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PRINTED 09/11/2012 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION X1 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER OMB NO. 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 WRMS11 Facility ID 002574 If continuation sheet Page 1 of 2 F 000 Continued From page 1 by Bev Faulkner RN. 0938-0391...
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