Health inspection·December 19, 2023

F 0580 circumstances that require a need to alter treatment. Level of Harm - Minimal harm or potential for actual harm This deficiency represents non-compliance investigated under Complaint Number OH00148932. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365626 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellbrook Health and Rehab 1957 North Lakeman Drive Bellbrook, OH 45305 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on of open and closed medical record review, staff interviews, resident representative interview, review of hospital records, review of the death certificate, and review of facility policy, the facility failed to appropriately assess and provide timely intervention for Resident #45 following a change in condition. This resulted in Immediate Jeopardy and placed Resident #45 at risk for serious life-threatening harm, negative health outcomes, and/or death when on [DATE] at approximately 3:06 P.M., Resident #45 complained of lower abdominal pain to Assistant Director of Nursing (ADON) #02 and was unable to tolerate palpation to his abdomen. After Resident #45 complained of abdominal pain, his bowel sounds were not assessed and the physician ordered imaging results, which indicated a possible bowel obstruction, and the results were not relayed to the physician timely. Consequently, Resident #45 was transferred to the hospital on [DATE] at 11:47 A.M. at the request of Resident #45 and his representative and was treated for severe sepsis before passing away on [DATE]. This affected one (Resident #45) of three residents reviewed for a change in condition. The facility census was 42. Residents Affected - Few On [DATE] at 12:08 P.M., the Administrator, Director of Nursing (DON), Regional Director of Operations (RDO) #300, and Regional Nurse #400 were notified Immediate Jeopardy began on [DATE] at approximately 3:06 P.M. when Resident #45 complained of abdominal pain and was not adequately assessed by licensed nursing staff. Resident #45 had test results that indicated a possible bowel obstruction, which was not addressed until Resident #45, and his representative requested Resident #45 be transferred out to the hospital for further evaluation. Resident #45 passed away on [DATE] due to pneumoperitoneum (air or gas in the abdominal cavity). The Immediate Jeopardy was removed on [DATE] when the facility implemented the following corrective actions: • On [DATE] at 1:00 P.M., Registered Nurse (RN) #500, Licensed Practical Nurse (LPN) #12, LPN #14, LPN #68, Minimum Data Set (MDS) LPN #72, and LPN #600 completed comprehensive assessments on all residents in the facility to identify any change of condition, evidence of constipation, and confirming dates of last bowel movement. Physicians will be notified of any changes as appropriate. • On [DATE] at 1:00 P.M., MDS LPN #72 reviewed the records of all residents receiving opioids and/or who are assessed to be at risk for constipation, to ensure care plans addressing the risk have been implemented, if appropriate. • On [DATE] at 1:00 P.M., Regional Nurse #400 reviewed all test results completed today to ensure the physician has been notified of the results, if appropriate. • On [DATE] at 1:05 P.M., RN [NAME] President of Clinical Services (VPCS) #800 reviewed the Change in Condition and Notification Policy to include steps on physician notification. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365626 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellbrook Health and Rehab 1957 North Lakeman Drive Bellbrook, OH 45305 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 • Level of Harm - Minimal harm or potential for actual harm On [DATE] at 2:00 P.M., the DON initiated in servicing for all nursing staff and respiratory staff in the facility on the revised Change in Condition and Notification policy, and on the need to ensure assessments are completed and documented if a resident experiences a change in condition. Licensed nurses will also be in serviced on the need to ensure that the physician is timely notified of all diagnostic testing results. Staff who are not educated by [DATE] will not be permitted to work until the in-servicing is completed. Residents Affected - Few • On [DATE] at 5:00 P.M., an ad hoc Quality Assurance (QA) Meeting was held with Medical Director (MD) #700, the Administrator, and DON, and reviewed the findings, discussed, and approved the plan of action. • The DON, ADON #02, and MDS LPN #72 will audit 24-hour reports and bowel movement records for physician and family notification of change in condition and diagnostic test results, and assessment of residents who experienced a change in condition or who had no bowel movement for three days and/or complaints of constipation. Audits will be completed daily for two weeks, and then three times a week for two weeks. • The QA Committee will monitor the results of the audits and follow-up as needed. • Review of the QA meeting minutes dated [DATE] from 5:00 P.M. to 6:00 P.M. revealed the Administrator, DON, and MD #700 participated in a meeting regarding change in condition and notification. • Interviews on [DATE] from 6:00 P.M. to 6:15 P.M. with LPN #16 and LPN #68 verified they had received education related to change in condition and bowel assessments. • Review of assessments dated [DATE] for Residents #12, #25, #27, #28, and #29 revealed they had been assessed by the facility for any changes in condition. • Review of staff education dated [DATE] confirmed LPN #16 and LPN #68 acknowledged they had received education on this date. The education included policies on pain management and notification of change as well as charts on how to respond to gastrointestinal signs and symptoms and laboratory tests/diagnostic procedures. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365626 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellbrook Health and Rehab 1957 North Lakeman Drive Bellbrook, OH 45305 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Although the Immediate Jeopardy was removed on [DATE], the facility remains out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility is still in the process of implementing their corrective action plan and monitoring to ensure on-going compliance. Residents Affected - Few Findings include: Review of the closed medical record for Resident #45 revealed he was admitted to the facility on [DATE], transferred to the hospital on [DATE], and passed away on [DATE]. Diagnoses included cerebral infarction due to embolism of unspecified cerebral artery, cerebral edema, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, occlusion and stenosis of unspecified carotid artery, acute embolism and thrombosis of left femoral vein, chronic atrial fibrillation, other low back pain, atherosclerosis of coronary artery bypass graft(s) without angina pectoris, congestive heart failure, chronic obstructive pulmonary disease, rheumatoid arthritis, other intervertebral disc degeneration lumbar region, old myocardial infarction, hyperlipidemia, and major depressive disorder. Review of the admission assessment dated [DATE] revealed Resident #45 ' s bowel elimination pattern was constipation. Review of the plan of care initiated on [DATE] and revised on [DATE] revealed Resident #45 was at nutritional/dehydration risk related to diagnoses of cerebral infarction due to embolism of unspecified cerebral artery, hypertension, hypotension constipation, depression, atrial fibrillation, hyperlipidemia, and chronic obstructive pulmonary disease. Interventions included administering medications per order and monitoring for ineffectiveness and/or side effects and notifying physician of abnormal findings. Review of the plan of care initiated on [DATE] and revised on [DATE] revealed Resident #45 required pain management and monitoring related to chronic back pain. Interventions included administer pain medication as ordered, evaluate, and establish level of pain on numeric scale/evaluation tool, evaluate characteristics and frequency/pattern of pain, evaluate need for routinely scheduled medications rather than as needed pain medication administration, evaluate what makes the pain worse, and observe for potential medication side effects. Review of the physician orders revealed Resident #45 had orders with start dates of [DATE] for MiraLax Oral Powder 17 grams (GM)/scoop to be given as one scoop by mouth one time a day for constipation, Sennosides-Docusate Sodium 8.6-50 milligrams (mg) with a dosage of one tablet by mouth at bedtime for constipation, Docusate Sodium 100 mg with a dosage of one tablet by mouth two times a day for constipation, and Bisacodyl Rectal Suppository with instructions to insert one suppository rectally as needed for constipation once daily. Review of the quarterly Minimum Data Set (MDS) assessment, dated [DATE], revealed Resident #45 had moderately impaired cognition. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene as well as supervision and setup assistance for eating. Review of the pain levels documented under the vitals tab of the electronic health record, revealed Resident #45 reported a pain score of eight on a zero to ten pain scale on [DATE] and [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365626 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellbrook Health and Rehab 1957 North Lakeman Drive Bellbrook, OH 45305 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the medication administration notes dated [DATE] and [DATE] revealed Resident #45 received as needed oxycodone hydrochloride oral tablet 5 mg with a dosage of one tablet by mouth every six hours as needed for pain. Review of the progress note dated [DATE] at 11:50 P.M. revealed Resident #45 complained of nausea and a new order for Zofran 4 mg as needed every six hours was ordered. Review of the medication administration notes dated [DATE] at 12:52 A.M. and 3:23 A.M. revealed Resident #45 complained of constipation and requested as needed rectal suppository, and the administration was noted as effective due to the resident having a medium bowel movement. There is no documentation related to an assessment of Resident #45 ' s bowels or that Resident #45 ' s representative had been notified. Review of the nursing progress note dated [DATE] at 3:06 P.M. revealed Resident #45 reported having pain in his lower abdomen. Resident #45 stated he last had a bowel movement the previous day that was loose. The on-call provider was notified and gave an order for a kidney, ureter, and bladder (KUB) X-ray. Review of the KUB X-ray results electronically signed by the interpreting physician on [DATE] at 5:02 A.M. documented Resident #45 had dilated loops of bowel, colonic fecal residual noted, an ileus type pattern favored, and an obstruction not excluded. The results recommended a computed tomography (CT) scan or follow-up as clinically warranted. Review of the nursing progress notes on [DATE] between 5:02 A.M. and 11:47 A.M. revealed no documentation that the physician or Resident #45 ' s representative had been notified of the KUB X-ray results. Review of the nursing progress note dated [DATE] at 11:47 A.M. revealed Resident #45 complained of severe abdominal pain and being unable to urinate. Resident #45 and his representative requested for him to be sent to the emergency room (ER) for further evaluation. Certified Nurse Practitioner (CNP) #200 was contacted, and Resident #45 was transferred to the hospital. Review of the hospital triage complaint dated [DATE] revealed Resident #45 presented to the ER with a complaint of abdominal pain that was a ten out of ten across his lower abdomen, which started yesterday morning. Resident #45 reported the pain was sharp, constant, and gradually worsening. Resident #45 expressed he had been constipated for the last two or three days. The complaint indicated Resident #45 ' s abdomen was distended with involuntary guarding particularly all across the lower abdomen and there was tenderness to percussion. Per the triage complaint, Resident #45 had a CT scan that noted free air and fluid in the abdominal cavity, which was compatible with perforation. The suspected perforation was located within the sigmoid colon (portion of large intestine before reaching the rectum), and secondary to acute sigmoid colonic diverticulitis (occurs when colon wall protrusions become infected; usually caused by a blockage of the inside space of a structure such as intestine or obstruction from stool; can burst open and spill fecal matter into the bloodstream causing sepsis). The CT scan also noted an associated small bowel obstruction. The triage complaint listed diagnoses of pneumoperitoneum, acute renal failure, severe sepsis, small bowel obstruction, abdominal aortic aneurysm without rupture, complete intestinal obstruction, and diverticulitis of sigmoid colon for Resident #45. Resident #45 was transferred to another ER for further evaluation and treatment. Review of the hospital history and physical dated [DATE] revealed Resident #45 ' s abdomen was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365626 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellbrook Health and Rehab 1957 North Lakeman Drive Bellbrook, OH 45305 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 distended, and no bowel sounds were heard. Level of Harm - Minimal harm or potential for actual harm Review of the hospital attending note dated [DATE] revealed Resident #45 appeared visibly uncomfortable and had a nasogastric tube with bilious output (bile). The physician relayed to Resident #45 regarding concerns for perforated colon and how sick he is and could continue to become if he does not get prompt surgical intervention. The note indicated that treatment was discussed with Resident #45 and his wife, including the possible complications and concerns related to Resident #45 ' s medical history and current medical conditions. It was noted Resident #45 declined to pursue aggressive treatment with his wife in agreement. The recommended treatment plan was antibiotics administered intravenously as Resident #45 and his wife were likely pursuing comfort care. Residents Affected - Few Review of the death certificate dated [DATE] revealed Resident #45 died on [DATE] from pneumoperitoneum due to sigmoid diverticulitis at the hospital. During a telephone interview on [DATE] at 10:01 A.M. with Resident #45 ' s representative stated Resident #45 was septic and in organ failure when he arrived at the hospital. The representative stated Resident #45 had started feeling sick on [DATE], complained of pain, and had vomited what he described to her as grass green throw-up. Surgery was an option, but there were concerns related to Resident #45 ' s prognosis because of his condition. Resident #45 ' s representative stated no staff from the facility alerted her to his condition when he first started feeling sick, and she only received information from Resident #45 via telephone. During an interview on [DATE] at 12:55 P.M., ADON #02 stated Resident #45 reported to her that he was having pain in his lower abdomen. ADON #02 stated when she went to palpate his stomach that Resident #45 would not allow her to palpate much or with pressure due to pain. ADON #02 expressed that she contacted the on-call provider and received an order for the KUB to determine if Resident #45 had a blockage. ADON #02 indicated Resident #45 had some bowel movements that were loose. ADON #02 advised the results from the KUB were received the next day, but that she was unaware what night shift had done with the results. ADON #02 stated she contacted Resident #45 ' s representative when she saw the results, and advised his wife that it was up to her if she wanted him sent out. ADON #02 stated she contacted the provider for Resident #45 to be sent out for evaluation. ADON #02 stated it would be normal to listen to bowel sounds when a resident had complaints like Resident #45 ' s, but ADON #02 confirmed she had not listened to Resident #45 ' s bowel sounds on [DATE]. ADON #02 also verified no documentation in Resident #45 ' s medical record of notification to his representative of his change in condition, or to the physician and Resident #45 ' s wife regarding the KUB results. During an interview via telephone on [DATE] at 2:14 P.M., LPN #54 stated she had received report at the start of her shift on [DATE] between 7:00 A.M. to 7:30 A.M. that Resident #45 had a KUB, and the results indicated he was impacted. LPN #54 stated the aide informed her that Resident #45 was in pain, and LPN #54 expressed she noted Resident #45 ' s abdomen was distended upon her examination of him prior to Resident #45 being transferred to the hospital but advised Resident #45 refused to allow much palpation due to pain. During an interview on [DATE] at 2:32 P.M., the DON and Regional Nurse #400 stated the facility had no procedure related to residents with constipation. Regional Nurse #400 stated a bowel assessment would be performed based on resident symptoms and if they had continued issues with constipation. Regional Nurse #400 advised Resident #45 had bowel movements on [DATE] and [DATE], and therefore would not pose a concern to staff, despite Resident #45 complaining of constipation and abdominal pain on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365626 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellbrook Health and Rehab 1957 North Lakeman Drive Bellbrook, OH 45305 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on [DATE] at 8:53 A.M., the DON and MDS LPN #72 revealed Resident #45 was at risk for constipation and prescribed routine and as needed medications for treatment of constipation. The DON verified the intervention on Resident #45 ' s care plan related to constipation was to administer medications as ordered. The DON and MDS LPN #72 advised bowel assessments would be conducted based on clinical judgement and on a case-by-case basis but were unable to elaborate how facility staff should know when such assessment should be performed. The DON advised Resident #45 had two bowel movements on [DATE] that were documented as constipated/hard. During an interview via telephone on [DATE] at 9:08 A.M., CNP #200 stated she had been made aware that Resident #45 had complained of abdominal pain on [DATE] and had a KUB. CNP #200 indicated a possible obstruction would be an urgent situation like appendicitis, and that a resident should be sent out within a matter of hours following review of X-ray results, and even earlier than that based on individual symptoms. CNP #200 inquired as to the timeframe between when the X-ray results were received by the facility and when Resident #45 was transferred out to the hospital because based on her understanding Resident #45 was transferred out shortly following review of the X-ray results. Review of the facility policy titled Notification of Changes, dated [DATE], revealed the facility must inform the resident, consult with the resident ' s physician and/or notify the resident ' s family member or legal representative when there is a change requiring such notification. The policy indicated circumstances requiring notification included significant change in the resident ' s physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status, and circumstances that require a need to alter treatment. This deficiency represents non-compliance investigated under Complaint Number OH00148932. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365626 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bellbrook Health and Rehab 1957 North Lakeman Drive Bellbrook, OH 45305 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure resident medical records were complete. This affected one (Resident #45) out of three residents reviewed for documentation. The facility census was 42. Findings include: Review of the closed medical record for Resident #45 revealed he was admitted to the facility on [DATE], transferred to the hospital on [DATE], and discharged on 11/17/23. Diagnoses included cerebral infarction due to embolism of unspecified cerebral artery, cerebral edema, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, occlusion and stenosis of unspecified carotid artery, acute embolism and thrombosis of left femoral vein, chronic atrial fibrillation, other low back pain, atherosclerosis of coronary artery bypass graft (s) without angina pectoris, congestive heart failure, chronic obstructive pulmonary disease, rheumatoid arthritis, other intervertebral disc degeneration lumbar region, old myocardial infarction, hyperlipidemia, and major depressive disorder. Review of the bladder elimination report from 11/01/23 through 11/14/23 revealed the last documented urine output was 11/13/23 at 12:26 A.M. Review of the bowel movement report from 11/01/23 through 11/14/23 revealed several blank spaces for 11/07/23 through 11/12/23. Review of the meal intake report from 11/01/23 through 11/14/23 revealed no data was documented for 11/13/23. During interview on 12/11/23 at 12:55 P.M., Assistant Director of Nursing (ADON) #2 revealed aides should document meal intakes after meals, and bladder and bowel eliminations after they occurred, and verified the incomplete documentation. This deficiency represents non-compliance investigated under Complaint Number OH00148932. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365626 If continuation sheet Page 9 of 9