Firesteel Healthcare Center

F-F684 occurred on 1/16/25, and based on the provider's implemented corrective action for the deficient practice confirmed on 1/22/25, the non-compliance is considered past non-compliance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 14 435109 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 435109 B. Wing 01/22/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 - Minimal harm or potential for actual harm 49958

Residents Affected - Few Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, and manufacturer's operator's instructions review the provider failed to ensure

*The safety of one of one sampled resident (2) who had to be lowered to the floor while in a sit-to-stand lift (a mechanical lift that requires the person to be able to partially bear weight on at least one leg when assisted from a seated position to a standing position) while being transferred.

*While transferring resident 2 from the commode to the recliner two of two certified nurse aides (CNA) (D and L) utilizing the sit-to-stand lift did not adjust the safety strap of the sling.

*Six of eight sit-to-stand lifts were used and maintained per the manufacturer's operator instructions.

Findings include:

1. Review of the provider's 1/12/25 SD DOH FRI regarding resident 2 revealed:

*On 1/11/25 at 9:30 p.m. while CNA C was attempting to transfer him with the sit-to-stand lift she lowered him to the floor because he was not able to maintain a safe standing position.

*He required two staff to assist him with transfers while using the sit-to-stand lift.

*The sit-to-stand leg strap was not used during that transfer.

*His Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated he was cognitively intact.

-He was his own responsible party and did not want his mother called.

*He was assessed and had no injuries.

*The physician was notified.

2. Interview on 1/21/25 at 2:06 p.m. with CNA H and CNA I regarding the use of mechanical lifts revealed:

*Some residents who used the mechanical sit-to-stand lift for transfers required the assistance of one staff and some required the assistance of two staff.

*Some residents had a lift sling stored in their room and others shared a sling that was stored on the lift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 14 435109 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 435109 B. Wing 01/22/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 *The care plan and special instructions in the resident's electronic medical record that indicated which type of lift, the size sling required, and the number of staff required to transfer each resident. Level of Harm - Minimal harm or potential for actual harm *The pocket care plan was a paper they carried that indicated how each was to be resident transferred.

Residents Affected - Few *They both had attended a training maybe a week ago regarding transferring residents with the mechanical lifts.

3. Observation and interview on 1/21/25 at 2:20 p.m. with resident 2, CNA D, and CNA L in resident 2's room revealed:

*Resident 2 was seated on the commode to the left of his recliner.

*He was wearing a lift sling around his back that was attached to the sit-to-stand lift. There was a second sling draped over the lift.

-The safety strap was not tight around his midsection.

*CNA D and CNA L then transferred resident 2 to his recliner using the sit-to-stand lift without adjusting the strap on the sling.

*CNA L removed the lift sling worn by resident 2, hung that sling on the back of his door, and exited the room with CNA D.

-CNA L said she knew which sling to use for resident 2 by the color of the sling's handle and because it was stored in his room.

Continued observation and interview on 1/21/25 at 2:25 p.m. with resident 2 revealed:

*He confirmed that the strap around his midsection had been very loose.

-He stated, Sometimes they tighten the strap and sometimes they don't.

*He recalled that he had slid out of the sit-to-stand lift about a week ago.

-The fall had occurred at night.

-There was one staff with him at that time, maybe [CNA C].

-He stated, It was not attached right.

-He confirmed that he had not been injured and stated he went down slow.

*At times one or two staff assisted him when transferring him with the sit-to-stand lift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 14 435109 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 435109 B. Wing 01/22/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 *He had to use the full-body lift (a mechanical lift and sling used to lift a person's full body) after the fall and stated, I hate that thing. Level of Harm - Minimal harm or potential for actual harm *He had begun working with physical therapy after the above incident so that he could return to using the sit-to-stand lift. Residents Affected - Few 4. Interview on 1/21/25 at 2:50 p.m. with CNA L revealed:

*Resident 2 had needed the full-body lift at one time, but had been working with therapy to use the sit-to-stand.

*She knew which lift and sling to use and how many staff were needed to assist resident 2 because it was on his care plan.

*She received facility training maybe last Friday on transferring residents with the mechanical lifts.

*She stated the lift sling had padding that should be under the belt and the belt should be tightened.

-She could not recall if she had tightened the belt when she transferred resident 2 during the above observed transfer that day.

5. Interview on 1/21/25 at 2:55 p.m. with CNA D regarding the above observed transfer with resident 2 that day revealed:

*Resident 2 required the full-body lift for transfers with nursing staff.

*Resident 2 had been working with therapy.

-The therapist assisted in transferring resident 2 onto the commode with the sit-to-stand lift.

--The therapist had cleared them to transfer resident 2 off the commode that day.

*She stated that the lift sling belt should be tight, but it loosens as they stand.

*CNA D could not recall if the belt had been tight when she transferred resident 2 off the commode.

-She stated, He already had the sling on.

6. Interview on 1/21/25 at 3:06 p.m. with physical therapist PT M revealed:

*He had been working with resident 2 because of concerns after his recent fall from the sit-to-stand lift.

*It had been unclear if there was a mechanical problem with the lift or if the fall occurred as a result of user error.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 14 435109 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 435109 B. Wing 01/22/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 *He had been trialing lifts, assessing safety, and providing education to staff during transfers with resident 2.

Level of Harm - Minimal harm or *The facility had sit-to-stand lifts capable of lifting 400 and 500 pounds. potential for actual harm *He had approved the CNAs to use a 500-pound capacity lift for the above observed transfer that day with Residents Affected - Few resident 2.

-Resident 2 weighed between 366 and 375 pounds.

*Two or three other lifts slowly descended with resident 2 in the standing position, which increased his risk of falling.

*He thought maintenance supervisor (MS) E had been checking the lifts and had been in contact with the lift vendor about any issues.

*He had educated staff today (1/21/25) when putting resident 2 on the commode.

-He expected the padding on the lift sling to be underneath the strap and the strap to be snug.

7. Interview on 1/21/25 at 3:53 p.m. CNA N revealed:

*Some of the lifts would not maintain the standing position and would slowly lower the resident back down while she had tried to transfer them.

-She had switched the lift batteries to see if that would help, but it had not helped.

*Most of the lifts go up to 400 or 500 pounds, but the older lifts were not used with heavier residents because

they could not hold as much weight.

8. Interview on 1/21/25 at 4:23 p.m. with MS E revealed:

*He was aware of staff concerns about some lifts that lowered with a resident in the lift.

-He was told it had been only with resident 2.

*He completed monthly inspections of the lifts and any required maintenance.

-Inspections and maintenance were tracked on TELS (maintenance electronic work order system).

-He used the lift serial numbers to identify the lifts and track the maintenance performed on them.

-Each lift was inspected for a list of items including the motor and several other areas.

-He stated, There hasn't been anything mechanically wrong with the lifts.

*The weight capacity was labeled on the side of each lift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 14 435109 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 435109 B. Wing 01/22/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 *The lift manufacturer representative had provided advice on possible problems that had been looked into.

Level of Harm - Minimal harm or *He expected staff to notify him of needed repairs or broken equipment through the TELS system. potential for actual harm *When lifts required repair, they were taken out of service. Residents Affected - Few *Recently some lifts have been replaced.

9. Phone interview on 1/21/25 at 5:30 p.m. with CNA C regarding the incident on 1/11/25 involving resident 2 revealed:

*She worked from 10:00 p.m. to 6:00 a.m. that night.

*Two CNAs and one nurse were responsible for the residents in the 100 and 200 hallways that night.

*She had used a sit-to-stand lift and had attempted to transfer resident 2 alone.

-She had not fastened the leg strap behind his legs.

-She could not recall if she had tightened the mid-body lift sling strap as he stood.

*She had used the smaller lift and he had been near that lift's weight capacity.

*She recalled he stood up and then slid down, and she tried to place him in his wheelchair and called for the nurse.

*The nurse arrived as she lowered him to the floor.

*She could not recall if the lift had started to lower him down that time but stated that some lifts would not stay up.

*Resident 2 did not need to be transferred on her shift very often and she did not know he required two staff to assist him.

*She stated she should have checked the care plan and the special instructions to know how he transferred.

*She received training on mechanical lift transfers when she was hired, annually, and again after that incident.

10. Observation and interview on 1/22/25 at 8:48 a.m. with resident 3 and CNA P during a transfer with the sit-to-stand lift revealed:

*Resident 3's lift sling was stored in her room and staff used one specific lift for her.

*Resident 3 put on her lift sling and tightened the strap herself.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 14 435109 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 435109 B. Wing 01/22/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 *Resident 3 stated a metal clip where the sling attached to the lift was missing and had been for a long time.

Level of Harm - Minimal harm or *She had not told anyone about the broken clip. potential for actual harm *CNA P stated she had not noticed the broken clip but would notify maintenance using the TELS system. Residents Affected - Few 11. Observation on 1/22/25 at 9:00 a.m. throughout the facility of the sit-to-stand lifts revealed:

*Lifts 960816, 706010794, and 70609707 were missing one of two metal clips where the sling attached to

the lift.

*Lift 41522 was missing one of two rubber clips where the sling attached to the lift and had been identified as

an older lift that lowered residents when in the standing position.

*Lift 905968 was missing one of two metal clips where the sling attached to the lift and had been identified as

a newer lift that lowered residents when in the standing position.

*Lift 41644 was missing two of two rubber clips where the sling attached to the lift and had been identified as

an older lift that lowered residents when in the standing position.

12. Observation and interview on 1/22/25 at 9:45 a.m. with MS E revealed he:

*Confirmed the above-listed lifts were missing those clips.

*Had checked for the presence of the clips during the monthly lift inspections.

*Had not been notified of the lift's missing parts.

*Expected staff that used the lifts would notify him through the TELS system if parts were missing.

13. Interview on 1/22/25 at 9:11 a.m. with director of nursing (DON) B regarding resident 2 revealed:

*She had expected resident 2 to have been transferred with two staff and the sit-to-stand lift the day he was lowered to the floor.

*She had been notified of the incident immediately after it occurred.

*She initiated staff education and mechanical lift competency checklists with all caregiver staff.

*There was no current performance improvement plan (PIP) involving the use of mechanical lifts or resident falls.

-She planned to initiate a PIP regarding falls at the next quality assurance performance improvement (QAPI) meeting on 1/30/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 14 435109 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 435109 B. Wing 01/22/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 *She had not conducted any audits regarding the use or condition of the sit-to-stand lifts.

Level of Harm - Minimal harm or *She expected the leg strap to be used on resident 2 and all residents other than resident 3 who had been potential for actual harm assessed for risk versus benefit, educated and signed a form that indicated she chose not use the leg strap.

Residents Affected - Few *Resident 2 had needed a full-body lift after the above incident and had been working with therapy to determine if he could safely use the sit-to-stand lift again.

*PT M cleared resident 2 to return to being transferred with the sit-to-stand lift today (1/22/24) with the assistance of two staff.

*The care plan had been updated to reflect those changes.

14. Review of resident 2's electronic medical record revealed:

*His weight was 365 pounds.

*His special instructions indicated Transfers: stand aid with 2 assist.

*His care plan indicated, Toilet Transfer: Total lift with two assists for transfers, and had not been updated to reflect the 1/22/25 lift change.

*Fall risk assessments completed on 1/7/24 and 4/15/24 indicated a high risk for falls

*A fall risk assessment completed on 1/12/25 indicated a moderate risk for falls.

*The care plan did not indicate which sit-to-stand lift was to be used for resident 2.

15. Interview on 1/22/25 at 10:15 a.m. with staff development RN G revealed:

*CNA C and CNA D had received education on the proper use of the lifts when hired, annually, and after the incident on 1/12/25.

*CNA L was an agency staff employee and, would have received training on the use of lifts through her agency, and had been re-educated and completed her competency at the facility after the incident on 1/12/25.

*Staff were trained to ensure the sit-to-stand mid-body lift sling strap was snug and tightened as the resident stood and that the leg strap was to be used with all residents unless the care plan stated otherwise.

16. Interview on 1/22/25 at 10:59 a.m. with executive director (ED) A revealed:

*Maintenance inspected the mechanical lifts monthly.

*He expected the staff that used the lifts to use the TELS system to report mechanical issues with the lifts.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 14 435109 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 435109 B. Wing 01/22/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 -He confirmed that no mechanical lift repair requests had been entered into the TELS system since 11/1/24.

Level of Harm - Minimal harm or -There was one TELS request from today (1/22/25) related to the missing clip on one of the lifts. potential for actual harm 17. Observation and interview on 1/22/25 at 11:45 a.m. with resident 2 and PT M during a sit-to-stand Residents Affected - Few transfer revealed:

*PT M trained CNA D and CNA R on transferring resident 2 with the sit-to-stand lift.

*PT M indicated only one of the lifts could be used with resident 2 because it was the only lift that had consistently held him up.

-It was marked with a small black X on one side.

*The mid-body lift strap was snug around the resident's body and tightened as he stood.

-Approximately five to six inches of strap extended out of the buckle.

18. Observation and interview on 1/22/25 at 12:03 p.m. and 2:20 p.m. with DON B of the mechanical sit-to-stand lifts revealed:

*The older model sit-to-stand lifts required a rubber clip where the sling would be attached, and the new lifts required metal clips.

*Lifts 960816, 706010794, 41522, 41644, and 70609707 had been repaired and now had the required clips.

*Lift 905968, identified as a newer lift that was missing the required clips and lowered residents when in the standing position was taken out of service.

*She was aware that one sit-to-stand lift had been reported as descending when used with resident 2.

*She was unaware that staff had concerns about three lifts descending when used with patients identified as heavier.

19. Review of resident 2's Physical Therapy Treatment Encounter Notes revealed:

*On 1/14/25 a note indicated, .staff needs to have education and training in correct use of one [brand name sit-to-stand lift] and .interviews of 2 CNA's reveals that at least one [brand name sit-to-stand lift] loses its ability to maintain the standing position and thus, the pt [patient] is descending from the starting position when transferred .

*On 1/15/25 a note indicated, Use of 500# [pound] heavy wt [weight] [brand name sit-to-stand lift] reveals the machine malfunctioning today and lowering pt when it is intended for maintaining the position . and trial of various batteries due to? [question] of low battery [as] possible cause of machine dropping.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 14 435109 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 435109 B. Wing 01/22/2025

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

Firesteel Healthcare Center 1120 East 7th Avenue Mitchell, SD 57301

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 *On 1/16/25 a note indicated, Pt has trial of 2 [brand name sit-to-stand lifts] with both losing ability to hold pt once upright in standing, and demonstration to maintenance supervisor . Level of Harm - Minimal harm or potential for actual harm *On 1/17/25 a note indicated a discussion with the maintenance supervisor regarding .cause for the machine not holding pt upright as is supposed to be the case with the 2 machines that are rated at 500# and that Residents Affected - Few resident 2's weight was 366.2 pounds.

20. Review of the provider's 1/21/25 TELS Resident Lifts report revealed:

*The checklist contained at least 12 areas to inspect that included:

-Check the sling hooks for bends or deflection.

-Inspect all surfaces on the lifts to ensure they are in good repair.

*There was no specific inspection of the metal clip listed.

*Task completion was Marked done on-time by [MS E] on 12/31/24.

Review of the [brand name sit-to-stand lift] Operator's Instructions revealed:

*The maximum lifting capacity of each lift is located on the opposite side of the stand mast from the battery receiver.

*All [brand name sit-to-stand lift] equipment must be maintained regularly by competent staff according to the maintenance checklist provided.

*For the safety of the patient, securely fasten the safety strap around the patient's torso. Secure the buckle and pull the strap to tighten.

*Verify the loops are properly hooked inside the pigtail and the end of the [brand name sit-to-stand lift] arms and the Safety Catch is in place, blocking the strap from exiting through the pigtail.

*As the patient is being raised, simultaneously tighten the safety strap buckled around their torso.

*The Safety & Maintenance Checklist included safety tabs need to be checked to make sure they are in place, with a photograph of the metal clips where the sling attached to the lift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 14 435109