Inspection Reports for
River Pointe Health Campus

IN, 47715

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 17.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

321% worse than Indiana average
Indiana average: 4.2 deficiencies/year

Deficiencies per year

32 24 16 8 0
2023
2024
2025

Occupancy

Latest occupancy rate 58% occupied

Based on a March 2025 inspection.

This facility has shown a decline in demand based on occupancy rates.

Occupancy rate over time

20% 40% 60% 80% 100% 120% Mar 2023 May 2023 Jul 2023 Feb 2024 Jun 2024 Aug 2024 Mar 2025

Inspection Report

Routine
Deficiencies: 2 Date: Jun 23, 2025

Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to residents' rights regarding advance directives and infection prevention and control practices.

Findings
The facility failed to ensure periodic review and updating of advance directives for one resident and failed to follow proper infection control practices during wound care for another resident, including improper handling of a catheter bag and lack of glove use.

Deficiencies (2)
F 0578: The facility failed to ensure a periodic review with a resident and resident representative regarding decisions of any advance directives and its provisions as preferences may change over time for Resident 48.
F 0880: The facility failed to ensure infection control practices were followed for Resident 15, including staff not wearing gloves during care and catheter bag and tubing touching the floor.
Report Facts
Residents Affected: 1 Residents Affected: 1

Employees mentioned
NameTitleContext
RN 22Registered NurseInterviewed regarding advance directives review
RN 24Registered NurseObserved and interviewed regarding infection control practices
LPN 21Licensed Practical NurseObserved performing wound care and infection control

Inspection Report

Complaint Investigation
Census: 58 Capacity: 100 Deficiencies: 0 Date: Mar 27, 2025

Visit Reason
This visit was conducted for the investigation of Complaint IN00455964.

Complaint Details
Complaint IN00455964 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.

Report Facts
Census Bed Type: 20 Census Bed Type: 38 Census Bed Type: 42 Census Payor Type: 25 Census Payor Type: 20 Census Payor Type: 13

Inspection Report

Complaint Investigation
Census: 39 Deficiencies: 0 Date: Aug 12, 2024

Visit Reason
This visit was conducted for the investigation of complaint IN00439332.

Complaint Details
Complaint IN00439332 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies were cited related to the allegations. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.

Inspection Report

Re-Inspection
Census: 49 Capacity: 68 Deficiencies: 0 Date: Jul 29, 2024

Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 06/24/24 was performed to verify compliance with fire safety and licensure requirements.

Findings
At this PSR to the Life Safety Code survey, River Pointe Health Campus was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with a functional fire alarm system.

Report Facts
Facility capacity: 68 Census: 49

Inspection Report

Life Safety
Census: 44 Capacity: 68 Deficiencies: 6 Date: Jun 24, 2024

Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101, 2012 edition.

Findings
The facility was found not in compliance with Life Safety Code requirements, with deficiencies including a fire door that did not latch, a stairway door with an impediment preventing latching, lack of documentation for sprinkler system inspections, quarterly rather than monthly firefighter recall elevator testing, an incomplete fire safety plan missing smoke barrier locations, and fire drills not held at varied times across all shifts.

Deficiencies (6)
Failed to ensure 1 of 4 sets of fire doors latched in the 2 hour fire separation wall between Assisted Living and skilled health care sections.
Failed to ensure 1 of 6 stairway enclosure doors was not provided with an impediment to prevent latching.
Failed to document sprinkler system inspections for 12 of the past 12 months for the sprinkler system's control valves.
Failed to ensure documentation was provided for monthly testing of 2 elevators firefighter recall; tests were only performed quarterly.
Failed to provide a complete facility specific written fire safety plan that accurately addresses all life safety systems including smoke barrier locations.
Failed to ensure fire drills were held at varied times for 3 of 3 employee shifts during 4 of 4 quarters.
Report Facts
Certified beds: 68 Census: 44 Fire door sets: 4 Stairway enclosure doors: 6 Months missing sprinkler inspection documentation: 12 Elevators: 2 Fire drills: 4

Employees mentioned
NameTitleContext
Jordan ShotsExecutive DirectorNamed in relation to review and education on deficiencies and plans of correction.
Director of Plant OperationsInvolved in observations, interviews, and corrective actions related to fire door, stairway door, sprinkler system, elevator testing, and fire safety plan.
Facility Maintenance SupportParticipated in observations and interviews regarding fire door, stairway door, sprinkler system, elevator testing, and fire safety plan.

Inspection Report

Annual Inspection
Deficiencies: 7 Date: Jun 13, 2024

Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care.

Findings
The facility was found deficient in multiple areas including resident dignity and privacy, medication self-administration care planning, notification of physicians for skin conditions, use of gait belts during transfers, medication storage and labeling, infection prevention and control practices, and vaccine education.

Deficiencies (7)
F 0550: The facility failed to ensure dignity was respected for 2 residents during observed care, including staff standing while assisting to eat and lack of privacy during toileting.
F 0554: The facility failed to ensure a resident requiring assistance with transferring had an order, evaluation, and care plan for self-administration of medication.
F 0580: The facility failed to notify the attending physician of new skin tears for 1 resident and lacked related orders and care plans.
F 0656: The facility failed to develop and implement complete care plans for 2 residents, including lack of care plan for self-administration of medication and inconsistent use of gait belts during transfers.
F 0761: The facility failed to ensure proper storage of medications, including loose pills in medication carts, medication refrigerators with improper temperatures, incomplete temperature logs, and unlabeled or expired medications in storage rooms.
F 0880: The facility failed to ensure staff followed infection control protocols, including improper use of personal protective equipment and failure to change gloves between tasks during care.
F 0883: The facility failed to provide education prior to administering flu vaccines for 5 residents, lacking documentation of education provided.
Report Facts
Residents affected: 2 Residents affected: 1 Residents affected: 1 Residents affected: 2 Residents affected: 5 Loose pills: 22 Temperature readings: 54 Temperature readings: 34 Expired medication: 1

Employees mentioned
NameTitleContext
RN 21Registered NurseObserved assisting Resident 24 and responsible for cleaning medication carts
DONDirector of NursingProvided multiple policy clarifications and interviews regarding care plans, infection control, and medication administration
CNA 3Certified Nurse AideObserved assisting Resident 31 and failing to change gloves between tasks
CNA 5Certified Nurse AideObserved assisting Resident 31 and failing to don proper PPE
Regional Support NurseProvided policies and guidelines during the survey

Inspection Report

Annual Inspection
Census: 37 Capacity: 78 Deficiencies: 12 Date: Jun 13, 2024

Visit Reason
This visit was for a Recertification and State Licensure Survey including a State Residential Licensure Survey conducted on June 7, 10, 11, 12, and 13, 2024.

Findings
The facility was found to have multiple deficiencies including failure to ensure resident dignity, proper medication self-administration orders and care plans, notification of physician for skin conditions, proper use of gait belts, medication storage issues, infection control breaches, incomplete vaccine education documentation, improper medication disposal, and failure to follow enhanced barrier precautions.

Deficiencies (12)
Failure to ensure dignity was respected for residents during care.
Failure to ensure a resident had an order, evaluation, and care plan for self-administration of medication.
Failure to notify attending physician of new skin tears and obtain wound care orders.
Failure to develop and implement care plans for residents regarding gait belt use and self-administration of medications.
Failure to properly label and store drugs and biologicals, including loose pills in medication cart and incomplete refrigerator temperature logs.
Failure to follow infection control protocols including glove changes and proper PPE use during Enhanced Barrier Precautions.
Failure to provide education prior to influenza immunization for residents.
Failure to maintain oxygen equipment in a safe and operational condition.
Failure to ensure a resident evaluated as unable to self-administer medications was free of accessible medications in their room.
Failure to administer the correct dose of medication during medication administration observation.
Failure to properly dispose of medications after being dropped during administration.
Failure to isolate a resident to the degree needed to isolate the infecting organism during wound care.
Report Facts
Survey dates: 5 Census Bed Type: 78 Resident census: 37 Deficiency counts: 12 Audit frequencies: 5

Employees mentioned
NameTitleContext
Lisa StallmanRN-BC, Clinical SupportSigned the inspection report
QMA 12Qualified Medication AideObserved administering medications and involved in medication disposal and infection control breaches
RN 21Registered NurseObserved assisting resident and responsible for medication cart cleaning
DONDirector of NursingProvided multiple interviews, policies, and explanations related to deficiencies
HHN 17Home Health NurseObserved performing wound care without proper PPE

Inspection Report

Renewal
Deficiencies: 0 Date: Jun 13, 2024

Visit Reason
Paper compliance review for the Recertification and State Licensure survey ending on June 13, 2024.

Findings
River Pointe Health Campus was found to be in compliance with 42 CFR part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.

Inspection Report

Complaint Investigation
Deficiencies: 2 Date: Feb 27, 2024

Visit Reason
The inspection was conducted in response to a complaint (IN00428144) regarding failure to notify a resident's representative of a fall and failure to follow the care plan for resident transfers.

Complaint Details
This citation relates to Complaint IN00428144 regarding failure to notify family of a fall and failure to follow care plan transfer protocols.
Findings
The facility failed to notify the representative of Resident B's fall until the next day and failed to follow the care plan for Resident C by assisting transfers with only one staff instead of two. Both incidents involved minimal harm with few residents affected.

Deficiencies (2)
F 0580: The facility failed to notify the resident's representative of a fall until the next day for Resident B. The fall was documented on 1/9/24 with delayed family notification despite policy requiring timely notification.
F 0656: The facility failed to follow the care plan for Resident C by assisting transfers with one staff instead of two as required. This resulted in a fall on 2/27/24 when Resident C was lowered to the bathroom floor by a single CNA.
Report Facts
Residents affected: 1 Residents affected: 1

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Feb 27, 2024

Visit Reason
Paper compliance review for the Investigation of Complaint IN00428144 survey ending on February 27, 2024.

Complaint Details
Investigation of Complaint IN00428144; facility found to be in compliance.
Findings
River Pointe Health Campus was found to be in compliance with 42 CFR part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review for the Investigation of Complaint IN00428144 survey.

Inspection Report

Complaint Investigation
Census: 85 Capacity: 85 Deficiencies: 2 Date: Feb 26, 2024

Visit Reason
This visit was conducted for the investigation of Complaint IN00428144 regarding allegations related to resident falls and care plan adherence.

Complaint Details
Complaint IN00428144 was substantiated with federal/state deficiencies cited at F580 and F656 related to fall notification and care plan adherence.
Findings
The facility failed to notify a resident's representative of a fall in a timely manner and failed to follow the plan of care for transfers for one resident. Nursing personnel were educated on fall notification protocols and adherence to care plans. No adverse effects were noted for the residents involved.

Deficiencies (2)
Failed to notify the resident's representative of a fall until the next day for 1 of 3 residents reviewed (Resident B).
Failed to follow the plan of care for transfers; a resident was assisted by one staff instead of two (Resident C).
Report Facts
Census: 85 Total Capacity: 85 Residents reviewed for fall notification: 3 Residents reviewed for transfer care plan adherence: 3 Audit sample size for fall notification: 3 Audit sample size for transfer care plan adherence: 5

Inspection Report

Complaint Investigation
Census: 87 Deficiencies: 0 Date: Oct 6, 2023

Visit Reason
This visit was conducted to investigate two complaints, IN00415566 and IN00418346, regarding the facility.

Complaint Details
Complaint IN00415566 and IN00418346 were investigated with no deficiencies found related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00415566 and IN00418346 were cited. The facility was found to be in compliance with relevant regulations.

Report Facts
Census Bed Type - SNF: 28 Census Bed Type - SNF/NF: 20 Census Bed Type - Residential: 39 Total Census: 87 Census Payor Type - Medicare: 14 Census Payor Type - Medicaid: 14 Census Payor Type - Other: 20 Total Census Payor: 48

Inspection Report

Complaint Investigation
Census: 96 Deficiencies: 2 Date: Jul 5, 2023

Visit Reason
This visit was conducted for the investigation of Nursing Home Complaint IN00410919, which included the investigation of Residential Complaint IN00410919.

Complaint Details
Complaint IN00410919 was investigated and related state deficiencies were cited at R0117. The facility was found in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint.
Findings
The facility was found to be in compliance with federal and state requirements regarding the complaint. However, deficiencies were cited related to staff qualifications for insulin administration and lack of physician order for self-administration of medications.

Deficiencies (2)
Facility failed to ensure residents received care by qualified staff; QMAs administered insulin without certification for 3 diabetic residents (Residents F, G, H).
Facility failed to ensure a physician order to self-administer medications was obtained for 1 resident (Resident C) with medications left at bedside.
Report Facts
Census: 96 Residents with insulin administration deficiency: 3 Residents observed for medication self-administration: 5 Survey dates: July 5 and 6, 2023

Employees mentioned
NameTitleContext
Jordan ShotsExecutive DirectorSigned the report
LPN 22Licensed Practical NurseObserved leaving medications with Resident C without physician order for self-administration
QMA 2Uncertified for insulin administration; documented insulin administration
QMA 3Uncertified for insulin administration; documented insulin administration
QMA 4Uncertified for insulin administration; documented insulin administration
QMA 5Interviewed regarding QMA insulin administration certification requirements
DONDirector of NursingInterviewed regarding insulin administration policy and self-administration medication orders
Regional ConsultantProvided facility policies and participated in interviews

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Jun 27, 2023

Visit Reason
Paper compliance review for the Investigation of Complaints IN00408526 and IN00408532 survey resulting in an unrelated deficiency ending on May 18, 2023.

Complaint Details
Investigation of Complaints IN00408526 and IN00408532; facility found in compliance with no deficiencies related to these complaints.
Findings
River Pointe Health Campus was found to be in compliance with 42 CFR part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Investigation of Complaint IN00408526 and IN00408532 survey and the unrelated deficiency.

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: May 18, 2023

Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of narcotic medication belonging to a resident (Resident B).

Complaint Details
The complaint investigation was substantiated with findings that narcotic medication was missing and improperly documented. A police report was filed regarding the lost medication.
Findings
The facility failed to ensure Resident B was free from misappropriation of their narcotic medication. A quantity of Norco 7.5-325 mg was unaccounted for, with incomplete narcotic counts and missing documentation. The facility initiated an investigation and a police report was filed.

Deficiencies (1)
F 0602: The facility failed to protect Resident B from misappropriation of narcotic medication. Multiple narcotic counts were not completed or documented properly, and a medication card containing Norco was lost.
Report Facts
Medication quantity lost: 30 Dates with incomplete narcotic counts: 14

Employees mentioned
NameTitleContext
RN 7Registered NurseSigned for the medication delivery on 4/23/23 and was on the hall when medication went missing
QMA 5Qualified Medication AideProvided information about narcotic count procedures and sign-in sheets
Director of NursingDirector of NursingConducted investigation and interviews related to the missing medication

Inspection Report

Re-Inspection
Census: 50 Capacity: 68 Deficiencies: 0 Date: May 18, 2023

Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/04/23 was performed to verify compliance with previous findings.

Findings
The facility was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code. The facility is fully sprinklered with a fire alarm system and had no deficiencies at the time of this survey.

Report Facts
Facility capacity: 68 Census: 50

Inspection Report

Complaint Investigation
Census: 92 Deficiencies: 1 Date: May 17, 2023

Visit Reason
This visit was for the investigation of Nursing Home Complaint IN00408526 and Residential Complaint IN00408532 at River Pointe Health Campus.

Complaint Details
Complaint IN00408526 and Complaint IN00408532 were investigated. No deficiencies related to the allegations were cited in either complaint. The narcotic misappropriation issue was unrelated to the complaints.
Findings
No deficiencies were cited related to the allegations in both complaints. However, an unrelated deficiency was cited regarding misappropriation of narcotic medication for one resident (Resident B).

Deficiencies (1)
Facility failed to ensure a resident was free from misappropriation of their property; narcotics (Norco 7.5/325 mg) were unaccounted for.
Report Facts
Census Bed Type - SNF/NF: 50 Census Bed Type - Residential: 42 Total Census: 92 Census Payor Type - Medicare: 15 Census Payor Type - Medicaid: 13 Census Payor Type - Other: 22 Medication quantity lost: 30 Dates narcotic counts not completed: 14

Employees mentioned
NameTitleContext
Jordan ShotsExecutive DirectorSigned the report
RN 7Registered NurseSigned for the medication delivery on 4/23/23 and was interviewed regarding missing medication
QMA 5Qualified Medication AideProvided information about narcotic medication administration and documentation practices
Director of NursingDirector of NursingInterviewed regarding the missing narcotic medication and investigation
Lead PharmacistLead PharmacistInterviewed about medication delivery and signing procedures

Inspection Report

Life Safety
Census: 53 Capacity: 68 Deficiencies: 8 Date: Apr 4, 2023

Visit Reason
The inspection was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.

Findings
The facility was found not in compliance with several Life Safety Code requirements including exit discharge walking surfaces, self-closing hazardous area doors, fire alarm system testing and maintenance, sprinkler system maintenance, corridor door smoke resistance, smoke barrier integrity, and smoke barrier door latching. Corrective actions and ongoing compliance measures were planned for each deficiency.

Deficiencies (8)
Failed to maintain the walking surface for 1 of 7 exit discharge areas with level changes creating a tripping hazard.
Failed to ensure corridor door to hazardous area (storage room 606) was provided with a self-closing device.
Failed to ensure documentation for sensitivity testing of all smoke detectors was complete; some detectors were not tested or documented properly.
Failed to maintain fire alarm system in accordance with NFPA 72; smoke detectors hanging from ceiling and some detectors not tested.
Failed to ensure sprinkler head escutcheon ring was in place, leaving a gap around sprinkler pipe.
Failed to ensure 1 of over 100 corridor doors resisted passage of smoke due to holes in door.
Failed to maintain smoke barrier wall integrity; a two inch hole with wires was not properly fire stopped.
Failed to ensure 1 of 5 sets of smoke barrier doors closed and latched properly to form a smoke resistant barrier.
Report Facts
Certified beds: 68 Census: 53 Exit discharge areas: 7 Hazardous area doors: 10 Smoke detectors not tested: 11 Sprinkler compartments: 5 Smoke barrier doors: 5

Employees mentioned
NameTitleContext
Jordan ShotsExecutive DirectorSigned report and participated in exit conference
Director of Plant OperationsNamed in multiple findings related to exit discharge, hazardous area doors, fire alarm system, sprinkler system, corridor doors, smoke barrier walls and doors

Inspection Report

Routine
Deficiencies: 5 Date: Mar 20, 2023

Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, resident accommodations, privacy, care planning, environmental safety, and other aspects of resident care at River Pointe Health Campus.

Findings
The facility was found deficient in multiple areas including failure to assess and document residents' capability to self-administer medications, inadequate accommodation of resident needs such as call light accessibility, breaches in resident privacy during care and medication administration, incomplete and non-implemented care plans for residents with infections and respiratory needs, and unsafe water temperatures exceeding 120 degrees Fahrenheit in resident rooms.

Deficiencies (5)
F 0554: The facility failed to ensure residents self-administering medications were assessed for capability and lacked physician orders, care plans, and assessments for self-administration for 3 residents.
F 0558: The facility failed to reasonably accommodate resident needs by not keeping call lights within reach for 4 residents.
F 0583: The facility failed to maintain resident privacy during medication administration and care for 2 residents, including leaving a computer screen with resident information visible.
F 0656: The facility failed to develop and implement comprehensive care plans with measurable interventions for residents with infections, IV site care, antibiotic use, and respiratory care for 3 residents.
F 0921: The facility failed to ensure safe water temperatures, with hot water exceeding 120 degrees Fahrenheit in 3 resident rooms and documented high temperatures in water logs.
Report Facts
Water temperature: 122.3 Water temperature: 123.1 Water temperature: 123.2 Water temperature: 119.4 Water temperature: 118.5 Water temperature: 122.5 Water temperature: 123 Water temperature: 122 Water temperature: 121 Water temperature: 122 Water temperature: 122

Inspection Report

Recertification
Census: 43 Capacity: 103 Deficiencies: 5 Date: Mar 20, 2023

Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaint IN00403738. The visit included a State Residential Licensure Survey.

Complaint Details
Complaint IN00403738 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found to have deficiencies related to resident self-administration of medications, reasonable accommodations for call light accessibility, resident privacy during care, comprehensive care planning for residents with respiratory and antibiotic needs, and water temperatures exceeding safe limits in resident rooms. No deficiencies were related to the complaint investigation.

Deficiencies (5)
Failed to ensure residents self-administering medications were assessed for capability and had appropriate orders, care plans, and assessments.
Failed to ensure residents received services with reasonable accommodation of needs, specifically call lights were out of reach for residents.
Failed to maintain resident privacy during medication administration and care; privacy curtains and doors were left open and computer screens with resident information were left visible.
Failed to develop and implement comprehensive person-centered care plans for residents with respiratory care and antibiotic use needs; care plans and interventions were lacking or not followed.
Failed to provide a safe, functional, and comfortable environment by maintaining water temperatures within safe limits; water temperatures in resident rooms exceeded 120 degrees Fahrenheit.
Report Facts
Survey dates: March 13, 14, 15, 16, 17, 20, 2023 Census Bed Type: 103 Resident census: 43 Residents observed for self-administration: 3 Residents reviewed for activities of daily living: 5 Residents observed for medication privacy: 4 Resident rooms observed for water temperature: 16 Water temperature: 122.3 Water temperature: 123.1 Water temperature: 123.2

Employees mentioned
NameTitleContext
Jordan ShotsExecutive DirectorSigned report
QMA 9Qualified Medication AideObserved administering medications and noted lack of order for self-administration
QMA 21Qualified Medication AideObserved medication storage and administration practices
Clinical Support 43Interviewed regarding lack of self-administration assessments
RN 23Registered NurseInterviewed regarding self-administration policies and oxygen flow rate adjustment
LPN 25Licensed Practical NurseInterviewed regarding medication administration and privacy practices
CNA 14Certified Nurse AideInterviewed regarding call light use and resident accommodations
Clinical Support 29Provided policies and interviewed regarding care plan and environmental compliance
DHS and/or designeeResponsible for audits and ongoing compliance monitoring

Inspection Report

Renewal
Deficiencies: 0 Date: Mar 20, 2023

Visit Reason
Paper compliance review for the Recertification and State Licensure survey ending on March 20, 2023.

Findings
River Pointe Health Campus was found to be in compliance with 42 CFR part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review to the Recertification and State Licensure Survey.

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