F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation and staff interview the facility failed to ensure Resident #129's indwelling urinary catheter bag
was covered for dignity and privacy. This affected one resident (#129) of one resident reviewed for dignity
related to urinary catheter bags. The facility identified four residents (#6, #12, #129, and #178) with urinary
catheters. The facility census was 22.
Findings include:
Review of the medical record for the Resident #129 revealed an admission date of 05/31/23. Diagnoses
included wedge compression fracture, diabetes, epidural hemorrhage, dementia, and pulmonary
hypertension.
Review of the Minimum Data Set (MDS) assessment dated [DATE] was still in process and had not yet
been completed.
Review of the physician's order dated 05/24/23 revealed resident had an indwelling urinary catheter and
required catheter care.
Observation on 05/30/23 at 2:20 P.M. revealed Resident #129 had a urinary catheter. The urinary catheter
bag contained urine and was hanging below the bed and visible from the hallway. Resident #129's urinary
catheter bag did not have a privacy cover.
Observation on 05/31/23 at 9:19 A.M., 10:50 A.M., 2:00 P.M. and 3:40 P.M. revealed Resident #129 had a
urinary catheter bag that was left uncovered and visible from the hallway.
Interview on 05/31/23 at 3:40 P.M. with Unit Manager #173 and the Director of Nursing (DON) confirmed
the facility had urinary catheter bag covers, and urinary catheter bags should be maintained with a privacy
cover. Unit Manager #173 and the DON confirmed Resident #129 did not have a urinary catheter bag
privacy cover in place.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
366411
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
366411
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Robert A Barnes Center
2225 Taylor Park Drive
Reynoldsburg, OH 43068
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 0553
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Allow resident to participate in the development and implementation of his or her person-centered plan of
care.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
resident interview, staff interview, record review, and facility policy review the facility failed to ensure
Resident #14 was offered an initial care conference. This affected one resident (#14) of two residents
reviewed for care conferences. The facility census was 22.
Findings include:
Review of the medical record for Resident #14 revealed a readmission date of 05/09/23. Diagnoses
included chronic obstructive pulmonary disease, diabetes, Fournier's gangrene, vascular disease, muscle
weakness, and colostomy status.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #14 was cognitively
intact with and required limited to extensive assistance of one staff member for all activities of daily living
and mobility.
Interview on 05/30/23 at 1:52 P.M. with Resident #14 revealed he would like to participate in care
conference meetings and would like his daughter to be invited as well. Resident #14 reported he had not
been invited to any care conferences since admission in 04/2023 and reported he was hospitalized and
returned 05/09/23.
Review of the medical record revealed no documented evidence of a care conference for Resident #14.
Interviews on 05/31/23 at 2:08 P.M. and 3:09 P.M. with Social Services (SS) #160 revealed the facility offers
a care conference within two weeks of admission to discuss the plan for admission. SS #160 revealed a
large majority of residents are short-term and are admitted for rehabilitation services. SS #160 confirmed
Resident #14 did not have a care conference due to SS #160 being on vacation. SS #160 revealed no
current plan to hold a care conference for Resident #14.
Review of the undated facility policy titled Care Conference revealed a purpose to include residents and
representatives in the planning process.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366411
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
366411
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Robert A Barnes Center
2225 Taylor Park Drive
Reynoldsburg, OH 43068
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 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
Based on interviews, medical record review, and review of the facility's discharge policy and procedure, the
facility failed to notify the Ombudsman when residents were discharged from the facility. This affected three
residents (#10, #16 and #78) out of three residents reviewed for discharges. The facility census was 22.
Findings include:
Review of Resident #10's medical record revealed an admission date of 4/22/23 with a fractured right
clavicle, cerebral infarction, and type two diabetes. He was discharged on 05/12/23.
Review of Resident #16's medical record revealed an admission date of 4/15/23. Diagnoses of unspecified
fracture part of the neck, osteoporosis with pathological fracture of the vertebra, and emphysema. Resident
#16 was discharged home on 5/15/23.
Review of Resident #78's medical record revealed an admission date of 03/07/23 for rehabilitation.
Diagnoses included chronic cholecystitis, type two diabetes, emphysema, and congestive heart failure. He
was discharged from the facility on 04/18/23.
Interview on 05/31/23 at 11:49 A.M. with Licensed Social Worker (LSW) #179 revealed she does not notify
the Ombudsman when residents are discharged from the facility to home.
Interview on 05/31/23 at 2:00 P.M. with the Administrator revealed it is not policy to notify the ombudsman
when residents are discharged to home.
Review of the undated Facility's Discharge Planning policy revealed no indication the Ombudsman should
be notified when a resident was to be discharged from the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366411
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
366411
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Robert A Barnes Center
2225 Taylor Park Drive
Reynoldsburg, OH 43068
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
observation, staff interview, record review, and facility policy review the facility failed to ensure Resident #21
received timely and appropriate care to prevent weight loss including obtaining weights as ordered,
providing supplements as ordered, and providing meals according to the meal ticket. This affected one
resident (#21) of one resident reviewed for nutrition. The facility census was 22.
Residents Affected - Few
Findings include:
Review of the medical record for Resident #21 revealed an admission date of 04/26/23. Diagnoses included
normal pressure hydrocephalus, muscle weakness, malnutrition, and mild cognitive impairment.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 was cognitively
impaired and required extensive assistance of two staff members for transfers. The MDS revealed the
resident had a deep tissue injury (DTI) pressure ulcer to the right heel (a purple or maroon localized area of
discolored intact skin or blood-filled blister due to damage of underlying soft tissue due to pressure and/or
shear.)
Review of the plan of care dated 05/25/23 revealed Resident #21 was at risk for alteration in nutrition with a
goal to maintain weight without significant weight loss with interventions to provide supplements as
ordered, nutrition to be monitored as needed (labs, weights, and intakes), and menu with preferences.
Review of physician orders for revealed the following orders:
•
04/26/23 to 05/10/23 revealed diet order of regular texture and regular consistency.
•
04/27/23 Remeron 15 milligrams (mg) tablet with instructions to give one-half tablet at bedtime for appetite
stimulant.
•
05/01/23 Ensure with meals for supplement.
•
05/03/23 weekly weights for four weeks then monthly with instructions to notify the provider and reweigh for
a two-to-five-pound weight difference.
•
05/10/23 regular diet mechanical soft texture.
•
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366411
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
366411
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Robert A Barnes Center
2225 Taylor Park Drive
Reynoldsburg, OH 43068
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
05/24/23 Magic cup (supplement) twice daily 120 milliliters (ml) with instructions to give at lunch and dinner.
Level of Harm - Minimal harm
or potential for actual harm
•
05/25/23 for Marinol oral capsule 2.5 mg twice daily for appetite stimulant.
Residents Affected - Few
Review of resident weights included:
•
04/26/23 - 94.8 pounds (lbs.)
•
05/03/23 - 93.4 lbs.
•
05/10/23 - 94.4 lbs.
•
05/24/23 - 85.0 lbs.
There was a significant weight loss of 10.34 percent (%) in 30 days, and review of medical record found no
documented evidence a reweight being obtained.
Review of the progress notes dated 05/24/23 revealed a weight change reflecting a significant weight loss
of 10.3% over 30 days, resident with poor intake with supplements and an unstageable DTI pressure
wound to the right heel with plan to add Magic cup 120 ml with lunch and dinner for nutritional support. On
05/26/23 Marinol oral capsule 2.5 mg was added with instructions for one capsule by mouth every morning
and at bedtime for appetite stimulant. On 05/27/23, Marinol oral capsule 2.5 mg with instructions to give
one capsule in morning and night for appetite stimulant was ordered, and the facility was waiting for it to be
delivered.
Observation on 05/30/23 at 11:58 A.M. of the lunch meal revealed Resident #21 did not receive the Magic
cup supplement on her tray.
Review of Resident #21's meal ticket dated 05/31/23 for lunch revealed the resident had an order for
mechanical soft food and instructions for food to be cut into bite size pieces. The supplements were not
included on the meal ticket.
Observation on 05/31/23 at 11:47 A.M. of the lunch meal revealed Resident #21 did not receive the Magic
cup supplement on her tray. Resident #21's meal ticket also stated a mechanically soft diet order and
instructions for food to be cut into bite size pieces.
Interview on 05/31/23 at 12:01 P.M. with State Tested Nursing Aide (STNA) #119 revealed the kitchen staff
make sure Magic cups are available and placed on the trays, and aides pass out the Ensure
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366411
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
366411
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Robert A Barnes Center
2225 Taylor Park Drive
Reynoldsburg, OH 43068
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
supplements. STNA #119 confirmed Resident #21's Magic cup was not provided with the lunch meal as
ordered and confirmed the resident's dessert was not cut into bite size pieces and reported typically
resident's food had not been cup up. STNA #119 revealed typically Resident #21 ate about 25% of her
meals and required significant encouragement. STNA #119 verified all weights taken by STNA's were
entered into the electronic medical record.
Residents Affected - Few
Interview on 05/31/23 at 2:28 P.M. with Dietitian #177 revealed being scheduled at the facility two days
weekly and meets with residents at the beginning of their admission to discuss preferences and dietary
concerns. Dietitian #177 revealed Resident #21 was not able to participate in the assessment due to poor
cognition. Dietitian #177 reported she reviewed weights for Resident #21 and recognized a weight was
missing on 05/17/23 and requested that nursing staff get this weight the next day. Dietitian #177 reported
the weight was not obtained until 05/24/23 and was found to have a significant weight loss. Dietitian #177
revealed all residents should have orders for weekly weights for four weeks and then monthly weights
ongoing and revealed regular issues with getting staff to complete resident weights as ordered. Dietitian
#177 revealed she was unaware of medication recommendations for an appetite stimulant and confirmed
several progress notes related to medication Marinol not being provided due to awaiting pharmacy delivery.
Dietitian #177 revealed she was unaware of the Magic cup was not being given as ordered.
Interview on 06/01/23 at 4:32 P.M. with the Director of Nursing (DON) revealed the Magic cup was marked
off as given with breakfast. The DON confirmed this did not match the physician's order.
Review of the undated facility policy titled Weights and Weight Change Management revealed residents
would be weight monthly unless ordered by a physician or recommended by a dietitian. The weight will be
documented in the medical record and weight changes will be addressed by the dietitian and
interdisciplinary team. Residents would be re-weighed if a significant weight loss was noted.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366411
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
366411
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Robert A Barnes Center
2225 Taylor Park Drive
Reynoldsburg, OH 43068
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 0730
Observe each nurse aide's job performance and give regular training.
Level of Harm - Minimal harm
or potential for actual harm
Based on review of personnel files and interviews the facility failed to complete employee evaluations for
four of four State Tested Nurse's Aides (STNAs) reviewed for personnel files (STNAs #130, #134, #148,
and #164). This had the potential to affect all facility residents. The facility census was 22.
Residents Affected - Many
Findings include:
1. Review of personnel file for STNA #164 hired on 02/01/21 had no evidence of a 90-day evaluation or an
annual evaluation since hire.
2. Review of personnel file for STNA #130 hired on 03/21/22 had no evidence of a 90-day evaluation or an
annual evaluation since hire.
3. Review of personnel file for STNA #134 hired on 04/21/22 had no evidence of a 90-day evaluation or an
annual evaluation since hire.
4. Review of personnel file for STNA #148 hired on 02/21/23 had no evidence of a 90-day evaluation since
hire.
Interview on 06/01/23 at 3:20 P.M. with Director of Human Resources #175 revealed facility was not doing
any performance evaluations since the start of the COVID-19 pandemic and revealed they had recently
restarted performance evaluations for newly hired staff but revealed no process in place to evaluate
previously hired employees.
Interview on 06/01/23 at 4:32 P.M. with the Director of Nursing (DON) revealed the facility had no policy
related to staff evaluations.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366411
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
366411
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Robert A Barnes Center
2225 Taylor Park Drive
Reynoldsburg, OH 43068
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 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, staff interview, and policy review the facility failed to ensure pureed foods were made to the
correct consistency and according to the recipe. This affected one resident (#6) who was the only resident
with pureed diet orders. The facility census was 22.
Findings include:
Review of the medical record for Resident #6 revealed an admission date of 03/17/23 with diagnosis
including a stroke.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively
impaired and required limited assistance from staff for eating.
Observation on 05/31/23 at 11:19 A.M. revealed Dietary Staff #180 when making the puree pasta with meat
sauce, placed two handfuls of pasta noodles into the food processor. Then added 2.5 scoops of spaghetti
with meat sauce using a 6-ounce (oz) scoop and blended the mixture. Then Dietary Staff #180 added
approximately one-half tablespoon of thickener to the mixture. After blending the mixture, the pureed food
was at the bottom of the food processor and pieces of food and noodle that had not been blended or
pureed were on the top and sides of the food processor. When Dietary Staff #180 scraped the pureed
mixture into the dishes to be placed on the warming cart, the chunks of noodle were also scraped into the
metal container and were visible sticking out of the pureed food.
Interview on 05/31/23 at 11:23 A.M. with Dietary Staff #180 and Dietary Manager #136 confirmed the
pureed food contained whole pieces of about 1-inch-long noodles.
Review of the Pureed Recipe instructions revealed food should be processed until fine in texture and
instructions to scrape down sides with a spatula and reprocess.
Review of the undated facility policy titled Therapeutic Diet revealed a purpose to assure residents receive
and consume food in the appropriate form as prescribed.
Review of the undated facility policy titled Texture and Consistency Modified Diets revealed a purpose for
texture and consistency-modified diets should be individualized with modifications. The policy revealed the
food and nutrition services department would be responsible for preparing and serving the correct
consistency of food as ordered and per the recipe.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366411
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
366411
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/01/2023
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Robert A Barnes Center
2225 Taylor Park Drive
Reynoldsburg, OH 43068
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, staff interview, and policy review the facility failed to ensure safe and sanitary
storage of all food materials in the dry storage, refrigerator, and freezer areas. This had the potential to
affect all 22 residents as they all received food from the kitchen. The facility census was 22.
Findings include:
Observation and interview on 05/30/23 at 9:39 A.M. with Dining Staff #144 in the unit kitchenettes revealed:
•
frozen pancakes with no date
•
unsealed ice cream
•
a yellow liquid substance in a bottle in dry storage with no label and no date
•
several spice containers that expired 03/21/18
Interview with Dining Staff #144 at the time of the observations confirmed the above findings.
Observation and interview on 05/20/23 at 10:45 A.M. with Dietary Manager #136 in the main kitchen
revealed six bottles of lime juice were found to have expired 02/27/23. Dietary Manager #136 confirmed the
finding at the time of the observation.
Review of the facility policy titled Food Supply and Storage Procedures, dated 10/13/12, revealed all food
shall be stored in such a manner as to maintain the safety for human consumption. Products should be
discarded after the used by date has passed and cannot be served to residents after the sell by date has
passed. All food items should be covered, labeled, and dated as appropriate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366411
If continuation sheet
Page 9 of 9