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PRINTED: 04/05/2018 FORM APPROVEDDivision of Health Service Regulation STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION NUMBER:A. BUILDING: ___(X3) DATE SURVEY

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What is formre were no deficiencies?

Formre were no deficiencies is a form used to report if there were no deficiencies found in a particular inspection or evaluation.

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Any individual or organization responsible for conducting the inspection or evaluation is required to file formre were no deficiencies if no deficiencies were found.

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The information required to be reported on formre were no deficiencies includes details about the inspection or evaluation process, the date it was conducted, and confirmation that no deficiencies were identified.

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