Kathleen Lucas, Unit Supervisor
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- Basil Rogers
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1 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: IXBL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: MEDICARE/MEDICAID PROVIDER NO. (L1) 2.STATE VENDOR OR MEDICAID NO. (L2) 5. EFFECTIVE DATE CHANGE OF OWNERSHIP (L9) /01/ /23/ DATE OF SURVEY (L34) 8. ACCREDITATION STATUS: (L10) 0 Unaccredited 2 AOA 1 TJC 3 Other 3. NAME AND ADDRESS OF FACILITY (L3) TALAHI NURSING AND REHAB CENTER (L4) 1717 UNIVERSITY DRIVE SOUTHEAST (L5) SAINT CLOUD, MN (L6) 7. PROVIDER/SUPPLIER CATEGORY 02 (L7) 01 Hospital 02 SNF/NF/Dual 03 SNF/NF/Distinct 04 SNF 05 HHA 06 PRTF 07 X-Ray 08 OPT/SP 11..LTC PERIOD OF CERTIFICATION 10.THE FACILITY IS CERTIFIED AS: From (a) : To (b) : 12.Total Facility Beds 77 (L18) X A. In Compliance With Program Requirements Compliance Based On: 1. Acceptable POC 13.Total Certified Beds 77 (L17) B. Not in Compliance with Program 09 ESRD 10 NF 11 ICF/IID 12 RHC 13 PTIP 14 CORF 15 ASC 16 HOSPICE CLIA 4. TYPE OF ACTION: 7 (L8) 1. Initial 3. Termination 5. Validation 7. On-Site Visit 8. Full Survey After Complaint 2. Recertification 4. CHOW 6. Complaint 9. Other FISCAL YEAR ENDING DATE: 12/31 And/Or Approved Waivers Of The Following Requirements: 2. Technical Personnel 6. Scope of Services Limit Hour RN 7. Medical Director 4. 7-Day RN (Rural SNF) 8. Patient Room Size 5. Life Safety Code 9. Beds/Room Requirements and/or Applied Waivers: * Code: A* (L12) 14. LTC CERTIFIED BED BREAKDOWN 15. FACILITY MEETS 18 SNF 18/19 SNF 19 SNF ICF IID 1861 (e) (1) or 1861 (j) (1): (L15) 77 (L37) (L38) (L39) (L42) (L43) (L35) 16. STATE SURVEY AGENCY REMARKS (IF APPLICABLE SHOW LTC CANCELLATION DATE): A recertification survey was conducted February 26, 2018 through March 1, 2018, and complaint investigation(s) were also completed at the time of the standard survey. At the time of the survey, an investigation of complaints: H , H , H , and H were completed and were all found to be unsubstantiated. 17. SURVEYOR SIGNATURE Date : 18. STATE SURVEY AGENCY APPROVAL Date: Kathleen Lucas, Unit Supervisor 05/02/2018 Joanne Simon, Enforcement Specialist 05/02/2018 PART II - TO BE COMPLETED BY HCFA REGIONAL OFFICE OR SINGLE STATE AGENCY (L19) (L20) 19. DETERMINATION OF ELIGIBILITY 20. COMPLIANCE WITH CIVIL RIGHTS ACT: X 1. Facility is Eligible to Participate 2. Facility is not Eligible (L21) Statement of Financial Solvency (HCFA-2572) 2. Ownership/Control Interest Disclosure Stmt (HCFA-1513) 3. Both of the Above : 22. ORIGINAL DATE OF PARTICIPATION 23. LTC AGREEMENT BEGINNING DATE 24. LTC AGREEMENT ENDING DATE 02/01/1987 (L24) (L41) (L25) 25. LTC EXTENSION DATE: 27. ALTERNATIVE SANCTIONS A. Suspension of Admissions: (L44) (L27) B. Rescind Suspension Date: 26. TERMINATION ACTION: (L30) VOLUNTARY 01-Merger, Closure 00 INVOLUNTARY 05-Fail to Meet Health/Safety 02-Dissatisfaction W/ Reimbursement 03-Risk of Involuntary Termination 04-Other Reason for Withdrawal 06-Fail to Meet Agreement OTHER 07-Provider Status Change 00-Active 28. TERMINATION DATE: (L45) 29. INTERMEDIARY/CARRIER NO. 30. REMARKS (L28) (L31) 31. RO RECEIPT OF CMS DETERMINATION OF APPROVAL DATE 04/03/2018 (L32) (L33) DETERMINATION APPROVAL FORM CMS-1539 (7-84) (Destroy Prior Editions)
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Mary Heim, HPR-Social Work Specialist 09/03/2013
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: NKFZ PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00858
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: 2LL3 PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
Brenda Fischer, Unit Supervisor 09/13/2012 Colleen B. Leach, Program Specialist 09/18/2012
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: LNUX PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY 3. NAME AND ADDRESS OF FACILITY
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: 8L7Q Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: X60T Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00712
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: H0RJ PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
Jessica Sellner, HFE, NEII 11/23/2011 Colleen B. Leach, Program Specialist 01/13/2012
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: DDG9 PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
Patricia Halverson, Unit Supervisor
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: VWX6 Facility ID:
Gary Nederhoff, Unit Supervisor
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: 94CQ Facility ID:
James Anderson, State Fire Marshall
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: 2HL7 PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00351
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: M4JX PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00719
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: 93NN PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: 2FT5 Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: 8MXL Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00940
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: FU8X PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
Michelle McFarland, HFE NEII
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: PH3B Facility ID:
07/23/ /21/2013 (L20)
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: 04CB PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00903
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: RHTV PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY 3. NAME AND ADDRESS OF FACILITY
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: 0D7L Facility ID:
Patricia Halverson, Unit Supervisor
DEPARTMENT OF HEALTH AND HUMAN SERVICES 1. MEDICARE/MEDICAID PROVIDER NO. (L1) 2.STATE VENDOR OR MEDICAID NO. (L2) 5. EFFECTIVE DATE CHANGE OF OWNERSHIP (L9) 6. DATE OF SURVEY (L34) 8. ACCREDITATION STATUS:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00166
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: 6PJU PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00861
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: 33K1 PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
Timothy Rhonemus, NFE NEII
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: 6VZG Facility ID:
Lou Anne Page, HFE NE II
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: Z6PT PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
Cheryl Johnson, HFE NEII
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICA SERVICES MEDICARE/MEDICA CERTIFICATION AND TRANSMITTAL PART I - TO BE BY THE STATE SURVEY AGENCY : VN0N Facility : 00587 1. MEDICARE/MEDICA
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00695
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: D9GP PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY 245507 596340100 12/06/2012
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00598
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: L7X6 PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY 3. NAME AND ADDRESS OF FACILITY
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: JSZI Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 00360
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: BFJG PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY 3. NAME AND ADDRESS OF FACILITY
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: GR6J Facility ID:
Terri Ament, Unit Supervisor
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: MKQC Facility ID:
Gloria Derfus, Unit Supervisor
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL ID: CU09 PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID:
Jane Teipel, HFE NEII
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICA SERVICES MEDICARE/MEDICA CERTIFICATION AND TRANSMITTAL PART I - TO BE BY THE STATE SURVEY AGENCY : S9GX Facility : 00847 1. MEDICARE/MEDICA
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL. PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY Facility ID: 23242
CENTERS FOR MEDICARE & MEDICA SERVICES MEDICARE/MEDICA CERTIFICATION AND TRANSMITTAL : KHKN PART I - TO BE BY THE STATE SURVEY AGENCY Facility : 23242 1. MEDICARE/MEDICA PROVER NO. (L1) 2.STATE VENDOR
Gayle Lantto, Unit Supervisor
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICA SERVICES MEDICARE/MEDICA CERTIFICATION AND TRANSMITTAL : 6EX1 PART I - TO BE BY THE STATE SURVEY AGENCY Facility : 00756 1. MEDICARE/MEDICA
Danette Bakken, HFE II
CENTERS FOR MEDICARE & MEDICA SERVICES MEDICARE/MEDICA CERTIFICATION AND TRANSMITTAL PART I - TO BE BY THE STATE SURVEY AGENCY : 3O28 Facility : 00125 1. MEDICARE/MEDICA PROVER NO.(L1) 245528 2. STATE
Teresa Ament, Unit Supervisor
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICA SERVICES MEDICARE/MEDICA CERTIFICATION AND TRANSMITTAL : JOZS PART I - TO BE BY THE STATE SURVEY AGENCY Facility : 00861 1. MEDICARE/MEDICA
Michele McFarland, HFE NE II
CENTERS FOR MEDICARE & MEDICA SERVICES MEDICARE/MEDICA CERTIFICATION AND TRANSMITTAL PART I - TO BE BY THE STATE SURVEY AGENCY : 2S25 Facility : 00124 1. MEDICARE/MEDICA PROVER NO. (L1) 2.STATE VENDOR
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY 3. NAME AND ADDRESS OF FACILITY
CENTERS FOR MEDICARE & MEDICA SERVICES MEDICARE/MEDICA CERTIFICATION AND TRANSMITTAL PART I - TO BE BY THE STATE SURVEY AGENCY : 02HR Facility : 00538 1. MEDICARE/MEDICA PROVER NO. (L1) 245255 2.STATE
Gayle Lantto, Supervisor
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICA SERVICES MEDICARE/MEDICA CERTIFICATION AND TRANSMITTAL PART I - TO BE BY THE STATE SURVEY AGENCY : 5LL3 Facility : 00979 1. MEDICARE/MEDICA
MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY
CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: GRIK Facility ID: 00936 1. MEDICARE/MEDICAID PROVIDER NO.
Lyla Burkman, Unit Supervisor
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICA SERVICES MEDICARE/MEDICA CERTIFICATION AND TRANSMITTAL PART I - TO BE BY THE STATE SURVEY AGENCY : 9DHU Facility : 00078 1. MEDICARE/MEDICA
Jonathan Hill, HFE NE II. Kate JohnsTon, Program Specialist. Posted 11/16/2015 Co.
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICA SERVICES MEDICARE/MEDICA CERTIFICATION AND TRANSMITTAL : VNT4 PART I - TO BE BY THE STATE SURVEY AGENCY Facility : 00797 1. MEDICARE/MEDICA
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICARE/MEDICAID CERTIFICATION AND TRANSMITTAL PART I - TO BE COMPLETED BY THE STATE SURVEY AGENCY ID: 0H11 Facility ID:
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31 (L37) (L38) (L39) (L42) (L43)
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICA SERVICES MEDICARE/MEDICA CERTIFICATION AND TRANSMITTAL PART I - TO BE BY THE STATE SURVEY AGENCY : 2NB3 Facility : 00365 MEDICARE/MEDICA
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICA SERVICES MEDICARE/MEDICA CERTIFICATION AND TRANSMITTAL PART I - TO BE BY THE STATE SURVEY AGENCY : MLV4 Facility : 00226 1. MEDICARE/MEDICA
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CENTERS FOR MEDICARE & MEDICA SERVICES MEDICARE/MEDICA CERTIFICATION AND TRANSMITTAL PART I - TO BE BY THE STATE SURVEY AGENCY : X8U4 Facility : 00979 1. MEDICARE/MEDICA PROVER NO. (L1) 245264 2.STATE
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