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PRINTED: 11/02/2016
FORM APPROVEDDivision of Health Service Regulation
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA
IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION
A.
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Information that must be reported may include resident demographics, staff qualifications, health and safety compliance, and any incidents or changes in resident conditions.
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