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Brenda Fischer, Unit Suservisor Kate Johnston, Program Ssecialist

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Brenda Fischer, Unit Suservisor Kate Johnston, Program Ssecialist DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL I PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility I I!"# $ I!"I %#&'I # (& (" "( "# 22 &F F"!I0I34 5 34% &F "!3I&(7 )081 )01 245269 )01 GOOD SHEPHERD LUTHERAN HOME 1. Initial 2. Recertification )051 1115 4TH AVENUE NORTH 23"3 ' (&# &# I!"I (& 3. Termination 4. CHOW )01 686240300 )061 SAUK RAPIDS, MN )071 56379 5. Validation 6. Complaint 7. On-Site Visit 9. Other 6 FF !3I' "3 !A"(9 &F &B( #2AI% %#&'I #$2@%%0I # !"3 9&#4 )01 8. 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NCORRECTE EFCENCES$ %S SR! OF 583683D)6 NCORRECTE EFCENCES cCSa356Bd SENT TO TE FCT!g YES NO FPGS CS a 356B# cD7873d EF c))8D6d V(H ) PX ) EENT h "BD))3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL I PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility I I!"# $ I!"I %#&'I # (& (" "( "# 22 &F F"!I0I34 5 34% &F "!3I&(2 )081 )01 245269 )01 GOOD SHEPHERD LUTHERAN HOME 1.
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