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PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES(X1) PROVIDER/SUPPLIER/LIGAND PLAN OF CORRECTIONIDENTIFICATION NUMBER:06/21/2017FORM

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What is this visit was for?

This visit is for a routine inspection by the regulatory agency.

Who is required to file this visit was for?

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

How to fill out this visit was for?

The visit report must be completed with details of the inspection findings.

What is the purpose of this visit was for?

The purpose of the visit is to ensure compliance with regulations and standards.

What information must be reported on this visit was for?

All findings, observations, and corrective actions must be reported.

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