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Printed: 06/28/2024 Form Approved OMB No. 09380391Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CIA IDENTIFICATION

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How to fill out 160 ne conifer blvd

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Start by writing the street number '160' in the designated area on the form.

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Then write the direction 'NE' for northeast in the appropriate section.

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Next, fill out 'Conifer Blvd' in the space provided for the street name.

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Make sure to include any additional information such as unit number or apartment number if applicable.

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