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Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O63T12 Facility ID: 380007 If continuation sheet Page 1 of 79
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O63T12 Facility ID: 380007 If continuation sheet Page 7 of 79
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FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O63T12 Facility ID: 380007 If continuation sheet Page 43 of 79
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FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O63T12 Facility ID: 380007 If continuation sheet Page 48 of 79
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FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O63T12 Facility ID: 380007 If continuation sheet Page 61 of 79
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FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O63T12 Facility ID: 380007 If continuation sheet Page 63 of 79
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FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O63T12 Facility ID: 380007 If continuation sheet Page 64 of 79
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FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O63T12 Facility ID: 380007 If continuation sheet Page 77 of 79
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FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: O63T12 Facility ID: 380007 If continuation sheet Page 79 of 79