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Y4 Y5 Item ID Prefix F0241 Date Correction Completed 02/27/2015 Reg. 483. 15 a ZZZZ LSC Reg. JS/KJ State Agency Reviewed By Signature of Surveyor 3/20/2015 33561 CMS RO Followup to Survey Completed on 2/5/2015 Form CMS - 2567B 9-92 Check for any Uncorrected Deficiencies. Y1 Y2 Multiple Construction A. Building Provider / Supplier / CLIA / Identification Number Y3 Date of Revisit 3/18/2015 B. Brianne Wolters Administrator Lakeside Health Care Center 439 William Avenue East P. O. Box 383 Dassel...
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