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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES (X1) PROVIDER×SUPPLIER×CIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 155104
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Indicate the date and time of the visit in the designated fields.
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Specify the purpose of the visit, such as a medical appointment, business meeting, or personal visit.
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What is this visit was for?
This visit is for a routine inspection of the facilities.
Who is required to file this visit was for?
The facilities manager is required to file this visit.
How to fill out this visit was for?
The visit report must be filled out accurately and completely.
What is the purpose of this visit was for?
The purpose of this visit is to ensure compliance with safety regulations.
What information must be reported on this visit was for?
The report must include details of any observed safety hazards and corrective actions taken.
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