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PRINTED: 06/12/2024 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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Form survey team entered is a form used to gather information from a survey team about their findings and observations.

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Information such as date of survey, location, survey team members, findings, observations, and recommendations must be reported on form survey team entered.

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