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PRINTED: 07/12/2021 FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION
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It is a complaint that has been marked as unsubstantiated due to lack of evidence or proof.
Any individual or entity who believes there has been a violation or wrongdoing.
The complaint can be filled out by providing detailed information about the incident, individuals involved, and any evidence available.
The purpose is to bring attention to potential violations or wrongdoing and request for an investigation.
Information such as date, time, location, individuals involved, description of incident, and any supporting evidence.
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