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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: 155159
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Begin by identifying the purpose of your visit. Consider if it was for a medical appointment, a business meeting, a personal visit, or another reason.
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Clearly state the specific details of the visit. Include the date, time, and location of the visit, as well as any additional pertinent information.
03
Describe the nature of the visit. Specify if it was a one-time visit, a follow-up appointment, a consultation, or any other relevant category.
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Provide any relevant background information. If there are any previous visits or interactions related to this one, mention them briefly.
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This visit was for a routine inspection.
The facility manager is required to file this visit report.
To fill out this visit report, the facility manager must provide details on the inspection findings and any actions taken.
The purpose of this visit was to ensure compliance with safety regulations.
The report must include details on the inspection date, findings, and corrective actions taken.
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