Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
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 The Willows At Okemos during CMS and state inspections, most recent first.
Food service equipment and surfaces were observed heavily soiled, including the exhaust vent, light assembly, ceiling surfaces, fryer, convection oven, stove, char broiler, steamer table, ice machine, and juice machine components. The ice machine had brown to black bacterial growth on the retention plate. Surveyors also observed the mechanical dish machine operating with wash and final rinse temperatures out of range, while facility policy required proper temperatures and accurate logging for sanitation.
Late Completion of Annual MDS Assessments: The facility failed to complete comprehensive annual MDS assessments on time for three residents. One resident with Alzheimer’s disease and COPD had an annual MDS finalized after the ARD, with the CAA process not completed and the MDS not transmitted; another resident with multiple chronic conditions had the CAA Summary signed late; and a third resident with obesity and anxiety had an annual MDS signed after the required completion date.
Quarterly MDS assessments were not completed on time for three residents. One resident had multiple chronic conditions including HF, CKD, DM2, AFib, epilepsy, chronic pain, OA, osteoporosis, obesity, and COPD with moderate cognitive impairment; another had PVD, AFib, HTN, osteoporosis, GERD, depression, dysphagia, insomnia, and a left AKA; and a third resident had COPD. The MDS nurse confirmed the overdue assessments and could not explain why they were not initiated or completed timely.
Inaccurate MDS Dental Coding: A resident with Alzheimer's disease and COPD had an Annual MDS that coded no oral dental concerns despite a BIMS score showing severe cognitive impairment and available coding options for broken dentures or edentulous status. The resident reported having dentures but not seeing them for months, and an LPN stated the dentures had been dropped and broken. The MDS nurse acknowledged the resident's dental status was not accurately coded.
A resident with hemiplegia and hemiparesis after CVA and moderate cognitive impairment had a care plan that was not revised to match current transfer needs. Staff reported the resident now required a hoyer lift with a 2-person assist, and the DON confirmed the resident had been downgraded because the resident could no longer bear weight, but the care plan still contained older transfer interventions.
Failure to implement pharmacy recommendations for lipid monitoring: A resident with severe cognitive impairment and multiple chronic conditions was receiving atorvastatin, and the pharmacist twice recommended adding a fasting lipid panel with the next lab draw and annually. Although the recommendations were marked accepted, no order or results for the lipid panel were found in the chart, and the DON confirmed the results were missing and could not explain why the recommendations were not completed.
A resident with severe cognitive impairment, stroke-related deficits, and Medicaid coverage reported a pending dental follow-up after being seen for tooth pain. The dental consult documented fractured and hopeless teeth and referred the resident to an oral surgeon for extractions, but an LPN stated the referral was never made.
Two residents with significant cognitive and physical impairments experienced falls with injury due to the facility's failure to provide adequate supervision and consistently implement individualized fall prevention interventions. Staff did not ensure the use of non-skid footwear, bolster mattresses, or maintain supervision as outlined in care plans, resulting in unwitnessed falls, injuries, and emergency medical treatment.
A resident with severe cognitive impairment and multiple health conditions was observed with long, dirty fingernails and eating with their hands, despite requiring substantial assistance with ADLs and hygiene. Staff and family interviews confirmed that nail care and hand hygiene were not consistently provided or documented, and care plan interventions for nail care were not followed.
The facility failed to ensure accurate MDS assessments for multiple residents, leading to discrepancies in their medical records. A resident was inaccurately coded for medications not prescribed, another was not coded for an antipsychotic medication they were taking, a third resident's hospice services were not reflected, and a fourth resident's discharge location was incorrectly documented.
The facility failed to properly store and label medications, including narcotics, in two medication carts, leading to potential misuse and errors. Observations revealed unlocked carts, unlabeled medication cups, and improperly stored medications. The DON confirmed that these practices were against facility policy, which requires locked carts and proper labeling to prevent errors.
The facility failed to provide timely care and services for two residents, resulting in a delay in treatment and unmet care needs. One resident suffered a fracture during a transfer, which was not promptly addressed, leading to worsened mobility and increased pain. Another resident missed pain clinic appointments due to transportation issues, resulting in increased discomfort and reliance on medication.
A resident with diabetic retinopathy missed critical eye appointments due to the facility's transportation issues. The facility's bus was out of service, and alternative transportation was not arranged, leading to rescheduled appointments. The resident's guardian was not informed of the appointments, and there was a lack of documentation in the resident's medical record. Staff acknowledged the transportation and communication failures, resulting in a deficiency in providing timely ophthalmology services.
The facility failed to maintain accurate medical records for two residents. One resident's medication administration was not documented correctly, with discrepancies in the timing and identification of medications. Another resident missed critical ophthalmology appointments due to transportation issues, and the facility did not document these appointments or follow-up care properly. This highlights a deficiency in the facility's documentation practices.
A facility failed to provide scheduled showers and ADL care for a resident, leading to potential feelings of worthlessness and uncleanliness. The resident, who was cognitively intact and had multiple health issues, reported missed showers and unchanged bed sheets. Records showed ten missed showers over two months. Staff interviews revealed that showers were scheduled twice weekly, but missed showers were not properly communicated or documented.
A resident with diabetes and under hospice care experienced critically low blood sugar levels, but the facility failed to document these incidents and follow physician's orders for monitoring and treatment. Interviews revealed communication lapses among staff, leading to confusion about the resident's care plan. The resident was transferred to the hospital without proper documentation of the reasons or condition at the time.
Food Service Equipment Not Properly Cleaned and Dishmachine Temperatures Out of Range
Penalty
Summary
Food service equipment and surfaces were found to be heavily soiled during an initial tour of the kitchen with the Director of Food Services. In the dry storage room, the return air exhaust ventilation grill had accumulated and encrusted dust and dirt deposits, and food splash residue was observed on the overhead light assembly and ceiling surfaces near the equipment storage rack. The Director of Food Services stated he would have maintenance clean the ventilation grill and dietary staff clean and sanitize the light assembly and ceiling surfaces. Additional kitchen equipment was observed with accumulated and encrusted food residue. The Pitco fryer, South Bend convection oven, South Bend stove top and oven, South Bend char broiler, Cleveland steamer stainless steel support table, and Juice Machine under splash and drip tray assembly all had residue on interior or exterior surfaces. The Manitowac ice machine interior white resin retention plate had brown to black psychrophilic bacterial growth extending along the lower retention plate ridge, measuring approximately 1-inch-wide by 30-inches-long. The Director of Food Services stated he would have dietary staff clean and sanitize these items as soon as possible. During a comprehensive tour, the mechanical dish machine was observed with a wash temperature of 130 degrees Fahrenheit and a final rinse temperature of 168 degrees Fahrenheit, both out of range, while the PSI was 23 and in range. Record review showed the facility’s Dishmachine Guideline required specific wash and rinse temperatures and required low or abnormal temperatures to be reported, and the Dishmachine Temp/Sanitizer Guideline required temperatures and sanitizer concentration to be accurately recorded and dishmachine problems to be promptly addressed. Additional policy review showed cleaning procedures for the grill, oven, and ice machine.
Late Completion of Annual Comprehensive MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive annual assessments timely for three residents reviewed. For one resident with Alzheimer’s disease and COPD, the annual MDS had an ARD of 3/4/26 and the resident was observed seated in a wheelchair in the dining room on 4/15/26; the MDS was finalized on 4/16/26, and the Section V CAA Summary was signed on 4/16/26. During interview, the MDS nurse stated Section Z was signed timely, but the CAAs had been worked on on 3/18/26 and were never completed, so the MDS was not transmitted. The report cited CMS guidance stating that comprehensive assessments require completion of both the MDS and CAA process, as well as care planning, and that the MDS completion date and CAA completion date must be no later than 14 days after the ARD. For another resident with insomnia, left above-the-knee amputation, CKD, severe protein malnutrition, type 2 diabetes, hypothyroidism, hyperlipidemia, urinary retention, anemia, PVD, GERD, and dementia, the annual MDS had an ARD of 1/29/26 and the Section V CAA Summary was not completed by a registered nurse coordinator for the CAA process until 2/20/26. The MDS nurse confirmed that the signature date of 2/20/26 indicated the MDS was completed late. For a third resident with obesity and anxiety, the annual comprehensive MDS had an ARD of 2/13/26 and a signed completion date of 3/1/26; the float MDS nurse stated the completion date should have been 2/27/26 and could not explain why the assessment was not completed timely.
Quarterly MDS Assessments Not Completed Timely
Penalty
Summary
The facility failed to complete quarterly MDS assessments for three of seventeen residents reviewed for comprehensive assessments. Resident #49 was admitted with diagnoses including heart failure, chronic kidney disease, type 2 diabetes, atrial fibrillation, epilepsy, chronic pain, osteoarthritis, osteoporosis, obesity, and COPD, and had a BIMS score of 9 indicating moderate cognitive impairment. The record showed the last MDS had an ARD of 11/25/2025, and the MDS nurse confirmed that no quarterly MDS had been completed since that assessment date. Resident #61 was admitted with diagnoses including PVD, atrial fibrillation, hypertension, osteoporosis, hyperlipidemia, GERD, depression, dysphagia, insomnia, and a left above-knee amputation. The last MDS had an ARD of 12/05/2025, and the MDS nurse stated the resident was due for a quarterly MDS on 03/07/2026 but could not explain why it was not initiated. Resident #51, a female resident with COPD, had a quarterly MDS with an ARD of 03/06/2026 and a signed completion date of 04/13/2026; during interview, the MDS float nurse stated it should have been signed by 03/20/2026 and could not explain why the former MDS nurse did not complete it timely.
Inaccurate MDS Dental Coding
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident, R12, on the Annual MDS with an Assessment Reference Date of 3/4/26. R12 was admitted with diagnoses including Alzheimer's disease and chronic obstructive pulmonary disease (COPD), and the MDS reflected a BIMS score of 4 out of 15, indicating severe cognitive impairment, while also coding that there were no applicable oral dental concerns. However, the MDS included coding options for broken or loosely fitting full or partial dentures and for being edentulous. On 4/14/26, R12 was observed seated in a wheelchair in his room and reported that he had dentures but had not seen them in a few months and did not know what happened to them. An LPN stated that R12 dropped and broke his dentures one to two months earlier, and the MDS nurse acknowledged that a quarterly observation and data collection dated 2/5/26 reflected that R12 had dentures and that his dental status was not accurately coded on the Annual MDS.
Care Plan Not Updated for Current Transfer Status
Penalty
Summary
The facility failed to revise R9’s care plan to reflect the resident’s current transfer status. R9 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and the Significant Change in Status MDS with an ARD of 1/22/26 showed moderate cognitive impairment with a BIMS score of 8 out of 15. During observation on 04/14/2026, R9 was lying in bed. In interview, a CNA reported that R9 transferred via hoyer lift with a two-person assist and stated that transfer status was included in the care plan. However, the care plan still contained older interventions for pivot transfers with one-person assistance and stand-and-pivot transfers to the right side, along with an intervention dated 4/12/23 for hoyer lift with two-person assistance. A physician order dated 1/23/26 reflected hoyer lift transfers with two-person assistance, and the DON reported that R9 had been downgraded to a hoyer lift because the resident could no longer bear weight and that the care plan should have been updated.
Failure to Implement Pharmacy Recommendations for Lipid Monitoring
Penalty
Summary
The facility failed to implement pharmacy recommendations for one resident reviewed for pharmacy services. The resident was admitted with diagnoses including right ulna fracture, dysphagia, depression, insomnia, anxiety, stroke, type 2 diabetes, hypertension, and pain. The most recent MDS showed a BIMS score of 07, indicating severe cognitive impairment. A Pharmacist Drug Regimen Review dated 07/29/2025 stated that the resident was receiving atorvastatin and recommended adding a fasting lipid panel with the next lab draw and annually; the response was marked accepted, but no order or results for a fasting lipid panel were found in the medical record. A second Pharmacist Drug Regimen Review dated 09/16/2025 repeated the recommendation to add a fasting lipid panel with the next lab draw and annually, and the response was again marked accepted. During interview, the DON stated that a fasting lipid panel should have been completed based on the pharmacy recommendations and confirmed that results were not present in the resident's record. The DON later stated she was unable to find the results and could not explain why the pharmacy recommendations had not been ordered or completed.
Delayed Oral Surgeon Referral After Dental Consult
Penalty
Summary
The facility failed to ensure a timely dental services referral for one resident. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side and vascular dementia, and the Quarterly MDS reflected severe cognitive impairment with a BIMS score of 3 out of 15. The resident had Medicaid as the payer source. During observation, the resident stated she had seen the dentist for a problem with a tooth on the lower left side of her mouth and said she was supposed to have a follow-up but had not heard anything yet. The dental consult documented severe pain with pressure in the lower left and some pain in the upper anterior left corner, noted fractured and hopeless teeth, and recommended removal of remaining upper teeth and lower fractured teeth by an oral surgeon, specifically referring the resident for removal of teeth #10, 11, and 18. In interview, an LPN stated the referral to the oral surgeon was never made after the dental appointment.
Failure to Implement and Communicate Fall Prevention Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement resident-centered care plan interventions for fall prevention for two residents with known fall risks. One resident, who was legally blind, hard of hearing, and had dementia, experienced multiple unwitnessed falls, including falling out of bed and later from a wheelchair in the hallway. Despite care plan interventions such as non-skid footwear, staff assistance with transfers, and the use of a bolster mattress, these measures were not consistently implemented. The resident was found wearing regular socks instead of non-skid footwear and was placed in a wheelchair in the hallway for supervision after a fall, but was left unattended while staff attended to other residents. This resulted in a second fall, causing a head laceration that required emergency medical treatment and sutures. Another resident, with severe cognitive impairment and a history of falls and hip fractures, also experienced a fall resulting in a major injury. The care plan for this resident included interventions such as keeping the call light within reach, staff assistance with transfers, and ensuring the floor was free of hazards. However, the resident was found on the floor in their room, undressed, and without staff present. The resident's family expressed concerns about the lack of monitoring and the unclear circumstances surrounding the fall. Documentation indicated that the resident was unable to use the call light due to cognitive impairment, and staff did not provide adequate supervision or implement all care plan interventions, such as the use of a winged mattress to help define space. Interviews with staff and family members revealed gaps in staff awareness and execution of planned interventions. Staff were unable to explain why certain interventions, such as non-skid footwear and bolster mattresses, were not in place at the time of the falls. Additionally, staffing levels and assignments contributed to periods when high-risk residents were left unsupervised. The lack of consistent implementation of individualized fall prevention strategies and insufficient supervision directly led to residents experiencing preventable falls with injury.
Failure to Provide ADL and Hygiene Care for Cognitively Impaired Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple medical diagnoses, including Alzheimer's disease, dementia, and recent femur fractures, was observed with long, uneven fingernails containing a dark, unknown substance underneath. The resident, who required substantial to maximum assistance with activities of daily living (ADLs) and moderate assistance with transfers, was seen eating with their hands in the dining room, using their fingers to pick up food. Staff interviews confirmed that the resident needed cueing and assistance for all tasks, including eating and hygiene, due to significant cognitive decline. The resident was also noted to have had a recent episode involving a large bowel movement and was described as having their hands in the BM, further emphasizing the need for hand hygiene support. Despite a care plan indicating that nail care should be provided on shower days and as needed, there was no documentation in the electronic medical record regarding the completion of nail care or hand hygiene for this resident. Family concerns were also raised about the lack of nail maintenance, with reports that requests for nail trimming had not been fulfilled. Facility policy on ADL documentation did not specifically address the provision of hygiene care, and direct care staff acknowledged the issue only after it was pointed out during the survey.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for four residents, leading to discrepancies in their medical records. Resident #4 was inaccurately coded as taking anticoagulant and opioid medications, despite physician orders indicating otherwise. Similarly, Resident #42 was not coded for taking an antipsychotic medication, which was confirmed by physician orders. These inaccuracies were acknowledged by the MDS coordinator upon review. Resident #34's MDS did not reflect that the resident was receiving hospice services, despite physician orders indicating the initiation of such services. The MDS staff acknowledged this oversight. Additionally, Resident #67's discharge MDS inaccurately indicated a discharge to the hospital, while documentation by a Nurse Practitioner confirmed the resident was discharged home. This error was identified during a review with the social worker, who confirmed the mistake.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure the proper storage and labeling of medications, including narcotics, in two of five medication carts, which could lead to potential misuse and medication administration errors. During an observation, a medication cart on the 100 hall was found unlocked and unattended, with non-nurse staff passing by. A Registered Nurse (RN) was observed retrieving an unlabeled medication cup containing unidentified pills from the cart, which she claimed were for a resident's scheduled medication. The cart also contained a blister pack of Levoquin without a name and a pharmacy-packaged Levaquin with a resident's name, which the RN could not explain. Additionally, several open eye drops with no open dates were found in the cart. The RN left the cart unlocked while attending to another resident, contrary to the facility's policy that requires medication carts to be locked when unattended. In another instance, a medication cart was found with a medication cup containing six unidentified pills and a piece of paper with a possible resident name. The Director of Nursing (DON) confirmed that medication carts should be locked when unattended, controlled drugs should be double locked, and medications should not be prepped in advance in unlabeled cups. The facility's policy mandates that medications be stored in containers that meet regulatory requirements and that only authorized personnel access medications. The observed practices deviated from these policies, increasing the risk of medication errors.
Failure to Provide Timely Care and Transportation
Penalty
Summary
The facility failed to provide appropriate care and services for two residents, resulting in a delay in treatment and unmet care needs. For one resident, a transfer incident led to a fracture in the right leg, which was not promptly addressed by the facility staff. Despite the resident's complaints of pain and a family member's insistence, the facility delayed sending the resident to the hospital for further evaluation. The resident's condition worsened, requiring a mechanical lift for transfers and increased pain medication, impacting her mobility and psychological well-being. The facility's investigation into the incident was inadequate, as it did not initially include an interview with the resident involved. The investigation also lacked proper documentation and signatures, raising concerns about the thoroughness of the facility's response. The staff involved in the transfer did not recall the resident's requests to stop the transfer, and there was a lack of immediate action to address the resident's pain and potential injury. For another resident, the facility failed to ensure timely transportation to scheduled pain clinic appointments due to the facility vehicle being out of commission. The resident, who relied on pain injections for chronic back pain, experienced increased discomfort and had to rely on additional medication due to missed appointments. The facility did not arrange alternative transportation, resulting in a delay in the resident receiving necessary pain management treatment.
Failure to Provide Timely Ophthalmology Services Due to Transportation Issues
Penalty
Summary
The facility failed to ensure timely ophthalmology services for a resident, resulting in missed treatments. The resident, a male with a history of type 2 diabetes mellitus with unspecified diabetic retinopathy, hypertension, chronic kidney disease, and depression, had a moderately impaired ability to make daily decisions. He reported missing two to three eye appointments, including necessary eye injections, due to the facility's transportation issues. The facility's bus had been out of service for months, and alternative transportation arrangements were not made, leading to the rescheduling of critical eye appointments. The resident's ophthalmology office confirmed that his last appointment was on December 23, 2024, and subsequent appointments were rescheduled due to transportation issues. The resident's guardian was unaware of the December 23 appointment and the need for follow-up appointments, indicating a lack of communication from the facility. The facility's Activities/Transportation staff confirmed the transportation issues and the failure to arrange alternative transportation, which was the responsibility of the nursing staff. The Director of Nursing and other staff members acknowledged the lack of documentation in the resident's electronic medical record regarding missed appointments and follow-up notes from ophthalmology visits. The facility's failure to arrange transportation and ensure proper documentation and communication with the resident's guardian contributed to the deficiency in providing timely ophthalmology services.
Deficiency in Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, R7 and R49, as observed during a survey. For Resident R7, the issue involved the administration and documentation of controlled medications. On the morning of January 28, 2025, a review of the narcotic record binder showed that R7 was documented as having received Norco, Xanax, and Tramadol at 11:00 a.m. However, an observation revealed an unlabeled medication cup with unidentified pills in the medication cart, which the nurse claimed were R7's 11:00 a.m. medications. This discrepancy indicates a failure to document medication administration accurately and in a timely manner, as expected by the Director of Nursing. For Resident R49, the deficiency involved incomplete documentation of ophthalmology appointments and follow-up care. R49, a male resident with a history of diabetes, hypertension, and chronic kidney disease, reported missing several eye appointments due to transportation issues, which were crucial for his ongoing treatment plan. The facility's records lacked evidence of consult notes for appointments on November 25, 2024, and December 23, 2024. Additionally, there was no documentation of a missed appointment on January 22, 2025. Interviews with staff revealed that the nursing staff was expected to obtain and document consult visit notes, but this was not done, leading to incomplete medical records for R49. The failure to maintain accurate and complete medical records for both residents highlights a significant deficiency in the facility's documentation practices. The lack of proper documentation for medication administration and follow-up care appointments could potentially impact the residents' treatment and care plans. The Director of Nursing acknowledged the absence of necessary documentation and the need to follow up with the ophthalmology office for missing consult notes.
Failure to Provide Scheduled Showers and ADL Care
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care, specifically bathing and showering, for a dependent resident, resulting in potential feelings of worthlessness and uncleanliness. The resident, a cognitively intact female with multiple diagnoses including hypertension, venous insufficiency, cirrhosis of the liver, a stage III pressure ulcer, and depression, was observed to be upset and un-groomed. She reported that staff had not changed her bed sheets for two weeks and that she missed her scheduled shower the previous day. A review of the resident's electronic medical records indicated that she had missed ten showers over a two-month period, with several entries noting that the activity did not occur. The resident's care plan required assistance with ADLs, including supervision with bathing. Interviews with facility staff revealed that showers were scheduled twice weekly, but if staff were unable to provide a shower, they were expected to communicate this to the next shift. The Director of Nursing acknowledged noticing missed showers in the resident's documentation and stated that staff had been educated on the issue.
Failure to Document and Follow Physician's Orders for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident's physician's orders and treatment were correctly documented and followed. The resident, who was admitted with a diagnosis of diabetes and later to hospice care, had specific orders for blood sugar monitoring and insulin administration. However, there were significant lapses in documentation and execution of these orders. On multiple occasions, the resident's blood sugar levels were critically low, yet there was no corresponding documentation in the progress notes or medication administration record (MAR). Additionally, there was a lack of communication and documentation regarding changes in the resident's care plan, such as the discontinuation of blood sugar checks and the administration of glucose. Interviews with nursing staff and the nurse practitioner revealed discrepancies in the communication and understanding of the resident's care needs. The nurse practitioner was not informed of the resident's critically low blood sugar levels, and there was confusion about whether blood sugar monitoring should continue. Furthermore, the resident was transferred to the hospital without proper documentation of the reasons for the transfer or the resident's condition at the time. These failures in documentation and communication contributed to the deficiency in providing appropriate treatment and care according to the resident's needs and physician's orders.
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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 Okemos
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Okemos | 0.8 mi | — | 0 | 0 |
| Ingham County Medical Care Facility | 2 mi | — | 18 | 0 |
| Medilodge Of Campus Area | 2.2 mi | — | 1 | 0 |
| Burcham Hills Retirement Center | 2.4 mi | — | 4 | 0 |
| Medilodge Of East Lansing | 3.5 mi | — | 26 | 0 |
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