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PRINTED 01/27/2017 FORM APPROVED Indiana State Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION X1 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER KEEPSAKE VILLAGE OF COLUMBUS X4 ID PREFIX TAG A. BUILDING X3 DATE SURVEY COMPLETED B. WING 010680 NAME OF PROVIDER OR SUPPLIER X2 MULTIPLE CONSTRUCTION C 01/24/2017 STREET ADDRESS CITY STATE ZIP CODE 2564 FOXPOINTE DR COLUMBUS IN 47201 SUMMARY STATEMENT OF DEFICIENCIES EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC...
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