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PRINTED 06/15/2017 FORM APPROVED Indiana State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION X1 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER X3 DATE SURVEY COMPLETED 06/13/2017 STREET ADDRESS CITY STATE ZIP CODE 607 VIRGINIA AVE JEWEL HOUSE X4 ID PREFIX TAG A. BUILDING B. WING 004352 NAME OF PROVIDER OR SUPPLIER X2 MULTIPLE CONSTRUCTION MADISON IN 47250 SUMMARY STATEMENT OF DEFICIENCIES EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION...
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