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DATE OF SURVEY 8. ACCREDITATION STATUS 0 Unaccredited 2 AOA 05 HHA 09 ESRD 13 PTIP 02 SNF/NF/Dual 06 PRTF 10 NF 14 CORF 03 SNF/NF/Distinct 07 X-Ray 11 ICF/IID 15 ASC 04 SNF 08 OPT/SP 12 RHC 16 HOSPICE 4. Y4 Y5 Item ID Prefix Correction Completed 08/26/2015 Reg. NFPA 101 LSC K0038 LSC K0050 ZZZZ LSC SR/KJ State Agency Reviewed By Reg. Signature of Surveyor 12424 09/25/2015 LSC K0076 CMS RO Followup to Survey Completed on Form CMS - 2567B 9-92 Check for any Uncorrected Deficiencies. Frank...
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