIV clinic to confirm their diagnosis and determine necessary treatment. Despite the physician's recollection of making the recommendation, there was no documentation to support that an appointment was made or attended. Another resident was observed using an air mattress without a physician's order or care plan specifying the appropriate settings. The Director of Nursing acknowledged that an order or care plan should have been in place. Similarly, another resident had a physician's order for an air mattress with specific settings, but observations revealed that the mattress was not set correctly, and the Director of Nursing confirmed that settings should be checked every shift. Additionally, the facility failed to obtain a physician's order to hold tube feeding for a resident who was away from the facility, despite the resident's inability to eat by mouth. The nursing staff acknowledged that an order should have been in place. Furthermore, another resident did not have physician's orders for heel booties and elevation of heels implemented, as the booties were found unused, and the treatment administration record inaccurately indicated that the treatment was provided.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed by surveyors. In the main kitchen storage room, several significantly dented cans, including carrots, beef stew, and tropical fruit salad, were found on the can rack, contrary to the facility's policy that dented cans should be set aside in the office for return due to the risk of botulism. Additionally, in the main kitchen refrigerator, an opened ham roast and a pan of cooked meat in juices were found undated and unlabeled, which is against the facility's policy requiring all refrigerated foods to be covered, labeled, and dated. Interviews with the cook and the Food Service Director confirmed these practices were not followed, highlighting a lapse in food safety protocols.
Inaccurate Medical Records and Documentation Errors
Penalty
Summary
The facility failed to maintain accurate and complete medical records for four residents, leading to several deficiencies. For one resident, the facility inaccurately maintained a diagnosis of MRSA despite hospital discharge paperwork indicating a negative result for the infection. This discrepancy was further complicated by the physician's uncertainty about the resident's MRSA status. Another resident's medical record failed to document the correct location for blood pressure measurements, as the care plan specified measurements should be taken on the left leg due to vascular implants, yet records showed measurements were taken on the arms multiple times. Additionally, a resident's medical record contained a progress note from another resident, indicating a failure to ensure that medical records included information pertaining only to the individual resident. Furthermore, the facility inaccurately documented the enteral feeding intake for another resident who was on a feeding tube, with inconsistencies noted in the medication administration record, especially when the resident was away from the facility. These inaccuracies were acknowledged by the nursing staff during interviews, highlighting a lack of adherence to proper documentation protocols.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident, identified as Resident #3, who was observed lying topless in bed with both the privacy curtain and the bedroom door open, exposing the resident to the hallway. This incident occurred despite the facility's policy on dignity and quality of life, which mandates staff to promote and protect resident privacy, including bodily privacy during care and treatment procedures. Resident #3, who has severe cognitive impairment and requires assistance with activities of daily living, has a care plan that acknowledges a preference for lying naked in bed and includes an intervention to assist with the privacy curtain as needed. During interviews, Nurse #2 acknowledged the dignity issue and mentioned that Resident #3 is known to pull open the curtain with a stick, although the stick could not be located during the survey. The nurse also noted the difficulty in closing the bedroom door due to the preferences of the resident's roommate. The Director of Nursing confirmed that the expectation is for the privacy curtain to be closed if a resident is exposed. Despite these acknowledgments, the resident was again observed topless with the curtain and door open, indicating a failure to adhere to the care plan and facility policy.
Failure to Notify Physician of Resident's Edema
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who exhibited edema in the left leg. The resident, who has a history of embolism and hemiplegia, reported increased leg swelling and pain to the occupational therapist, but no action was taken. Observations confirmed the swelling, and interviews revealed that the nursing staff did not notify the physician or nurse practitioner, despite the resident's complaints and the worsening condition. Nurse #2 acknowledged the swelling but did not consider it significant enough to report, attributing it to the resident's normal condition. However, the resident's medical record did not indicate any existing condition that would cause such edema. Rehab staff confirmed that they had informed Nurse #2 about the swelling, but the information was not relayed to the physician. The physician and nurse practitioner were unaware of the resident's condition, indicating a breakdown in communication and failure to follow the facility's policy on physician notification for changes in condition.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean and homelike environment for a resident who was admitted in October 2010 with diagnoses including anemia and severe cognitive impairment. The resident, who requires assistance with activities of daily living, was observed on multiple occasions lying in bed surrounded by approximately 6-7 dead cockroaches. Additionally, a soiled brief was found on the floor next to the resident during two separate observations. Interviews with the Director of Nursing and the Corporate Nurse revealed that housekeeping is expected to clean rooms daily and address pest issues as needed, indicating a lapse in maintaining the resident's environment.
Failure to Investigate Resident's Report of Drug and Alcohol Use
Penalty
Summary
The facility failed to investigate a report of drug and alcohol use as reported by a resident. The resident, who was admitted with diagnoses including atrial fibrillation, chronic pain, and anxiety disorder, had a BIMS score indicating intact cognition. The resident reported to a prior social worker that they observed their roommate using drugs in the bathroom and consuming alcohol in the room. The resident was advised to submit a grievance but was discouraged from writing their account, leading them to believe that the report would not be investigated. Consequently, the resident did not submit a grievance. Interviews with the Corporate Nurse and the Director of Nursing revealed that they were unaware of the report. The Corporate Nurse later confirmed that the prior social worker had noted the resident's reluctance to submit a grievance due to perceived inaction. A grievance was recorded in the grievance book, but it only mentioned the resident's dissatisfaction with their roommate and visitors, without addressing the drug and alcohol use allegations. The grievance book lacked documentation of any investigation into the resident's report, indicating a failure to follow the facility's policy on investigating allegations of abuse.
Failure to Complete Significant Change in Status Assessments
Penalty
Summary
The facility failed to adequately identify and assess significant changes in the status of two residents, leading to deficiencies in care. For one resident, the facility did not complete a Significant Change in Status Minimum Data Set (MDS) assessment despite the resident experiencing significant weight loss, the removal of an indwelling urinary catheter, and the development of a stage 4 pressure ulcer. The resident's medical records indicated ongoing issues with weight loss and the presence of a pressure ulcer, which were not self-limiting, yet no significant change assessment was initiated within the required 14-day period. Another resident was admitted to hospice care, a change that also required a Significant Change in Status MDS assessment. However, the facility failed to complete this assessment within the mandated timeframe. The resident had been diagnosed with malignant neoplasm of the temporal lobe, depression, and dementia, and was severely cognitively impaired. The decision to admit the resident to hospice care was documented, but the necessary assessment to reflect this significant change in status was not conducted. Interviews with facility staff revealed a lack of adherence to the guidelines outlined in the Resident Assessment Instrument (RAI) manual. The Director of Nursing indicated that the MDS nurse was responsible for monitoring residents for significant changes, but the assessments were not completed as required. The corporate nurse acknowledged that a significant change MDS should have been completed for the resident admitted to hospice care, highlighting a gap in the facility's compliance with assessment protocols.
MDS Assessment Fails to Reflect Indwelling Catheter Use
Penalty
Summary
The facility failed to accurately reflect the status of a resident when the Minimum Data Set (MDS) assessment did not indicate the presence of an indwelling urinary catheter. The resident, admitted in May 2023 with neuromuscular dysfunction of the bladder, was observed with a urinary catheter drainage bag on February 11, 2025. Despite this, the MDS assessment dated January 16, 2025, did not document the use of the catheter. The resident's physician orders and treatment administration records confirmed the use of a Foley catheter since May 2023. Interviews with nursing staff and a corporate nurse corroborated the presence of the catheter, highlighting the discrepancy in the MDS documentation.
Failure to Create Timely Baseline Care Plan
Penalty
Summary
The facility failed to create a baseline care plan within the required 48 hours of admission for a resident, leading to a deficiency. The resident was admitted in January 2025 with diagnoses including acute embolism and deep vein thrombosis of the left upper extremity. A review of the medical record showed that a baseline care plan was not completed within the specified timeframe. During an interview, a Unit Manager confirmed that a baseline care plan should be completed within two days of admission to guide caregivers on the resident's care needs.
Failure to Develop Comprehensive Care Plan for Dialysis and Skin Impairment
Penalty
Summary
The facility failed to develop and implement a comprehensive resident-centered care plan for a resident with end-stage renal disease and osteomyelitis. The resident, who was admitted with diagnoses including renal dialysis dependence and a surgical wound, did not have a care plan addressing dialysis or the actual skin impairment upon admission. The Minimum Data Set (MDS) assessment indicated the resident had moderate cognitive impairment, was on dialysis, and had a surgical wound with infections. Physician orders specified dialysis on certain days and care for the dialysis catheter site and left foot dressing. However, the care plans did not reflect these needs. During an interview, a Unit Manager acknowledged that the resident should have a person-centered care plan for dialysis and skin impairment, triggered by the MDS completion.
Failure to Assist Resident with Meals
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for a resident, specifically in the area of meal supervision. The resident, who was admitted with diagnoses including dementia, dysphagia, and schizophrenia, was observed on multiple occasions sitting with a breakfast tray without any staff present to assist or supervise, despite the care plan indicating the need for such support. The resident's most recent Minimum Data Set (MDS) indicated severe cognitive impairment, further underscoring the need for assistance. Interviews with facility staff revealed a lack of awareness and adherence to the resident's care plan. A Certified Nursing Assistant (CNA) and a nurse both stated that the resident did not require supervision or assistance with eating, contradicting the care plan. The Director of Nurses (DON) confirmed that the care plan should be followed if it indicates the need for supervision or assistance. This discrepancy between the care plan and staff actions led to the deficiency in providing appropriate care for the resident's ADLs.
Failure to Address Edema in Resident
Penalty
Summary
The facility failed to address a change in condition related to edema management for a resident who was admitted with a history of embolism and hemiplegia. The resident, who had intact cognition, reported increased leg swelling and pain in the left calf to the occupational therapist, but no action was taken. Observations noted the resident's left leg was large and swollen, and the medical record did not indicate any edema or related diagnoses. Despite the resident's complaints and visible swelling, the nursing staff did not notify the nurse practitioner or physician, assuming the condition was normal for the resident. Interviews with staff revealed that the resident's leg swelling was known but not communicated to the appropriate medical personnel. Nurse #2 acknowledged the swelling but did not consider it necessary to inform the nurse practitioner or physician. Rehab staff confirmed that they had notified Nurse #2 about the swelling, but no further action was taken. The nurse practitioner and physician were unaware of the condition until eight days after the initial report, when an ultrasound was finally ordered to rule out a deep vein thrombosis.
Failure to Follow Up on Cataract Surgery Recommendation
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain their vision. Specifically, the facility did not follow up on a recommendation for cataract surgery for a resident who was admitted with diagnoses including stiff man syndrome and anxiety. The resident, who is cognitively intact with a BIMS score of 15 out of 15, was noted to have impaired vision and did not use corrective lenses. A consultant eye doctor had recommended cataract surgery and a follow-up with an ophthalmologist within 3-4 months, but the facility did not document any follow-up actions or consultations regarding this recommendation. The resident expressed during interviews that their vision had worsened since admission and that they were responsible for making their own healthcare decisions. Despite the resident's desire to proceed with cataract surgery, there was no evidence in the medical record of any follow-up or scheduled appointments. Interviews with facility staff, including a nurse and the Director of Nurses, revealed a lack of awareness and action regarding the necessary follow-up for the resident's cataract surgery, indicating a failure in communication and coordination of care within the facility.
Failure to Follow Physician's Order for Air Mattress Settings
Penalty
Summary
The facility failed to provide care and services consistent with professional standards of practice by not adhering to a physician's order regarding air mattress settings for a resident with pressure ulcers. The resident, who was admitted with multiple sclerosis and stage 3 and 4 pressure ulcers on the back and sacrum, was observed on two occasions with the air mattress set at 100 pounds, contrary to the physician's order of 150 pounds. The care plan specified that the air mattress should be set as ordered to aid in pressure redistribution. Interviews with the Director of Nursing and a nurse confirmed that the air mattress settings should be checked every shift to ensure compliance with the physician's order.
Failure to Administer Continuous Enteral Feeding as Ordered
Penalty
Summary
The facility failed to adhere to professional standards for the administration of enteral feeding for a resident diagnosed with multiple sclerosis, dysphagia, and gastrostomy status. The resident, who was cognitively intact, was observed to have gone on a leave of absence from the facility for seven hours without receiving the prescribed enteral feeding. The physician's order required the resident to receive continuous enteral feeding of Osmolite 1.5 at 55 ml/hour for 24 hours a day, which was not followed during the resident's absence. The medical record did not indicate that the physician was notified about the interruption in the resident's enteral feeding. Interviews with the nursing staff confirmed that the resident should have been receiving the feeding continuously and that the physician should have been informed if the resident did not receive the feeding as ordered. This oversight in communication and adherence to the physician's order led to the deficiency identified by the surveyors.
Deficiencies in Respiratory Care and Equipment Maintenance
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in labeling, dating, and maintaining respiratory equipment. For one resident, who was admitted with anemia and severe cognitive impairment, the oxygen tubing was not labeled or dated, and the oxygen concentrator's filter was covered in dust. This was observed on multiple occasions, and it was noted that the night nurse was responsible for changing the tubing weekly, while maintenance was tasked with changing the filters. Another resident, admitted with chronic pain syndrome and lack of coordination, had nebulizer tubing that was not labeled with a date and was not stored properly in a bag. Despite being cognitively intact, the resident's nebulizer equipment was observed to be improperly stored and unlabeled on several occasions. Interviews with nursing staff and the Director of Nursing confirmed that respiratory equipment should be labeled, dated, and stored correctly, but these procedures were not followed.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, identified as Resident #28, who was admitted with diagnoses including dementia without behaviors, dysphagia, and schizophrenia. The resident was receiving antipsychotic medications, Haldol and Olanzapine, but did not receive a psychiatric consult as required. The resident's physician had ordered a psychological evaluation and treatment for adjustment to the need for placement in the facility and medication management if required. However, the facility did not ensure that the psychiatric consult was completed, and the resident was not enrolled in psychiatric services. The deficiency was further highlighted when the resident exhibited aggressive behavior, attempting to throw a computer and trying to open a back door forcefully. Despite these incidents, the facility did not follow through with the necessary psychiatric evaluation. The Director of Nursing was unaware that the request for psychiatric services form was blank in the resident's chart and that the resident had not been enrolled in psychiatric services. Additionally, a Consultant Pharmacist had recommended an AIMS evaluation, but this was not completed, and the resident was not seen by psychiatric services as required.
Failure to Conduct AIMS Assessment for Resident on Antipsychotics
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications and properly assessed for adverse reactions to psychotropic medications. Specifically, the facility did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident who was receiving antipsychotic medications, Haldol and Olanzapine, initiated in December 2024. The facility's policy required an AIMS assessment every six months for residents on antipsychotic medications, but the resident's medical record did not indicate that such an assessment was completed. The resident, who was admitted with diagnoses including dementia without behavioral disturbance, dysphagia, and schizophrenia, had a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 6 out of 15. Despite the consultant pharmacist's recommendation to perform an AIMS evaluation, the resident's medical record lacked evidence of this assessment. Interviews with facility staff, including a nurse and the Director of Nursing, confirmed that AIMS assessments were expected to be completed by psych services but were not documented in the resident's records.
Infection Control Breach: Improper Glove Use
Penalty
Summary
The facility failed to adhere to proper infection control practices, which increased the risk of contamination and spread of infection among residents. During observations on two separate occasions, a certified nursing aide was seen exiting a resident's room with a bag of soiled linen while wearing the same gloves used to bag the linen. The aide then walked through the hallway and disposed of the dirty linen in the linen chute before removing the potentially contaminated gloves. This practice was contrary to the infection control standards, as confirmed by the Infection Preventionist, who stated that gloves should not be worn in hallways and staff should remove gloves and perform hand hygiene before entering the hallway.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mattapan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Boston Home, Inc (the) | 1.4 mi | — | 0 | 0 |
| St Joseph Rehab & Nursing Care Center | 2.3 mi | — | 5 | 0 |
| Bostonian Nursing Care & Rehabilitation Center | 2.5 mi | — | 0 | 0 |
| Laurel Ridge Rehab And Skilled Care Center | 2.6 mi | — | 0 | 0 |
| Recuperative Services Unit-hebrew Rehab Center | 2.8 mi | — | 1 | 0 |
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