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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:15569011/05/2012FORM

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What is this visit was for?

This visit is 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 actions taken.

What is the purpose of this visit was for?

The purpose of this visit is to ensure compliance with safety regulations and to identify any potential hazards.

What information must be reported on this visit was for?

The report must include details of the inspection, any issues found, and any corrective actions taken.

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