S. DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICAL ASSISTANCE CERTIFICATION AND TRANSMITTAL ID: 70837 Facility ID: 00844 PART I TO BE COMPLETED BY THE STATE SURVEY AGENCY 1. MEDICARE/MEDICAID PROVIDER NO. 9 (L26) 4. TYPE OF ACTION: 3. NAME AND ADDRESS OF FACILITY (L3) ACUMEN SCENIC SHORES 255542 (L1) 048540300 5. EFFECTIVE DATE CHANGE OF OWNERSHIP (L9) 01/01/2011 0 Hospital 14 TIP 9. Other 9. Full Survey After Complaint 22 CIA 05 SNF/NF/Dual 06/23/2014 05 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICAL ASSISTANCE CERTIFICATION AND TRANSMITTAL ID: 71247 Facility ID: 00844 PART I TO BE COMPLETED BY THE STATE SURVEY AGENCY 1. MEDICARE/MEDICAID PROVIDER NO. 10 (L28) 4. TYPE OF ACTION: 3. NAME AND ADDRESS OF FACILITY (L3) ACUMEN SCENIC SHORES 255542 (L1) 048540300 5. EFFECTIVE DATE CHANGE OF OWNERSHIP (L9) 01/01/2011 0 Facility 15 TIP 9. Other 9. Full Survey After Complaint 22 CIA 05 SNF/NF/Dual 06/23/2014 05 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICAL ASSISTANCE CERTIFICATION AND TRANSMITTAL ID: 72122 Facility ID: 00844 PART I TO BE COMPLETED BY THE STATE SURVEY AGENCY 1. MEDICARE/MEDICAID PROVIDER NO. 11 (L29) 4. TYPE OF ACTION: 3. NAME AND ADDRESS OF FACILITY (L3) ACUMEN SCENIC SHORES 265542 (L1) 048540300 5. EFFECTIVE DATE CHANGE OF OWNERSHIP (L9) 01/01/2011 0 Facility 16 TIP 9. Other 9. Full Survey After Complaint 22 CIA 05 SNF/NF/Dual 06/23/2014 05 U.S.
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: HF42 Facility ID: 00844 PART I TO BE COMPLETED BY THE STATE SURVEY
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