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STTE " COE 9OO SEER TERN OE )))5 4T ENE NORT S@ RS N 56AB7 TE&F GHIPGQ &F RPSI1HQH2 TU V W0V1&X&H2 SQVQH F0GYHUPG XPG QEH H2&RVGH H2&RV&2 V'28PG C1&'&RV1 VTPGVQPGU SIGPYHSH'Q SH'2SH'QF IGP(GVS QP FEP` QEPFH 2HX&R&H'R&HF IGHY&P0F1U GHIPGQH2 P' QEH CSa356B SQVQHSH'Q PX HX&R&H'R&HF V'2 1V' PX CPGGHRQ&P' QEVQ EVYH THH' RPGGHRQH2 V'2 QEH 2VQH F0RE RPGGHRQ&YH VRQ&P' `VF VRRPSI1&FEH2$ EVRE 2HX&R&H'RU FEP012 TH X011U &2H'Q&X&H2 0F&'( H&QEHG QEH GH(01VQ&P' PG SC IGPY&F&P' '0STHG V'2 QEH &2H'Q&X&RVQ&P' IGHX&b RP2H IGHY&P0F1U FEP`' P' QEH CSa356B cIGHX&b RP2HF FEP`' QP QEH 1HXQ PX HVRE GHW0&GHSH'Q P' QEH F0GYHU GHIPGQ XPGSd$ ITEM DATE ITEM DATE ITEM DATE !4 !5 !4 !5 !4 !5 GHX&b FD)66 CPGGHRQ&P' GHX&b FD3C3 CPGGHRQ&P' GHX&b FDAD7 CPGGHRQ&P' 4CA$)DcXdc3d 4CA$3DcfdcAdc&&d 4CA$35 RH($ e CPSI1HQH2 RH($ e CPSI1HQH2 RH($ e CPSI1HQH2 SC D68)B83D)6 SC D68)B83D)6 SC D683483D)6 GHX&b FDA)3 CPGGHRQ&P' GHX&b FDA)5 CPGGHRQ&P' GHX&b FD44) CPGGHRQ&P' 4CA$35cVdcAd 4CA$35c2d 4CA$65 RH($ e CPSI1HQH2 RH($ e CPSI1HQH2 RH($ e CPSI1HQH2 SC D683483D)6 SC D683483D)6 SC D68)B83D)6 GHX&b CPGGHRQ&P' GHX&b CPGGHRQ&P' GHX&b CPGGHRQ&P' RH($ e CPSI1HQH2 RH($ e CPSI1HQH2 RH($ e CPSI1HQH2 SC SC SC GHX&b CPGGHRQ&P' GHX&b CPGGHRQ&P' GHX&b CPGGHRQ&P' RH($ e CPSI1HQH2 RH($ e CPSI1HQH2 RH($ e CPSI1HQH2 SC SC SC GHX&b CPGGHRQ&P' GHX&b CPGGHRQ&P' GHX&b CPGGHRQ&P' RH($ e CPSI1HQH2 RH($ e CPSI1HQH2 RH($ e CPSI1HQH2 SC SC SC REVIEWED BY REVIEWED BY DATE SIGNATURE OF SURVEYOR DATE STATE AGENCY (INITIALS) BF/KJ 08/ /2016 33925 07/18/2016 REVIEWED BY REVIEWED BY DATE TITLE DATE CMS RO (INITIALS) FOLLOWUP TO SURVEY COMPLETED ON CEC@ FOR N! 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.