Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around January 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 Wellbridge Of Grand Blanc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dementia, repeated falls, and orders for 1-person assist with transfers and 2-person assist with a walker was left in a common area after lunch without staff supervision or call light access. Despite needing substantial/maximal assistance with toileting and being on Plavix, the care plan lacked specific bathroom-assistance interventions, and no staff accompanied or monitored the resident when she went alone into a nearby common-area bathroom. A CNA later heard the resident screaming and found her on the bathroom floor next to her wheelchair after an unwitnessed fall, with a scalp laceration and hematoma that required ED evaluation and six staples. Interviews confirmed no staff were present in the common area at the time, and leadership stated that residents have the right to go to the bathroom on their own, even though assessments and prior falls showed this resident needed supervision and assistance.
A resident's GLP-1 (Ozempic) injection medication was not protected from staff misappropriation when an RN, not assigned to administer the drug, was observed on video surveillance removing two Ozempic pens from the secured medication refrigerator without proper documentation or justification. The resident did not experience adverse effects, but the unauthorized removal of the medication was confirmed through internal investigation and staff interviews.
A resident with severe cognitive decline and mobility issues experienced multiple falls resulting in injuries and fractures due to inadequate supervision and monitoring. Despite the resident's risk factors and history of falls, the care plan interventions were not effectively updated to prevent further incidents. Interviews with staff highlighted a lack of specific supervision for the resident, and the facility's falls reduction policy was not adequately implemented.
The facility failed to employ a full-time qualified social worker to meet the psychosocial, mental, and behavioral health care needs of its residents. The Transitional Care Coordinator, who is not a qualified social worker, has been assisting with social work roles. The previous social worker resigned without notice, and a new hire did not show up for orientation. Two social workers from sister facilities are temporarily sharing the role. The facility is certified for 128 beds, and this deficiency potentially affects all 124 residents.
Two residents experienced significant weight changes without appropriate care plan updates. A resident undergoing hemodialysis gained 29.1 pounds over 17 days without interventions, while another resident lost 27 pounds post-surgery without care plan updates. The facility failed to follow its re-weigh policy, leading to unmet care needs.
A resident with limited mobility and cognitive intactness did not receive timely activity assessments or adapted activities to meet her needs. Despite expressing a desire for engagement, the facility failed to update her activity assessments since admission and did not document efforts to include her in suitable activities, contrary to their Life Enrichment Programs policy.
A resident's urinary drainage bag and tubing were improperly placed on the floor, risking cross-contamination and infection. The resident, with dementia and quadriplegia, required extensive assistance and had a Foley catheter due to urinary retention. Facility records lacked interventions to keep the drainage system off the floor, violating infection prevention guidelines.
The facility failed to ensure timely re-weighs for two residents, leading to a lack of weight monitoring and follow-up of abnormal weights. A resident with end-stage renal disease experienced significant weight gain without care plan interventions, while another resident experienced significant weight loss without re-weighs or interventions. The Registered Dietitian acknowledged the lack of timely re-weighs and care plan updates.
A resident with a history of aphasia and dysphagia did not receive the prescribed enteral feeding rate due to a failure by nursing staff to follow physician's orders. The feeding pump was set at 70 ml/hr instead of the ordered 75 ml/hr, despite the resident's recent weight loss. The DON confirmed that nurses are responsible for setting the correct rate.
A resident who had recently undergone knee replacement surgery did not receive prescribed pain medications during her stay at the facility. Despite the availability of oxycodone in the medication dispensing system, the nurse was still processing orders and awaiting pharmacy approval. The resident, upset by the lack of pain management, called 911 and left the facility against medical advice. No pain assessments or medications were recorded during her stay.
The facility did not ensure that clinical staff levels were visibly posted for residents and visitors, as required by the SOM. Surveyors observed the absence of such postings in key areas, and the HR Director had to assist in locating the information, which was found in a binder not easily accessible.
A facility failed to properly care plan for a resident on Invega and coordinate with community mental health services. The resident, diagnosed with schizoaffective disorder, bipolar disorder, and anxiety, expressed concerns about discharge and communication with their HOPE case manager. The care plan lacked details on community mental health services and the case manager's contact information. Staff interviews revealed poor communication and coordination, with discrepancies in discharge planning and medication administration.
A resident with cognitive impairments was administered the antipsychotic medication Abilify without obtaining informed consent, as required by the facility's policy. The resident's medical records lacked documentation of consent and a risk-versus-benefit analysis for the medication, despite staff acknowledging the need for such consent.
The facility failed to properly handle and store controlled substances, with 8 out of 19 medication punch cards in the narcotic cabinet showing puncture holes. An LPN found a resident's Armodafinil 50mg with taped-over holes, indicating a medication count discrepancy. The DON confirmed this was against policy and wasted the tablets. Further inspection revealed additional punctured narcotic punch cards, including lorazepam and Norco, highlighting non-compliance with medication handling policies.
A resident reported concerns about not receiving their Norco medication correctly, leading to the discovery of a discrepancy in the narcotic medication count. The facility's documentation did not match the actual pill count, and the DON and another nurse signed off on a dose after confirming with the administering nurse via phone. The facility's policy lacked guidance on documenting administered narcotics.
Unsupervised Common-Area Bathroom Use Leads to Unwitnessed Fall With Head Laceration
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and assistance to prevent accidents for a cognitively impaired resident who fell in a common-area bathroom. The resident had severe cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 5/15, dementia, Alzheimer’s disease, repeated falls, and a history of an intracapsular right femur fracture from a prior unwitnessed fall that required surgical repair. The resident’s MDS Section GG and MD orders showed she required at least one-person assistance for transfers and two-person assistance with a walker, and needed substantial to maximal assistance with toileting, hygiene, and lower-body dressing. She was also incontinent and on Plavix, a blood thinner that may cause bleeding. Despite these documented needs and risks, the care plan did not include specific interventions for assisting her to and from the bathroom, and the incontinence care plan intervention to provide assistive devices had not been updated or revised since its original date. On the date of the incident, the resident was seated with other residents in a common area after lunch, near the common-area bathroom by the dining room. At approximately 1:05 PM, she went alone into the common-area bathroom without staff assistance. No staff were present in the common area at that time, and there was no call light access in the common area when residents needed to use the bathroom. A CNA walking by heard the resident screaming for help and found her on the bathroom floor; the fall was unwitnessed. The CNA notified the RN, who responded and found the resident lying face down next to her wheelchair, with blood all over the floor and a laceration on the top of her head and a hematoma on the left side of her forehead. The fall incident report documented that the resident stated she had been using the bathroom and attempted to get back into her wheelchair when she fell. Interviews and record review confirmed that no staff had taken the resident to the common-area bathroom or were monitoring the residents in the common area at the time of the fall, despite the resident’s known impulsivity, tendency to forget she needed assistance, and care plan direction that she needed to be watched and not left without staff in the common area. The RN who responded to the fall confirmed that no staff were in the common area when the resident was found, only a group of residents. The social worker who completed the BIMS assessment reported that the resident was more confused in the afternoon, required one-person assistance for transfers, and should not have gone to the bathroom on her own. During interviews, the DON and Administrator asserted that residents have the right to go to the bathroom on their own and cannot be stopped, and the Administrator initially believed the fall had occurred in the resident’s own bathroom rather than the common-area bathroom. The facility’s Fall Reduction Program, which is intended to provide a safe environment and reduce risk, was in place but the implementation for this resident did not prevent her from being left unsupervised in the common area and accessing the bathroom alone, leading to an unwitnessed fall with a head laceration requiring six staples and a hematoma. On a subsequent observation, the resident was seen in the hallway, confused, teary-eyed, and self-ambulating in her wheelchair, unable to state her name or room number, with visible bruising on both sides of her head and a healing scalp laceration. A staff member was yelling her room number from down the hall rather than directly assisting her, and the DON ultimately led her into her room and shut the door. This observation further illustrated her ongoing confusion and need for direct assistance and supervision, consistent with the prior assessments and fall history documented in her record.
Failure to Protect Resident's GLP-1 Medication from Staff Misappropriation
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's GLP-1 (Ozempic) injection medication from staff misappropriation. The resident, who had diagnoses including Type 2 Diabetes Mellitus, Chronic Kidney Failure, Heart Failure, and Obesity, was prescribed Ozempic as part of her diabetes management regimen. The medication was stored in a secured medication room refrigerator, as per facility protocol. However, a discrepancy was noted when the medication could not be located during routine preparation for administration, and subsequent review of the medication administration record (MAR) and narcotic log did not account for the missing medication. An internal investigation, including review of video surveillance footage, revealed that an RN who was not assigned to administer the medication was observed removing two Ozempic pens from the medication refrigerator. The RN was seen taking the pens, removing one from its packaging, and leaving the medication room with both pens without documenting the removal in the MAR or shift count sheet. There was no documentation of a need for a second dose, nor any record of medication return or disposal in accordance with facility policy. The RN initially denied taking the medication but later admitted to the act when confronted with video evidence. The resident involved did not recall missing any medications and did not experience blood sugar complications during her stay. Interviews with the resident and her family indicated some confusion regarding her medication regimen, but the primary issue was the unauthorized removal of the medication by staff. The incident was reported to local authorities and the state, and the facility conducted an audit to ensure no other medications were missing.
Failure to Prevent Falls and Injuries in Resident
Penalty
Summary
The facility failed to provide a safe and monitored environment to prevent falls for a resident, resulting in multiple falls with injuries and fractures. The resident, who had severe cognitive decline and required substantial assistance with mobility, experienced three falls over several months. The first fall occurred in the hallway, resulting in a fractured right elbow, which was not witnessed by staff but by a visitor. The facility's investigation noted the resident's pain and subsequent treatment, but the care plan did not address the resident's tendency to walk independently. The second fall happened when the resident attempted to answer the door, leading to an abrasion on the right arm. Despite the resident's confusion and inability to walk independently, the care plan interventions were not updated to address these specific risks. The third fall resulted in a fractured left hip, with the resident found on the floor after attempting to stand independently. The care plan was revised to include interventions such as encouraging group activities and family visits, but these were not specific to preventing falls. Interviews with staff, including a nurse and the DON, revealed a lack of specific supervision and monitoring for the resident, despite an increase in overall nursing staff. The facility's policy on falls reduction emphasized individualized interventions and ongoing assessments, but these were not effectively implemented for the resident, as none of the falls were witnessed by staff, and the interventions were not tailored to the resident's needs.
Failure to Employ Full-Time Qualified Social Worker
Penalty
Summary
The facility failed to employ a qualified social worker on a full-time basis to meet the psychosocial, mental, and behavioral health care needs of its residents. This deficiency was identified during an interview with the Transitional Care Coordinator, who admitted to assisting with social work roles despite not being a qualified social worker. The Coordinator is currently enrolled in a Bachelor of Social Work program, and a social worker from a sister facility reviews her assessments. The facility's Administrator confirmed that their previous social worker resigned without notice in December 2023, and a new hire in September 2024 did not show up for orientation, leaving the position unfilled. As a temporary measure, two social workers from sister facilities began sharing the full-time role, working Monday to Thursday. The facility is certified for 128 beds, and a Medicaid Bed Count waiver temporarily reduced their bed count to 116 from January to June 2024, but it returned to 128 in July 2024. Despite these efforts, the facility's failure to employ a full-time qualified social worker had the potential to affect all 124 residents residing in the facility.
Deficient Care Planning for Residents with Weight Changes
Penalty
Summary
The facility failed to establish a comprehensive person-centered care plan for two residents, resulting in significant deficiencies in care. Resident #32, who is undergoing hemodialysis, experienced a substantial weight gain of 29.1 pounds over a 17-day period without any updated care plan interventions. Despite the resident's complex medical history, including conditions such as end-stage renal disease and heart failure, the care plan was not revised to address the weight gain until prompted by a state surveyor. The Registered Dietitian (RD) acknowledged the weight gain and fluid overload risk but did not implement timely interventions or re-weighs, relying instead on post-dialysis weights from the dialysis center. Resident #41, who had recently undergone gall bladder surgery, experienced significant weight loss without appropriate care plan updates. The resident's weight dropped from 192.4 pounds to 165.9 pounds over a month, a loss of 27 pounds, without any care plan interventions being added. The facility's re-weigh policy was not followed, as re-weighs were not performed within the preferred 48-hour timeframe, and the resident's weight was only monitored weekly. The RD admitted that the re-weight was not conducted to verify the actual weight loss, despite the resident's complex medical conditions, including coronary artery disease and chronic kidney disease. The deficiencies in care planning for both residents highlight a failure to adhere to the facility's policies on weight monitoring and care plan updates. The lack of timely interventions and re-weighs for significant weight changes indicates a gap in the facility's ability to provide adequate care for residents with complex medical needs. These oversights resulted in unmet care needs and potential health risks for the residents involved.
Failure to Provide Adequate Activity Programming for Resident
Penalty
Summary
The facility failed to complete timely comprehensive activity assessments and provide ongoing programming to meet the interests of a resident, resulting in a deficiency. The resident, who was admitted with diagnoses including Peripheral Vascular Disease, Diabetes, Major Depressive Disorder, and Polyneuropathy, had only one activity assessment completed at the time of admission in March 2023. Despite being cognitively intact and able to express her needs, the resident reported that she was unable to participate in many activities due to limited mobility in her hands and that no adaptations were made to accommodate her participation. The resident expressed feelings of inactivity and lack of engagement, as she was often left to rest in her room without suitable activities. The Activities Director acknowledged the lack of updated assessments, which should have been completed every three months, and admitted that no adaptations were made to include the resident in group activities. The director also confirmed that there was no documentation of efforts to engage the resident in independent leisure pursuits, such as providing music, an iPad, or encouraging her to get out of bed. The facility's policy on Life Enrichment Programs, which mandates daily activities tailored to each resident's needs, was not adhered to, as evidenced by the lack of documented assessments and adapted activities for the resident.
Improper Placement of Urinary Drainage Bag and Tubing
Penalty
Summary
The facility failed to ensure proper placement of a urinary drainage bag and tubing for a resident, leading to a potential risk of cross-contamination and infection. On October 1, 2024, it was observed that the urine drainage bag of a resident was hooked to the bed frame and resting on the floor, with a loop of the catheter tubing also on the floor. A Certified Nursing Assistant (CNA) confirmed that the bag and tubing should not be on the floor and subsequently placed a basin under the drainage bag and tubing. The resident involved had been admitted to the facility with diagnoses including dementia, quadriplegia, and stroke, requiring extensive assistance with all activities of daily living and was severely cognitively impaired. The resident had a 16 French indwelling Foley catheter with a 10 ml retention balloon due to urinary retention. The facility's records indicated a protocol to check the catheter system every shift for patency and integrity, but there was no intervention documented to ensure the urine drainage bag and tubing were kept off the floor, contrary to guidelines for preventing catheter-associated urinary tract infections.
Failure to Monitor Weight Changes in Residents
Penalty
Summary
The facility failed to ensure timely re-weighs for weight loss or weight gain for two residents, resulting in a lack of weight monitoring completion and follow-up of abnormal weights. Resident #32, who has a complex medical history including end-stage renal disease and receives hemodialysis, experienced significant weight gain over a 17-day period without any care plan interventions being added. Despite the resident's weekly weight gain of approximately 6 pounds, no re-weighs were conducted, and the care plan was not updated until after the state surveyor's inquiry. Resident #41, who is cognitively intact and has a history of medically complex conditions, experienced a significant weight loss over a period of time without any care plan interventions. The resident's weight dropped from 192.4 pounds to 165.9 pounds, a loss of 27 pounds, without re-weighs being conducted to verify the actual weight. The facility's policy required re-weighs for a weight change of +/- 5 pounds, but this was not adhered to, and the re-weigh policy did not specify a time frame for re-weighs to be performed. The Registered Dietitian (RD) acknowledged the lack of timely re-weighs and the absence of care plan interventions for both residents. The RD stated that re-weighs should ideally be performed within 48 hours, but this was not done. The RD also noted that Resident #32's weights were taken from post-dialysis weights sent from the dialysis center, and Resident #41's weight monitoring was inconsistent, with the facility only relying on weekly weights after a significant weight loss.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility failed to follow physician's orders for enteral feeding for a resident, resulting in the resident not receiving the prescribed amount of enteral feeding. The resident, who has a medical history including aphasia, dysphagia, and a transient ischemic attack, was observed with their enteral feeding set at 70 ml/hr, despite a physician's order for 75 ml/hr. This discrepancy was noted over two consecutive days, with the feeding pump incorrectly set at 70 ml/hr instead of the ordered 75 ml/hr. The resident experienced a weight loss of 5.6% over a short period, prompting the Registered Dietitian to increase the feeding rate to 75 ml/hr to address the weight loss. However, the nurses responsible for setting the pump rate did not adhere to the updated physician's order. The Director of Nursing acknowledged the error and confirmed that the nurses on the floor are responsible for ensuring the correct rate of infusion on the pump, as per the facility's policy on enteral nutritional feeding.
Failure to Provide Pain Management Leads to Resident Leaving Facility
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who had recently undergone a left knee joint replacement. The resident, who was admitted to the facility with multiple diagnoses including pain and anxiety, did not receive any of the prescribed pain medications during her stay. The resident was admitted late in the evening and requested pain medication shortly after admission, but the nurse was still processing the physician orders and awaiting pharmacy approval for the narcotic. Despite the availability of oxycodone in the medication dispensing system, the resident did not receive it and was offered Tylenol instead, which she refused. The resident became upset due to the lack of pain management and called 911 to be taken back to the hospital. The facility's records showed that there were no pain assessments conducted for the resident, and the Pain Level Summary report was blank. Additionally, there were no progress notes related to the resident's admission or stay, and no admission assessment or vital signs were recorded. The resident's Medication Administration Record also indicated that she did not receive any medications during her stay. Interviews with the facility's Administrator and Corporate Nurse revealed that the nurse was actively trying to obtain the necessary orders and medications, but the resident left against medical advice before the process was completed. The Administrator acknowledged that the resident was upset about not receiving her pain medication and that the facility had not adequately prepared to meet the resident's needs upon her late-night admission. The resident was subsequently transferred to a different nursing home after her hospital visit.
Failure to Post Clinical Staff Levels
Penalty
Summary
The facility failed to ensure that clinical staff posting of licensed and unlicensed staff levels were visible for residents and visitors to review. This deficiency was identified through observations, interviews, and record reviews conducted by surveyors. According to the State Operations Manual (SOM), facilities are required to post the total number and actual hours worked by licensed and unlicensed nursing staff responsible for resident care per shift. This information must be displayed in a prominent place accessible to residents and visitors. However, during multiple observations on different days, surveyors noted the absence of such postings in the front lobby and resident care areas, including the 100 and 600 halls. On one occasion, the surveyor had to request assistance from the Human Resource (HR) Director to locate the clinical nursing hours posting. The HR Director eventually found the 'Staffing Report & Concerns Contact' form dated 10/2/2024, which was tucked into the back side of the front cover of a white binder labeled 'Public Information' on a low-level coffee table in the front lobby. The form included the nursing hours for different shifts, but its placement was not readily visible or accessible to residents and visitors, as required by the SOM.
Failure to Coordinate Mental Health Services and Care Plan for Antipsychotic Medication
Penalty
Summary
The facility failed to adequately care plan for a resident receiving an antipsychotic injectable medication, Invega, and did not ensure coordination with community mental health services. The resident, who was diagnosed with schizoaffective disorder, bipolar disorder, and anxiety, expressed concerns about their discharge and the need to communicate with their HOPE case manager. Despite these concerns, the resident's care plan did not include information about their community mental health services or the case manager's contact details. Upon review, it was found that the resident's electronic medical record lacked a physician's order to coordinate care with community mental health services. Additionally, the discharge planning documentation did not mention the resident's involvement with the HOPE network. The social worker had not assessed the resident, and the transitional care coordinator had only recently scheduled a meeting with the case manager. The resident's care plan also failed to address the administration of the Invega medication, which was provided by the HOPE network. Interviews with facility staff revealed a lack of communication and coordination regarding the resident's mental health services and discharge planning. The unit manager confirmed that the resident was due for an Invega injection and that the medication was available in-house. However, the discharge plan incorrectly indicated that the resident would be moving to an assisted living facility, while the resident believed they were returning to their private apartment. This discrepancy highlighted the facility's failure to ensure proper coordination and communication with the resident's community mental health services.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to obtain informed consent for the administration of an antipsychotic medication, Abilify, for a resident diagnosed with multiple cognitive and mood disorders, including vascular dementia with agitation and major depressive disorder. The resident, who was cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 7 out of 15, was prescribed Abilify for depression starting in July 2024. Despite the facility's policy requiring informed consent and education on potential side effects for psychotherapeutic medications, no consent for Abilify was found in the resident's medical records. The records only contained consents for other medications, such as trazadone and Lexapro. Interviews with facility staff, including the Transitional Care Coordinator and a Registered Nurse, confirmed that Abilify, being an antipsychotic, required consent, which was not obtained. The staff acknowledged the oversight and noted that the initial assessment for Abilify was missed. Additionally, there was no documentation of a risk-versus-benefit analysis for the use of Abilify in the resident's medical record, further indicating a lapse in the facility's adherence to its medication management policies.
Improper Handling and Storage of Controlled Substances
Penalty
Summary
The facility failed to ensure proper handling and storage of controlled substances, as evidenced by the presence of puncture holes in 8 out of 19 medication punch cards in the 100 Hall Controlled/Narcotic substance medication cabinet. During an observation, it was noted that a resident's medication, Armodafinil 50mg, had two tablets with taped-over punch holes, indicating a discrepancy in the medication count. The Licensed Practical Nurse (LPN) on duty acknowledged the issue, attributing it to the night shift nurse who failed to waste the tablets as required by the facility's policy. The Director of Nursing Services (DON) confirmed that the practice of taping over punched holes was not acceptable and proceeded to waste the tablets. Further inspection revealed additional deficiencies, with six more narcotic punch cards showing puncture marks from either a fingernail or an ink pen. These included medications for both sampled and unsampled residents, such as lorazepam and Norco. The facility's policies on controlled substances and medication disposal were not adhered to, as evidenced by the improper handling and storage of these medications, which could lead to cross-contamination and ineffective medication administration.
Narcotic Medication Documentation Discrepancy
Penalty
Summary
The facility failed to ensure accurate documentation of narcotic medications for a resident, leading to a discrepancy in the medication count. The resident, who was cognitively intact and had a history of peripheral vascular disease, polyneuropathy, and anxiety disorder, expressed concerns about not receiving their Norco medication correctly. Upon review, it was found that the Medication Administration Record (MAR) indicated a scheduled administration of Norco every six hours, but there was a discrepancy between the Controlled Substance Proof-Of-Use Record and the actual count of pills in the blister pack. The discrepancy arose when the last recorded removal of a pill was at 11:00 PM, but the physical count showed one less pill than documented. The Director of Nursing (DON) and another nurse later signed the Proof-Of-Use Record for a dose supposedly given at 6:00 AM, based on a phone confirmation with the nurse who had forgotten to sign the record. The facility's policy on controlled substances did not address the documentation of administered narcotic medications, contributing to the oversight.
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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 Grand Blanc
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Oaks At Woodfield | 2.6 mi | — | 2 | 0 |
| Medilodge Of Grand Blanc | 4 mi | — | 19 | 0 |
| Regency At Grand Blanc | 4.2 mi | — | 3 | 0 |
| Wellbridge Of Fenton | 6.1 mi | — | 9 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 6.4 mi | — | 15 | 0 |
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