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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: 15G751
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Begin by writing the purpose or reason for the visit. Is it for a medical appointment, a social visit, or a business meeting?
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What is this visit was for?
This visit was for a routine inspection of the facility.
Who is required to file this visit was for?
The facility manager is required to file this visit.
How to fill out this visit was for?
The visit report must be filled out completely and accurately.
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 information reported must include any safety hazards found during the inspection.
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