Inspection·August 19, 2021

F 0657 EHR. Level of Harm - Minimal harm or potential for actual harm On 08/17/21 at 2:55 P.M., an interview with Licensed Social Worker #26 revealed she did not have documentation of the facility holding any additional care planning conferences for Resident #4 other than the one documented on 02/18/21. She denied a care planning conference for the resident had been completed around the time her quarterly MDS assessment was done in May 2021. Residents Affected - Few A review of the facility's policy on Care Plans/ Assessment- Resident/ Family Participation updated 10/16 revealed it was the facility's policy that each resident and his/ her family members were encouraged to participate in the development of the resident's comprehensive assessment and care plan. The procedure indicated the resident and his/ her family were invited to attend and participate in the resident's assessment and care planning conference. The resident assessments were begun on the first day of admission and completed no later than the 14th day after admission. Advance notice of the care planning conference was provided to the resident and authorized representative. Such notice would be provided in writing. The social service director or designee was responsible for contacting the resident's family and for maintaining records or such notices. Documentation was to include the date and time the resident and authorized representative were provided notification of the conference, the method of contacting the resident and the authorized representative, reason the resident and/ or authorized representative were unable to attend, and the date and signature of the individual providing notification of the conference to the resident and the authorized representative. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 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 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to ensure a resident with known significant weight loss had their meal intakes consistently recorded to aid in monitoring her nutritional status. This affected one (Resident #25) of one residents reviewed for nutrition. Residents Affected - Few Findings include: A review of Resident #25's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included dementia, dysphagia, feeding difficulties, mood disorder, anxiety disorder, and cognitive communication deficit. A review of Resident #25's physician's orders revealed she was on a no added salt diet, pureed texture with thin liquids. Her meals were to be served in bowls and she was to receive her beverages in a two handed spouted cup for self feeding. She received a four ounce frozen nutritional treat with her lunch. They were to record her total intake for all three meals. A review of Resident #25's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognition was severely impaired. Mood indicators present included a poor appetite. She required an extensive assist of one for eating. Her height was 63 inches and her weight was 117 pounds. The resident was identified as having had a significant weight loss and not on a physician prescribed weight loss program. A review of Resident #25's care plans revealed she was at risk for an altered nutrition. Her goals were to receive adequate nutrition to meet her estimated nutrition needs, not have a significant weight loss and her labs to be maintained within normal limits. Her interventions included offering/ providing a substitute of an equal nutritive value if less than 50% was consumed at her meals and monitor weekly weights x 4, then monthly if stable. A review of Resident #25's weights recorded under the vital sign tab of the electronic health record revealed she had a significant weight loss noted on 08/02/21. Her weight had reduced from 128 pounds on 05/17/21 to 116 pounds on 08/02/21 representing a 12 pound or 9% weight loss in three months. A review of Resident #25's progress notes confirmed she was known to have had a significant weight loss as a dietician note dated 07/07/21 identified a significant weight loss x one and three months related to diminished intakes. She was receiving nutritional supplements and had been started on Remeron (an antidepressant) as an appetite stimulant. A dietician's note dated 07/28/21 revealed Resident #25 continued with weight loss over the past week as her weight was down to 115.6 pounds. The dietician indicated the resident's intakes remained varied and she was known to refuse breakfast meals at times. The resident's house supplement order was increased from 4 ounces twice a day to 4 ounces three times a day. A review of Resident #25's meal intakes recorded in the electronic health record under the vital sign tab for the last 32 days (07/17/21- 08/16/21) revealed the staff were not consistently recording the resident's meal intakes after each meal. Out of the the 96 meals that should have been recorded, only 54 had been recorded. There were 42 meals in which the percentage of the resident's meal intake were not recorded. There were seven days (07/21/21, 07/26/21, 07/27/21, 07/28/21, 08/09/21, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 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 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 08/10/21, and 08/12/21) in which none of the three meals provided that day were recorded to show how much the resident ate or if she ate at all. Findings were verified by the Director of Nursing (DON). On 08/17/21 at 2:07 P.M., an interview with the DON revealed STNA's were responsible for documenting a resident's meal percentage consumed in the kiosk after each meal was served. She was asked what the purpose was of recording a resident's meal intake and she confirmed it was to help in monitoring their nutritional status. She acknowledged Resident #25 had multiple missing meal intakes for July and August 2021 and was known to have had a significant weight loss. She also confirmed the dietician would use that information to determine the need for any additional interventions to supplement the resident's nutritional intake if she was not consuming much of her meals. The facility's administrative staff denied having any nutritional policies that addressed the need to record a resident's meal intake with each meal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 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 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, record review, and policy review, the facility failed to ensure the medication error rate was less than five percent. Three errors out of 25 opportunities were observed, resulting in a 12 percent medication error rate. This affected two residents (Resident #22 and Resident #193) out of three residents observed for medication administration. Residents Affected - Few Findings include: 1. Review of Resident #22's medical record revealed an admission date of 08/20/18, with diagnoses including hypertension, peripheral vascular disease, and diabetes mellitus. Review of Resident #22's August 2021 physician orders revealed an order for Flonase Allergy Relief spray with directions for two sprays in each nostril daily, and Lidocaine adhesive four percent patch with directions to apply the patch to the resident's lower back at night and remove in the morning. Observation of Resident #22 on 08/18/21 at 7:48 AM revealed Registered Nurse (RN) #48 apply only one spray of Flonase Allergy Relief to each nostril. Continued observation revealed RN #48 take off the resident's Lidocaine patch and apply a new one to her lower back. Interview on 08/18/21 at 8:43 AM RN #48 verified that she should have administered two sprays of Flonase into each of Resident #22's nostrils and should not have applied a new Lidocaine patch. Review of the facility's policy titled, Medication Administration-General Guidelines, dated 05/2020, revealed before administering each medication the five rights should be assessed. These included the right resident, right drug, right dose, right route, and right time. 2. Review of Resident #193 medical record revealed an admission date of 08/08/21, with diagnoses including hypertension, diabetes mellitus, and muscle weakness. Review of Resident #193 August 2021 physician orders revealed an order for Humalog Insulin 100 units/milliliter to be given per sliding scale. The scale revealed that insulin should not be administered until the resident reached a blood sugar level of 150. At that time two units should be given. Observation on 08/18/21 at 11:04 A.M. Licensed Practical Nurse (LPN) #42 obtained Resident #193's blood sugar which showed a result of 137. Continued observation at 11:20 A.M. revealed LPN #42 administer two units of Humalog insulin to Resident #193. Interview on 08/18/21 at 11:22 A.M. LPN #42 verified with a blood sugar of 137 Resident #193 should not have received any insulin. Review of the facility's policy titled, Medication Administration-General Guidelines, dated 05/2020, revealed before administering each medication the five rights should be assessed. These included the right resident, right drug, right dose, right route, and right time. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 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 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two vials of tuberculin solution were labeled correctly after they were opened. This had the potential to affect all 44 residents residing in the facility. Findings include: Observation [DATE] at 9:39 A.M. of the facility medication storage room revealed two vials of Aplisol Tuberculin solution that were open, used, but were not dated. Interview on [DATE] at 9:45 A.M. Registered Nurse (RN) #10 verified that the facility failed to date the bottles of Tuberculin after opening, and therefore she was unable to verify when the vials would expire or if they were expired. Review of the Aplisol tuberculin insert for the tuberculin revealed that vials in use more than 30 days should be discarded. Review of the facility's policy, Medication Storage dated 05/2020, revealed medications dispensed in the manufacturers original container will be labeled with the manufactures expiration date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 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 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to implement appropriate infection control practices in response to known and/ or suspected COVID-19 infections within the facility. This had the potential to affect all 44 residents that resided in the facility. Residents Affected - Many Findings include: 1. On 08/16/21 at 12:10 P.M., an observation of the dining process for the lunch meal served on the 100 hall revealed there were eight residents (Resident #6, #7, #8, #14, #15, #25, #35 and #42) sitting in the hallway awaiting their meal. The staff had them sitting in the hall near the television that was on the wall outside room [ROOM NUMBER]. The residents had bedside tables set up in front of them to be served their lunch meal on them. Six of the residents were noted to be sitting at a distance of less than six feet from one another. All of the residents had surgical masks on but five of the eight had their mask pulled down underneath their nose. All of the residents observed in that area were supposed to be under droplet precautions following a possible exposure to a COVID-19 positive employee. On 08/16/21 at 12:15 P.M., nursing staff were observed to be delivering trays into the resident rooms for those on the 100 hall that were not out in the hallway for their meal. The nursing staff were observed to leave the resident's room after donning and doffing their personal protective equipment (PPE), which included a gown, gloves, surgical mask over an N95 mask and eye goggles. The staff continued to wear their eye goggles when leaving the room but were not observed to properly disinfect the eye goggles with an appropriate disinfectant cleaner when leaving the room. The staff were then noted to enter the next resident's room to deliver trays. State tested Nursing Assistant (STNA) #21 was noted to leave room [ROOM NUMBER] and enter room [ROOM NUMBER] without disinfecting her eye goggles. STNA #100 was noted to enter room [ROOM NUMBER] and then room [ROOM NUMBER] without disinfecting her eye goggles when leaving both rooms. STNA #21 was then noted to enter room [ROOM NUMBER] and room [ROOM NUMBER] with PPE on. Both rooms were of residents who were on droplet isolation precautions and neither had barrels in them for the disposal of her PPE. STNA #21 left the room and entered the hallway with her PPE on before doffing (removing) her PPE on while standing in the middle of the hall. When she left room [ROOM NUMBER], she was noted to tuck her potentially contaminated gown between her left upper arm and her torso so she could retrieve a plastic bag out of her pocket to put the PPE in. She then took the plastic bag down the hall to dispose of it in a utility room. On 08/16/21 at 12:43 P.M., an interview with STNA #21 revealed they did not have PPE barrels in rooms 129 or 136 and verified she did not doff her PPE until she entered the hallway after leaving the residents' room. She was not sure why those rooms did not have barrels in them for the disposal of PPE as all residents on the hall were in droplet isolation precautions. She confirmed she did not disinfect her eye goggles when leaving room [ROOM NUMBER] and before she entered room [ROOM NUMBER]. She also denied disinfecting her goggles when she left room [ROOM NUMBER]. She stated the nurses' medication administration cart had alcohol wipes in it for them to use to disinfect their goggles. She denied they had them in the PPE carts that were located in the hallway. She was then asked about the dining room being closed and why they were placing the residents in the hallway in close proximity to one another. She acknowledged they were not socially distanced as they should be. She stated they quit using the dining room when they had a positive COVID-19 resident and acknowledged by placing them all in the same area in the hall defeated the purpose of closing the dining room down. She reported those eight residents who were served their meals in the hallway were those that needed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 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 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many supervision or feeding assistance with their meals. She stated they probably should have them outside their doorway so they were not congregated in one small area where social distancing could not be met. On 08/16/21 at 12:55 P.M., an interview with the Administrator revealed the facility shut down it's dining room when a resident tested positive on a rapid test for COVID-19. She acknowledged by sitting the residents in close proximity to one another in the hallway for their meal defeated the purpose of closing the dining room as they were still not being socially distanced as they should be. She reported they were still looking into the process to ensure residents were being socially distanced as they should be. She acknowledged rooms [ROOM NUMBERS] did not have barrels in them for the disposal of soiled linen and trash despite the residents in those rooms being on droplet isolation precautions. She confirmed the rooms should have barrels in them and denied any shortages to explain why they were not. She reported they must not have been put in there yet. She also acknowledged staff were observed to leave those rooms with their PPE on not doffing them until they came out into the hallway. She was informed STNA's were observed to leave resident rooms who were on droplet isolation precautions without cleaning their goggles. She stated they could disinfect them with an alcohol wipe or use soap and water in the resident's bathroom but should be done when leaving the room and before entering another resident's room. 2. On 08/18/21 at 8:23 A.M., an observation noted three residents (Resident #22, #25, and #35) to be sitting in the hallway by the 100 hall nurses station. None of the three residents were noted to have masks on. The residents were not eating at the time the observation and did not have their trays in front of them to show they recently finished eating. On 08/18/21 at 8:34 A.M., Resident #7 was observed to be wheeled out of her room by a staff member. The resident did not have a mask on when assisted out of her room and down the hall. She was placed in the hall in front of the TV and was not encouraged by staff to put her mask on. Findings were verified by RN #48. On 08/18/21 at 8:38 A.M. an interview with RN #48 revealed all residents on that unit were considered to be in droplet isolation precautions following a possible exposure to a COVID-19 positive resident. She reported they were to encourage the residents to remain in their room but, if they came out, they were supposed to have a mask on. She reported the three that were observed in the hall by the nurses station required supervision, which is why they put them in the hall. 3. On 08/18/21 at 8:35 A.M., an observation noted staff to be collecting breakfast trays from resident rooms and placing them in a closed food cart. STNA #100 was noted to be out in the hallway receiving the trays from another staff member who was in the residents' rooms with PPE on passing the trays through the doorway. STNA #100 handled the trays with ungloved hands placing them inside the food cart. She was then observed to record the residents' meal intake on a clipboard she had on top of the food cart with a pen. She was observed to handle the drawers of a PPE cart outside a resident's room to don PPE before entering the room to retrieve a breakfast tray. She did not perform hand hygiene or use hand sanitizer after handling the trays before touching and potentially contaminating other surfaces. Findings were verified by STNA #100. On 08/18/21 at 8:40 A.M., an interview with STNA #100 confirmed she did not have gloves on when she handled the breakfast trays passed out of the residents' rooms for her to load into the food cart. She also confirmed she did not wash her hands or use hand sanitizer, after handling the trays removed from the residents' rooms who were on droplet precautions, before touching other surfaces with her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 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 366369 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Altercare Thornville Inc. 14100 Zion Road Thornville, OH 43076 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 0880 potentially contaminated hands. Level of Harm - Minimal harm or potential for actual harm A review of the facility's policy on Transmission Based Precautions: Droplet Precautions undated revealed the facility would utilize droplet precautions (in addition to standard precautions), for specified residents known or suspected to be infected with microorganisms transmitted by droplet that can generate by the resident during coughing, sneezing, talking, or the performance of procedures. The procedure included wearing a mask when working within six feet of the resident. For resident transportation, they were to limit the movement and transport of the resident from the room to essential purposes only. If transport or movement was necessary, minimize resident dispersal of droplets by masking the resident. Residents Affected - Many A review of the facility's COVID-19 policy revealed the facility was to limit communal dining and group activities. They were to remind residents and staff to practice social distancing when not delivering/ receiving direct care. They were to remind staff about the importance of good hand hygiene. They were to perform proper hand hygiene with soap and water or alcohol based hand rub before and after all resident contact, contact with potentially infectious material and before putting on and upon removal of PPE, including gloves. A review of the facility's policy on Face Shields and Goggles updated 04/26/21 revealed it was the facility's policy to wear face shields or goggles to reduce the risk of transmission of infectious agents when engaging in resident care encounters. Employees providing care and services to residents would be provided a face shield or goggles to utilize throughout their shift. Eye protection was required when caring for residents in quarantine or isolation rooms. Eye protection was to be disinfected when exiting a COVID-19 quarantine room, when visibly soiled or when donning/ doffing. 4. Observation on 08/16/21 from 12:40 P.M. to 12:51 P.M. revealed Therapist #50 walking into Resident #33 and Resident #194 room with full personal protective equipment (PPE) on (gown, gloves, mask, and eye protection/face shield). They walked out of that room, doffed (took off) all of their PPE appropriately and used appropriate hand washing techniques. They did not clean the face shield. After that room, they put full PPE back on and walked into Resident #13 and Resident #197 room. After finishing in that room, they completed the same doffing and hand washing tasks; but did not clean the face shield again. At the time of the observation all residents in the facility were on droplet isolation precautions. Interview with Therapist #50 on 08/16/21 at 12:51 P.M. confirmed that the facility keeps cleaning wipes in the PPE carts near each room so they can clear their eye protection after entering each resident's room. Therapist #50 confirmed that they are to clean their face shield after entering/leaving each room that is on isolation precautions; and confirmed that this process was not completed. Review of facility Face Shield and Goggles policy (dated 04/26/21) revealed the purpose of the policy was to reduce the risk of transmission of infectious agents, face shields/eye protection will be utilized when engaging in patient care encounters. Eye protection is required when caring for residents in a quarantine or isolation room. Eye protection is to be disinfected when exiting a COVID-19 quarantine room, when visibly soiled, and when donning/doffing. Disinfect the inside and outside of the faceshield or goggles using an EPA approved disinfectant or bleach solution. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366369 If continuation sheet Page 9 of 9