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70 a Life Safety from Fire and the 2000 edition of the National Fire Protection Association NFPA 101 Life Safety Code LSC and 410 IAC 16. PRINTED 10/28/2016 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. 0938-0391 X2 MULTIPLE CONSTRUCTION X3 DATE SURVEY COMPLETED A. BUILDING 01 02 R 155327 B. WING NAME OF PROVIDER OR SUPPLIER STREET ADDRESS...

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