Altenheim Health & Living Community
Inspection history, citations, penalties and survey trends for this long-term care facility in Indianapolis, Indiana.
- Location
- 3525 E Hanna Ave, Indianapolis, Indiana 46237
- CMS Provider Number
- 155196
- Inspections on file
- 36
- Latest survey
- March 25, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Altenheim Health & Living Community during CMS and state inspections, most recent first.
A resident with bipolar disorder, morbid obesity, and diabetes repeatedly refused a prescribed trazodone 50 mg dose for insomnia over multiple days, later reporting passive suicidal ideations and emotional distress. Although the MAR documented numerous refusals and a behavioral health note described an ED visit for passive suicidal ideation and concerns about antidepressant inconsistencies, there was no documentation that the physician was notified of the refusals until the medication was discontinued. The SSD and Social Service Assistant were unaware of the trazodone prescription and the refusals, and the refusals were not discussed in clinical meetings as was customary, contrary to the facility’s documentation policy requiring recording of services and changes in condition.
A resident with multiple diagnoses, including bipolar disorder, morbid obesity, diabetes, hypertension, heart failure, anxiety, vitamin D deficiency, and constipation, had several ordered medications (amlodipine, aspirin, buspirone, divalproex, metoprolol succinate, and polyethylene glycol) with missing documentation on the MAR for specific dates and shifts. During review of the MAR for a one-month period, numerous administration times were left blank with no indication whether doses were given or omitted. An LPN acknowledged that the MAR documentation should have been completed, and the DON provided a charting policy requiring documentation of medication administration, showing that the blanks were not consistent with facility policy.
Two residents were affected when a nurse discharged a resident with another resident's Novolog insulin pen, failing to verify the medication labels inside the bag and relying only on the external identification sticker. The DON confirmed that the facility's policy did not require label verification on discharge medications, contributing to the error.
A facility failed to secure prescription injectable medication for a resident. Two sealed enoxaparin sodium injections were found on a shelf in the resident's closet, contrary to the facility's policy requiring medications to be stored in a secured area. An LPN confirmed the injections should have been locked in the medication cart. The DON provided the facility's drug storage policy, which was not followed in this case.
A facility failed to provide adequate care for a resident with a pressure ulcer. The resident, with conditions including diabetes and malnutrition, was admitted with a stage 1 pressure ulcer. Hospital orders required specific wound care and repositioning, but the facility did not develop a care plan or follow physician's orders for treatment. The resident's wound treatment was not completed on multiple occasions, and the wound was not measured weekly as required by the facility's policy.
The facility failed to monitor daily weights for three residents dependent on dialysis, as required by physician orders. Despite being weighed during dialysis sessions, the facility's nursing staff did not consistently perform daily weight checks, with numerous instances of missing records and unexplained omissions. Interviews confirmed the deficiency, which was acknowledged by the facility's DNS and Corporate Clinical Support Director, highlighting a lapse in following prescribed care plans.
The facility failed to maintain an effective pest control program, resulting in a mice infestation affecting five residents. Observations included mouse droppings in various locations and evidence of mice chewing on food items. Despite initial treatments, the infestation persisted, with the Maintenance Director reporting catching 157 mice over the past couple of months.
Failure to Address Repeated Refusal of Behavioral Health Medication
Penalty
Summary
The facility failed to ensure a resident with bipolar disorder received necessary behavioral health services when she repeatedly refused a prescribed medication for insomnia without appropriate follow-up. The resident, who was not cognitively impaired and had diagnoses including bipolar disorder, morbid obesity, and diabetes, reported that she believed she had refused an insomnia medication and had been sent to the hospital because she did not care if she died. Physician orders showed trazodone 50 mg at bedtime was started and later discontinued, and the MAR documented multiple refusals of this medication across numerous dates. A behavioral health note recorded that the resident presented to the emergency department with passive suicidal ideations, several life stressors, increased emotionality, and reported inconsistencies with her antidepressant medication. Despite these refusals and behavioral health concerns, the clinical record lacked documentation that the physician was notified of the ongoing refusals until the date trazodone was discontinued. A late-entry progress note indicated the resident’s refusal of trazodone had been discussed in a care plan meeting, but the Social Service Director stated he was not aware of the details of the refusals, and the Social Service Assistant reported she was unaware both of the trazodone prescription and the resident’s refusals. The Social Service Assistant indicated that medication refusals are normally discussed in clinical meetings, but this resident’s refusals had not been discussed to her knowledge. The facility’s charting and documentation policy required that all services performed and changes in condition be recorded to ensure consistency between family, physicians, and social services, but this was not followed in this case.
Incomplete MAR Documentation for Multiple Medications
Penalty
Summary
The deficiency involves incomplete and inaccurate documentation on the Medication Administration Record (MAR) for one resident. Resident B’s clinical record showed multiple active physician orders for medications including amlodipine for hypertension, aspirin for heart failure, buspirone for anxiety, cholecalciferol for vitamin D deficiency, divalproex for bipolar disorder, metoprolol succinate for hypertension, and polyethylene glycol for constipation. Several of these orders had start dates and, for some, discontinue dates, while others had no stop dates noted. Review of the MAR for the period from 2/1/26 through 2/28/26 revealed missing documentation entries for multiple medications on specific dates and shifts. Specifically, the MAR lacked documentation for administration of amlodipine, aspirin, divalproex, metoprolol succinate, and polyethylene glycol on the morning shifts of 2/12/26 and 2/19/26, and for buspirone at 12:00 p.m. on 2/12/26. These MAR entries were left blank, with no indication whether the medications were given or omitted. During an interview, an LPN stated that the documentation should have been completed on the MAR. The DON provided the facility’s Charting and Documentation policy, which states that medication administration must be documented, confirming that the observed blanks on the MAR were not in accordance with facility policy and accepted standards.
Failure to Verify Medication Labels During Discharge
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of residents, specifically in ensuring the accurate receiving and dispensing of medications. During the discharge process, a resident with diagnoses including diabetes mellitus and dependence on renal dialysis was sent home with another resident's Novolog insulin pen. The LPN responsible for the discharge removed insulin pens from a bag labeled with the resident's identification sticker but did not verify the labels on the actual medication inside the bag. The Director of Nursing confirmed that the nurse should have checked the medication labels and was unsure whether the error originated from the pharmacy or from staff placing the medication in the wrong bag. A review of the facility's discharge planning policy revealed that it did not require staff to confirm medication labels when providing discharge medications to residents. This oversight contributed to the error, as staff relied solely on the external bag label rather than verifying the medication itself. The incident was identified during interviews and record reviews, highlighting a lapse in procedures intended to ensure residents receive the correct medications upon discharge.
Failure to Secure Prescription Injectable Medication
Penalty
Summary
The facility failed to ensure the security of prescription injectable medication for a resident. During an observation, two sealed enoxaparin sodium injections, which are prescription blood thinner injections, were found lying on a shelf in the resident's closet. This was contrary to the facility's policy, which requires medications to be stored in a medication cart or other secured area. An LPN confirmed that the injections should have been locked in the medication cart and not left unsecured in the resident's closet. The Director of Nursing provided a copy of the facility's drug storage policy, which was undated, indicating that the current policy was not followed in this instance.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care and services for a resident admitted with a pressure ulcer. The resident, who had diagnoses including physical debility, diabetes, and malnutrition, was admitted with a stage 1 pressure ulcer. Hospital discharge orders required the application of barrier cream to a deep tissue injury in the sacral region and repositioning every two hours. However, the facility did not develop a care plan for the sacral pressure wound, and there was no physician's order to turn the resident side to side starting from the admission date. The resident's sacral wound treatment was not completed as ordered on 8 out of 14 days, with reasons including the resident being unavailable or up in a chair. The facility's Medication Administration Record indicated several instances where the treatment was not administered or left blank. Additionally, the sacral wound was not measured weekly as required. The facility's Wound Management Policy, which mandates weekly documentation of wound assessments, was not followed, contributing to the deficiency.
Failure to Monitor Daily Weights for Dialysis Residents
Penalty
Summary
The facility failed to provide adequate care and services for residents requiring dialysis, as evidenced by the lack of daily weight monitoring for three residents. These residents, who were dependent on renal dialysis due to end-stage renal disease, had physician orders for daily weight checks to monitor fluid management and prevent complications. However, the facility's records showed multiple instances where these weights were not obtained, and in many cases, no reason was documented for the omission. Resident 54, who was cognitively intact and dependent on dialysis, had several missing daily weights over a period of months. The facility's records indicated various reasons for the missed weights, such as the resident being unavailable or the weight being on hold, but often lacked any explanation. Similarly, Resident 59, who was moderately cognitively intact, also had missing weight records, with some entries lacking reasons for the omission. Resident 67, who was cognitively intact, experienced the same issue, with numerous daily weights not recorded and no reasons provided in several instances. Interviews with the residents and staff revealed that while dialysis staff weighed the residents during dialysis sessions, the facility's nursing staff did not consistently perform daily weight checks as required. The Director of Nursing Services and the Corporate Clinical Support Director acknowledged the failure to obtain all prescribed daily weights, which was contrary to the facility's hemodialysis policy and protocol for following physician orders. This deficiency highlights a significant lapse in adhering to physician-prescribed care plans and ensuring the safety and well-being of residents undergoing dialysis.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a mice infestation affecting five residents. During an initial tour, housekeeping staff indicated issues with mice in several resident rooms. Observations included mouse droppings in various locations such as dressers, closets, and windowsills, as well as evidence of mice chewing on food items. Residents reported seeing live mice in their rooms, and staff confirmed the presence of mice droppings in multiple rooms over the past few months. Interviews with the Director of Nursing Services (DNS) and the Maintenance Director revealed that the pest control provider had been treating the infestation since December 2023, initially conducting treatments twice weekly. However, after mid-February, the frequency was reduced to monthly as no new evidence of mice was found. Despite this, the Maintenance Director reported catching 157 mice over the past couple of months, indicating the infestation persisted in certain areas of the facility. Documentation provided by the DNS included a pest sighting log and customer service reports from the pest control provider, which showed a history of mice sightings and treatments. The facility's pest elimination policy outlined a proactive approach to pest control, including regular inspections and treatments. However, the DNS and staff were unaware of ongoing issues, suggesting a lapse in communication and reporting of new sightings.
Latest citations in Indiana
Surveyors found that staff failed to follow physician orders for several residents, including not documenting required physician notification and new insulin orders after a critically high blood glucose, not consistently obtaining or recording ordered daily weights, and administering antihypertensive and midodrine medications despite blood pressure readings outside ordered hold parameters. Documentation on the MAR and related records included unexplained "NA," "X," and blank entries for required weights, and cardiac and BP-related medications were given when systolic blood pressure was below or above specified thresholds, contrary to written orders and facility policy.
Informed consent was not documented before a psychotropic med was started for one resident with dementia and anxiety, and it was not documented before another resident's Vraylar dose was increased for aggression. The DON stated the consent form should be completed before initiation or dose increase, and the facility policy required informed consent before starting or increasing a psychotropic med.
A resident with alcohol abuse, anxiety, and major depressive disorder was transferred to the ER and later planned for transfer to another LTC facility, but no Discharge MDS was completed. The MDS coordinator stated the discharge MDS was not done at discharge and should have been completed within the required timeframe; the facility did not have a resident assessment policy and used RAI criteria for timing.
An MDS assessment failed to accurately reflect a resident's status when an antidepressant prescribed for insomnia was not documented on the admission MDS. The resident had Alzheimer's disease and major depressive disorder, and the MDS coordinator later confirmed the assessment was incorrect.
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
A resident with documented diagnoses of CHF, atherosclerotic heart disease, and pacemaker dependence was admitted with clear record entries noting the presence and use of a cardiac pacemaker, including in the admission evaluation, skin assessment, and a physician note. However, the resident’s care plan did not address the pacemaker at all. The MDS Coordinator acknowledged that the pacemaker should have been care planned, noting that while there is no specific MDS item for pacemakers, diagnosis codes or nursing assessments should trigger care plan development. The Unit Manager confirmed that nursing, social services, and the MDS Coordinator can add items to care plans, and the facility’s care plan policy—emphasizing resident-focused, safety-oriented care—was in place but not applied to this resident’s pacemaker.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was discharged to an acute care hospital, but review of MDS listings showed that no discharge MDS assessment was completed for that resident. The MDS Coordinator acknowledged that a discharge assessment is required whenever a resident leaves the facility and could not explain why it was missed. The Executive Director reported there was no specific facility policy for MDS assessments and that staff relied on the RAI manual for guidance.
A resident with a fractured wrist returned from an orthopedic visit wearing a new black wrist splint after the cast was removed, but the clinical record lacked an updated physician order and instructions for splint use and care. Staff also did not document follow-up with the physician, and the care plan was not revised when the splint began being used; the DON acknowledged the missing order and lack of a policy for obtaining updated physician information.
The facility failed to document assessment and monitoring of a resident’s bruising and post-procedure condition, and failed to follow ordered medication hold parameters for two residents. One resident returned from an outpatient spinal injection with no nursing note or assessment, another had persistent bruising with no documentation, and two residents received Metoprolol and midodrine despite pulse or BP values outside ordered limits. A separate resident was observed with purple discolorations and a black scab, but the skin record did not reflect assessment or monitoring.
Failure to Follow Physician Orders for Insulin, Daily Weights, and BP-Related Medications
Penalty
Summary
The deficiency involves multiple failures to follow physician orders for medication administration and monitoring. For one resident with type 2 diabetes, peripheral vascular disease, and failure to thrive, a physician’s order directed use of Humalog insulin per a specific sliding scale and required physician notification if blood glucose exceeded 400. A blood sugar of 470 was recorded on one date, and the Medication Administration Record (MAR) showed that 5 units of Humalog were given, but there was no documentation in the MAR, assessment tab, or progress notes that the physician was contacted or that new insulin orders were obtained, despite the DON later stating that an additional 5 units had been ordered. Two residents with orders for daily weights did not have those weights consistently obtained or documented as ordered. One resident with heart failure, hypertension, and chronic kidney disease had a physician’s order for daily weights on dayshift, but on multiple dates in February, March, and April, the MAR/TAR and related documentation showed entries marked as “NA,” “X,” or left blank, with no recorded weights, no physician notification, and no explanation for the missing data. Another resident with hypertension, anxiety disorder, and severe protein-calorie malnutrition also had a daily weight order, yet on numerous dates in April and May, weights were marked “NA” without corresponding weights, physician notification, or explanatory documentation; one weight entry was crossed out and the re-weight was not obtained until the following day. LPNs provided differing explanations for “NA” and “X,” indicating inconsistent understanding of documentation practices. Additional deficiencies occurred in the administration of cardiac and blood pressure–related medications contrary to ordered hold parameters. One resident with hypertension had orders for amlodipine, hydralazine, and losartan potassium, each with instructions to hold the medication if systolic blood pressure (SBP) was less than 110, yet the MAR showed these medications were administered on specific dates when the SBP was below the ordered hold threshold. Another resident with hypertension and systolic and diastolic congestive heart failure had been hospitalized for severe hypotension and returned on midodrine with an order to hold the medication if SBP was greater than 110; however, the MAR showed multiple doses were given on various dates when SBP was outside the ordered hold parameter. These actions were inconsistent with the facility’s own policies requiring medications to be administered only as prescribed and weights to be accurately obtained and documented, and they formed the basis of the cited quality of care deficiency.
Informed Consent Not Documented Before Psychotropic Medication Start or Increase
Penalty
Summary
The facility failed to ensure informed consent was obtained and documented before starting or increasing psychotropic medications for 2 residents reviewed for unnecessary medications. One resident with diagnoses including dementia with psychotic behaviors and anxiety had Rexulti 1 mg initiated for dementia with agitation, with the medication started the next day, but the Psychoactive Medication Consent and Management Agreement dated after the start lacked documentation from the resident's representative giving consent for the new psychotropic medication. Another resident with diagnoses including Alzheimer's disease, major depressive disorder, psychotic disorder, and anxiety had Vraylar increased from 1.5 mg to 3 mg for aggression, with the higher dose started the next day. The Psychoactive Medication Consent and Management Agreement was dated after the increase and documented telephone consent on that later date. The DON stated the consent form should be completed prior to initiation or increase of a new psychotropic medication, and the facility policy required informed consent to be obtained and documented before initiation or an increase in dosage, including discussion of risks, benefits, and alternatives.
Discharge MDS Not Completed Timely
Penalty
Summary
The facility failed to ensure the Discharge MDS assessment was completed within the required timeframe for Resident 108. The resident’s record showed diagnoses of alcohol abuse, anxiety, and major depressive disorder. A progress note dated 12/18/25 at 12:50 a.m. documented that the resident was transferred to the emergency room, and another note dated 12/18/25 at 11:38 a.m. stated the resident would be transferred to another LTC facility upon discharge from the hospital. Review of the resident’s MDS assessments showed that no Discharge MDS assessment had been completed. The RAI 3.0 User’s Manual indicated the Discharge MDS must be completed within 14 calendar days after the discharge date and submitted within 14 days after completion. During interview, the MDS coordinator stated the discharge MDS was not completed at discharge and should have been completed within 14 calendar days of the discharge date; she also stated the facility did not have a resident assessment policy and used the RAI tool criteria for completion timeframes.
Inaccurate MDS Assessment Failed to Document Antidepressant Medication
Penalty
Summary
The facility failed to ensure an MDS assessment accurately reflected a resident's status for 1 of 32 residents reviewed for MDS accuracy. Resident 23 had diagnoses including Alzheimer's disease and major depressive disorder. Review of the April 2026 MAR showed the resident was prescribed mirtazapine at bedtime on 4/2/26 for insomnia, but the 4/9/26 admission MDS assessment did not document an antidepressant prescription. During interview, the MDS coordinator stated the 4/9/26 MDS assessment was incorrect and should have included the antidepressant medication.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Include Cardiac Pacemaker in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive care plan addressing a resident’s cardiac pacemaker. The resident was admitted with diagnoses including presence of a cardiac pacemaker, congestive heart failure, atherosclerotic heart disease, and heart failure with reduced ejection fraction, with documentation indicating pacemaker dependence. An admission skin assessment noted no skin issues other than the pacemaker, and an admission evaluation documented that the resident utilized a cardiac pacemaker device. A physician’s note further confirmed the resident’s pacemaker dependence as part of her medical history. Despite this documented history and device use, the resident’s care plans did not include any interventions or problem statements related to the pacemaker. During interviews, the MDS Coordinator acknowledged that the pacemaker was not included in the care plan and stated it should have been, explaining that although there is no specific MDS item for pacemakers, a diagnosis code or nursing assessment documentation should trigger care plan development. The Unit Manager reported that nursing, social services, and the MDS Coordinator all have the ability to add items to a resident’s care plan. The facility’s Plan of Care policy, provided by the DON, stated that the care plan is to be resident-focused, provide optimal personalized care, and prioritize resident safety, but this was not followed for the resident’s pacemaker.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Failure to Complete Required Discharge MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to complete a required discharge Minimum Data Set (MDS) assessment for one resident. Record review showed that Resident 90 was admitted on an unspecified date and discharged on 2/10/26 to an acute care hospital, but the MDS listings contained no completed discharge assessment for this resident. During interview, the MDS Coordinator confirmed that a discharge assessment should be completed whenever a resident is discharged and could provide no reason why this assessment was missed for Resident 90. In a separate interview, the Executive Director stated there was no facility policy regarding MDS assessments and that assessments were completed using the Resident Assessment Instrument (RAI) manual. These findings were cited under 410 IAC 3.1-31(d).
Missing Physician Order and Care Plan Update for New Wrist Splint
Penalty
Summary
The facility failed to ensure follow-up was obtained for physician orders and instructions after a resident returned from an orthopedic follow-up appointment with a new left wrist splint. The resident had a fractured carpal bone from a fall that occurred while in the facility and was severely cognitively impaired on the admission MDS. After the resident’s cast was removed at the orthopedic visit, the resident returned wearing a black splint with tie string and was to wear it at all times except for bathing, but the clinical record did not contain an updated physician order or associated instructions for the splint. The record also lacked documentation that facility staff contacted the physician to obtain the updated order and instructions, and the care plan was not revised when the splint was first used. During interviews, the Unit Manager and DON acknowledged that the care plan had not been updated until later and that the record lacked a physician order showing the cast had been discontinued and the splint ordered. The DON also stated the facility lacked a policy for obtaining updated physician orders, progress notes, and specific instructions for the facility.
Failure to document assessments and follow medication parameters
Penalty
Summary
The facility failed to provide care according to orders and documented parameters for multiple residents. One resident with diagnoses including stroke, dementia, and osteoarthritis had an outpatient medial branch block at a surgery center, but there were no nursing progress notes documenting the procedure, the time the resident left the facility, the time the resident returned, or any assessment of the bandage or the resident’s condition on return. The Director of Nursing stated there was no documentation or assessment when the resident came back from the outpatient procedure. Another resident was observed with a dark purple bruise to the left antecubital area on multiple observations, but the record contained no documentation of that bruising. The resident’s diagnoses included anxiety disorder, major depressive disorder, diabetes, heart failure, high blood pressure, and acute kidney failure. The resident had care plan entries related to bruising and bleeding risk from anticoagulant use and bruising from needle sticks, and weekly skin observations documented no bruises. The DON stated the resident had a blood draw, but there was no documentation regarding the bruise to the left arm. Two residents had medications administered outside ordered parameters. One resident received Metoprolol Tartrate 50 mg twice daily for high blood pressure with instructions to hold if pulse was less than 60, but the MAR showed doses given when the pulse was below 60 on several occasions. Another resident on hospice care received midodrine 5 mg three times daily with instructions to hold if systolic blood pressure was greater than 110, but the MAR showed the medication was administered multiple times when systolic blood pressure exceeded that limit. In addition, a resident was observed with purple discolorations and a black scab on the left forearm, wrist, and hand, but the weekly skin assessment documented no bruising and there was no documentation that the discolorations were assessed or monitored.
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