Summerhill Elderliving Home & Care

F-F600

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 15 115430 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115430 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summerhill Elderliving Home & Care 500 Stanley Street Perry, GA 31069

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 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or 21213 potential for actual harm Based on interviews, record review, review of the facility's policy titled Documentation of Medication Residents Affected - Few Administration, and review of the Licensed Practical Nurse (LPN) job description, the facility failed to ensure that services being provided by a licensed nurse met professional standards of quality including inaccurate documentation of medication administration for one resident (Resident R2), from a total sample of 11 residents. Actual harm was identified to have occurred on 12/19/2024 when a Licensed Practical Nurse (LPN) CC administered the wrong resident's medications to Resident R2. Resident R2 was sent to the hospital and admitted for monitoring of potential side effects.

Findings include:

The facility had a Documentation of Medication Administration policy, dated 3/22/2017. The policy documented that the nurse shall document all medications administered to each resident on the resident's electronic Medication Administration Record (eMAR). The policy included that administration of medication must be documented immediately as medications administration is being done per individual resident.

Review of LPN CC's personnel file revealed a Licensed Practical Nurse Job Description. The job description documented a position summary of an LPN which included that the LPN provides direct patient care under

the supervision of a registered nurse. The LPN contributes to patient care, provides a therapeutic environment, and is expected to abide by the standards, the job description, policies and procedures of the nursing department and hospital. The job description also documented that one of the principle duties and responsibilities included administering medications and treatments utilizing the five Rights of Medication Administration and two patient identifiers.

Further review of LPN CC's personnel file revealed a Clinical Competency Testing evaluation. The evaluation included that LPN CC had between mid-level and advanced-level experience with medication administration and advanced-level experience in a nursing home setting.

On 12/19/2024, a significant medication error occurred when LPN CC incorrectly administered another resident's medications to Resident R2. Further review revealed Resident R2 was sent to the hospital emergency room for evaluation and admitted for observation due to polypharmacy and syncopial episode.

LPN CC documented in a written statement that on 12/19/2024, that she asked Resident R2 if his name was Resident R2 or Resident R6's last name. Resident R2 incorrectly stated Resident R6's last name. LPN CC looked at the picture on the Medication Administration Record (MAR) (for Resident R6), which she documented resembled Resident R2. Her statement included that

she administered Resident R6's oral medications (to Resident R2). When she arrived at Resident R6's room to administer medication to his roommate, she realized her error when Resident R6 was lying in his bed and was wearing different clothing.

Further review of the facility's conclusion summary revealed that following the medication error on 12/19/2024, LPN CC was relieved of her medication cart at 11:50 am and subsequently sent home.

However, after being relieved of her medication cart on 12/19/2024 at 11:50 am, LPN CC then documented administering medications to Resident R2, who was no longer in the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 15 115430 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115430 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summerhill Elderliving Home & Care 500 Stanley Street Perry, GA 31069

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 0658 Review of Resident R2's MAR revealed that LPN CC signed off administering 10 medications at 12:44 pm- 12:45 pm, that were scheduled for 9:00 am. The medications signed off as administered included docusate sodium 100 Level of Harm - Minimal harm or milligrams (mg), GlycoLax powder, Linzess 72 micrograms (mcg), probiotic oral capsule, Zetia 10 mg, potential for actual harm Klor-Con 20 milliequivalents (mEq), Lasix 40 mg, metoprolol succinate extended release 25 mg, amlodipine besylate 2.5 mg, and a chewable aspirin 81 mg. Residents Affected - Few However, review of the hospital Emergency Department (ED) Physician Documentation revealed that Resident R2 was seen by the physician at the hospital on 12/19/2024 at 12:15 pm.

During an interview on 1/9/2025 at 4:05 pm, that included RN Supervisor EE and the Director of Nursing (DON), RN Supervisor EE stated that the Education Nurse took the keys to the medication cart before 11:30 am (on 12/19/2024) and LPN CC was off of the hall but could still document. The DON stated that when she spoke with LPN CC (over the phone, after the medication error), LPN CC did not indicate she gave Resident R2 his own medications. The DON stated that she thought LPN CC signed items off on the MAR before she left the facility because the items were signed off after 12:00 pm. During an interview on 1/13/2025 at 11:05 am, the Education Nurse confirmed she took over the medication cart for LPN CC on 12/19/2024.

Cross reference to

F-F689

2. Review of clinical record for Resident R2 revealed that he was admitted to the facility on [DATE REDACTED] and had diagnoses that included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction, aphasia, dysphagia, cerebral atherosclerosis, atherosclerotic heart disease, hypertension, hyperlipidemia, major depressive disorder, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, and vitamin D deficiency.

A review of the care plan dated 10/30/2020 revealed that Resident R2 had a communication problem related to aphasia following cerebral infarction. Further review of the care plan dated 1/16/2020 revealed interventions

in place for licensed nursing staff to administer medications as ordered for cardiac prophylaxis, altered cardiovascular status, gastro-esophageal reflux disease, hyperlipidemia, depression, history of cerebral vascular accident and vitamin D deficiency.

However, on 12/19/2024, Licensed Practical Nurse (LPN) CC failed to administer the correct medications to Resident R2 as care planned and ordered.

A review of facility investigation information including a 12/19/2024 Facility Incident Report Form, staff written statements, and a 12/23/2024 conclusion summary, revealed that Resident R2 received oral medications that were ordered for Resident R6 on 12/19/2024 around 9:03 am. Resident R2 was subsequently admitted for observation due to polypharmacy and a syncopial episode.

LPN CC documented in a written statement that on 12/19/2024, Resident R2 was pushed (in his wheelchair) to the medication cart. LPN CC asked Resident R2 if his name was Resident R2 or Resident R6's last name. Resident R2 incorrectly stated Resident R6's last name. LPN CC looked at the picture on the Medication Administration Record (MAR) (for Resident R6), which she documented resembled Resident R2. Her statement included that she administered Resident R6's oral medications (to Resident R2).

During an interview on 1/9/2025 at 4:05 pm, which included RN Supervisor EE and the Director of Nursing (DON), RN Supervisor EE stated that she was coming out of a meeting (on 12/19/2024) when LPN CC told her about the medication error. RN EE went to put her paperwork down on her desk and said she was going to call the Nurse Practitioner and check on Resident R2. As RN EE rounded the corner to go that way, the CNA called out about Resident R2 being on the floor. When questioned why LPN CC asked Resident R2 if his name was the last name of Resident R2 or Resident R6 (instead of just asking him what his name was), the DON stated that she did not know why LPN CC asked the question that way. The DON stated that Resident R2 jokes and can be silly. RN Supervisor EE stated that Resident R2 was probably joking when he told LPN CC his name was Resident R6.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 15 115430 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115430 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summerhill Elderliving Home & Care 500 Stanley Street Perry, GA 31069

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 0656 Review of the 12/19/2024 hospital Emergency Department (ED) Physician Documentation revealed that it was determined that Resident R2 had a vasovagal syncope (fainting) episode while having a bowel movement. Level of Harm - Actual harm Additional differential diagnoses included medication error, polypharmacy, and chronic obstructive pulmonary disease exacerbation. Poison control was contacted about the medication error and recommended baseline Residents Affected - Few laboratory tests, an electrocardiogram (EKG), monitoring vital signs and 24-hour observation. Resident R2 was subsequently admitted to the hospital.

Cross reference to

F-F760

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 15 115430 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115430 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summerhill Elderliving Home & Care 500 Stanley Street Perry, GA 31069

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21213 Residents Affected - Few Based on interviews and record reviews, the facility failed to ensure that bed bolsters were secured, and that Activities of Daily Living (ADL) care was provided by the appropriate number of staff, to prevent accidents for one of 11 residents (R) (Resident R1) sampled for ADL care. Actual harm was identified to have occurred on 12/21/2024, when a Certified Nursing Assistant (CNA) AA provided ADL care to Resident R1 by herself, instead of with the required two-person assistance. Resident R1 fell from the bed and sustained a laceration to the right side of

the forehead.

Findings include:

Review of the clinical record for Resident R1 revealed that she was admitted to the facility on [DATE REDACTED] and had diagnoses that included, but were not limited to, Alzheimer's disease, fibromyalgia, dementia, and adult failure to thrive.

Review of the 10/11/2024 Quarterly Minimum Data Set (MDS) assessment revealed that Resident R1 was cognitively impaired and dependent on staff for ADL, including bed mobility.

Review of physician's orders revealed a corresponding physician's order, dated 1/22/2024, for padded bolsters to bilateral sides of the bed to define the bed parameters and bring a sense of security related to fear of falling from the bed.

The ADL self-care performance deficit care plan problem included an intervention, dated 1/25/2022, that documented Resident R1 required total assistance from two staff to turn and reposition in bed. There was also an intervention, dated 1/25/2022, that indicated Resident R1 was not toileted. She was incontinent of bowel and bladder, wore adult briefs, and was checked and changed.

Review of the Fall Risk Evaluation form, dated 10/9/2024, revealed that Resident R1 was assessed as being at moderate risk for falls.

Review of progress notes revealed a 12/21/2024 6:28 am nurse's note entry that documented Licensed Practical Nurse (LPN) HH was notified by staff that Resident R1 was observed on the floor. Resident R1 was observed to be on

the floor beside the bed with blood on the floor. Resident R1 was responding normally to verbal and physical stimuli.

The nurse's note documented that Resident R1 had a cut above the right eyebrow and a scrape to the right knee with noticeable bleeding in both areas. Hospice services, Resident R1's family, and the physician were notified, and Resident R1 was sent to the hospital emergency room for evaluation.

Review of the 12/21/2024 hospital emergency department physician documentation revealed that Resident R1 sustained a 3-centimeter (cm) laceration to the right forehead and received three sutures to close the wound.

A 12/21/2024 nurse's note at 2:47 pm documented that Resident R1 had returned to the facility. The resident had three sutures to the right side of the forehead and a dressing wrapped around her head.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 15 115430 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115430 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summerhill Elderliving Home & Care 500 Stanley Street Perry, GA 31069

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 0689 A review of facility investigation information, including a 12/21/2024 Facility Incident Report Form, staff written statements from 12/21/2024, and a 12/23/2024 conclusion summary, revealed that Resident R1 fell out of bed Level of Harm - Actual harm during the provision of ADL care by one staff person, CNA AA. CNA AA documented in a 12/21/2024 statement that she went to Resident R1's room on her rounds to perform care. As she had the resident turned on her Residents Affected - Few right side (in bed) to get changed, the sheet and the bolster started sliding off, causing the resident to fall off

the bed.

During an interview on 1/6/2025 at 2:00 pm, the Director of Nursing (DON) stated that from what she determined, the bolsters were not secured to the bed, and Resident R1 rolled off onto the floor. The DON also confirmed that CNA AA did not follow Resident R1's care plan.

During an interview on 1/7/2025 at 2:16 pm, CNA AA stated that on 12/21/2024, she had positioned Resident R1 on her side (in the bed) to change her because she had a bowel movement. CNA AA stated that the bolster slid off really fast, and Resident R1 fell (on the floor) and hurt herself. CNA AA confirmed that she was alone in Resident R1's room providing care.

After Resident R1's fall out of bed with head injury sustained on 12/21/2024, in-service education was provided to nursing staff on following the care plan and Kardex and checking bolsters on the bed on 12/21/2024. CNA AA was also removed from the schedule and then terminated on 12/23/2024. Review of the Payroll Change Form, dated 12/23/2024, revealed that CNA AA was terminated. In addition, a 30 Day Resolution plan was developed on 12/23/2024 to address the CNA's failure to follow the care plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 115430 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115430 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summerhill Elderliving Home & Care 500 Stanley Street Perry, GA 31069

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 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21213 potential for actual harm Based on interviews, record reviews, and review of the facility policies titled Administering Medications and Residents Affected - Few Adverse Consequences and Medication Errors, the facility failed to ensure that one resident (Resident R2) was free from significant medication errors, from a total sample of 11 residents. Actual harm was identified to have occurred on 12/19/2024 when a Licensed Practical Nurse (LPN) CC administered the wrong resident's medications to Resident R2. Resident R2 was sent to the hospital and admitted for monitoring of potential side effects.

Findings include:

The facility had an Administering Medications policy, dated 4/7/2023. The policy statement documented that medications shall be administered in a safe and timely manner, and as prescribed. The policy interpretation and implementation section included that the individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident included verbally asking the resident their name, checking the photograph attached to the medical record, and if necessary, verifying resident identification with other facility personnel.

The facility also had an Adverse Consequences and Medication Errors policy, dated 3/22/2017. The policy included a definition of medication error. A medication error was defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional providing services. Examples of medication errors included omission, unauthorized drug, wrong dose, wrong route, wrong dosage form, wrong drug and wrong time and/or failure to follow manufacturer instructions or accepted professional standards.

However, LPN CC failed to accurately verify the correct resident prior to administering medications to Resident R2 on 12/19/2024.

Review of clinical record for Resident R2 revealed that he was admitted to the facility on [DATE REDACTED] and had diagnoses that included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction, aphasia, dysphagia, cerebral atherosclerosis, atherosclerotic heart disease, hypertension, hyperlipidemia, major depressive disorder, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, and vitamin D deficiency.

A review of facility investigation information, including a 12/19/2024 Facility Incident Report Form, staff written statements, and a 12/23/2024 conclusion summary, revealed that Resident R2 received oral medications that were ordered for Resident R6 on 12/19/2024 around 9:03 am. At 11:00 am Registered Nurse (RN) Supervisor EE was notified by Certified Nursing Assistant (CNA) KK that Resident R2 had fallen in the bathroom. Resident R2 was assisted back to bed and assessed. The Nurse Practitioner (NP) (who was onsite) at the same time was notified and evaluated Resident R2, and he was sent to the hospital emergency room for further evaluation. Resident R2 was subsequently admitted for observation due to polypharmacy and a syncopial episode.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 115430 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 115430 B. Wing 01/28/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Summerhill Elderliving Home & Care 500 Stanley Street Perry, GA 31069

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 0760 LPN CC documented in a written statement that on 12/19/2024, Resident R2 was pushed (in his wheelchair) to the medication cart. LPN CC asked Resident R2 if his name was Resident R2 or Resident R6's last name. Resident R2 incorrectly stated Resident R6's last Level of Harm - Minimal harm or name. LPN CC looked at the picture on the Medication Administration Record (MAR) (for Resident R6), which she potential for actual harm documented resembled Resident R2. Her statement included that she administered Resident R6's oral medications (to Resident R2). LPN CC continued to administer medications to other residents. When she arrived at Resident R6's room to administer Residents Affected - Few medication to his roommate, she realized her error when Resident R6 was lying in his bed and was wearing clothing different from the resident who had identified himself as Resident R6 earlier at the medication cart. She documented that she immediately located Resident R2 and took his vital signs, which were within normal limits. LPN CC included in her statement that she proceeded to look for the Nurse Manager, but was unable to locate her, so she continued to check on Resident R2 until she was able to speak to the Nurse Manager. Minutes later, a CNA reported that Resident R2 fell . LPN CC documented that she, several CNA's, the Nurse Manager, and the NP went to Resident R2's room.

During an interview on 1/9/2025 at 4:05 pm, which included RN Supervisor EE and the Director of Nursing (DON), RN Supervisor EE stated that she was coming out of a meeting (on 12/19/2024) when LPN CC told her about the medication error. RN EE went to put her paperwork down on her desk and said she was going to call the Nurse Practitioner and check on Resident R2. As RN EE rounded the corner to go that way, the CNA called out about Resident R2 being on the floor. When questioned why LPN CC asked Resident R2 if his name was the last name of Resident R2 or Resident R6 (instead of just asking him what his name was), the DON stated that she did not know why LPN CC asked the question that way. The DON stated that Resident R2 jokes and can be silly. RN Supervisor EE stated that Resident R2 was probably joking when he told LPN CC his name was Resident R6.

Review of Resident R2's physician ordered medications and review of Resident R6's physician ordered medications and December 2024 Medication Administration Record (MAR) revealed that on 12/19/2024 the medications signed out by LPN CC and administered in error to Resident R2 at 9:02 am - 9:03 am included allopurinol 300 milligrams (mg), amiodarone 200 mg, aspirin 325 mg, escitalopram 20 mg, Flomax 0.4 mg, Integra supplement, Linzess 145 micrograms (mcg), Potassium Chloride extended release 10 milliequivalents (mEq), carvedilol 3.125 mg, Eliquis 2.5 mg, hydralazine 50 mg, Magox 400 mg, dicyclomine 10 mg, and gabapentin 300 mg.

Review of the 12/19/2024 hospital Emergency Department (ED) Physician Documentation revealed that it was determined that Resident R2 had a vasovagal syncope (fainting) episode while having a bowel movement. Additional differential diagnoses included medication error, polypharmacy, and chronic obstructive pulmonary disease exacerbation. Poison control was contacted about the medication error and recommended baseline laboratory tests, an electrocardiogram (EKG), monitoring vital signs and 24-hour observation. Resident R2 was subsequently admitted to the hospital. Review of additional hospital documentation including the History and Physical and Discharge Instructions and Summary revealed that while hospitalized , Resident R2 tested positive for influenza and remained hospitalized until 12/24/2024, at which time he was discharged back to the facility.

During an interview on 1/16/2025 at 2:44 pm, the Medical Director confirmed that the medication error was significant, and could be for someone else, but not harmful or life threatening for Resident R2. When questioned if the vasovagal syncope episode was caused by the medication error, the physician responded no, that they were separate issues. The Medical Director stated that Resident R2 had a remote history of having a vasovagal episode.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 115430