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PRINTED: 09/20/2022 FORM APPROVEDDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:125062OMB NO. 09380391 (X2) MULTIPLE CONSTRUCTION A. BUILDING ___ B. WING ___NAME OF PROVIDER OR SUPPLIER09/02/2022STREET ADDRESS, CITY, STATE, ZIP CODE4297A OMAO ROADHALE KUPUNA HERITAGE HOME, LLC (X4) ID PREFIX TAG(X3) DATE SURVEY COMPLETEDKOLOA, HI 96756SUMMARY
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