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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: 05/17/2013

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What is this visit was for?

This visit was for a routine inspection.

Who is required to file this visit was for?

The business owner is required to file this visit.

How to fill out this visit was for?

The visit report must be completed with detailed information about the inspection.

What is the purpose of this visit was for?

The purpose of this visit was to ensure compliance with regulations and safety standards.

What information must be reported on this visit was for?

The information reported must include date of visit, findings, corrective actions taken, and signatures of inspectors.

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