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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: 155235

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What is this visit was for?

This visit was for conducting a routine inspection of the facility.

Who is required to file this visit was for?

The facility manager or owner is required to file this visit.

How to fill out this visit was for?

The visit should be documented in a report detailing the findings and any recommendations for improvements.

What is the purpose of this visit was for?

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

What information must be reported on this visit was for?

Information such as the date of the visit, areas inspected, any violations found, and corrective actions taken must be reported.

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