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PRINTED 09/19/2016 FORM APPROVED Indiana State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION X1 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER KEYSTONE WOODS X4 ID PREFIX TAG A. Survey Dates September 15 2016 Facility Number 010409 Provider Number 010409 AIM Number N/A Census Bed Type Residential 59 Total 59 Census Payor Type Medicaid 33 Other 26 Sample 4 Keystone Woods was found to be in compliance with 410 IAC 16. 2-5 in regard to the PSR to the State Residential...
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